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UCLAnaesthesia
ANAESTHESIAANDCRITICALCARE
SpecialStudiesModule2019
RoyalFree&UniversityCollegeMedicalSchoolUNIVERSITYCOLLEGELONDON
CONTENTS
Page
• INTRODUCTION 1
• OBJECTIVES 3
• SCHEDULE 4
• TOPICS1. PreoperativeAssessment 72. AirwayManagement 123. ConductofAnaesthesia 164. OxygenDelivery 215. Peri-operativeFluidTherapy 286. PainandAnalgesia 357. PerioperativeComplications 408. Basic&AdvancedLifeSupport 439. SickPatientScenarios 51
• PROCEDURESCHECKLIST 59
• ATTENDANCECHECKLIST 60
• ASSESSMENTFORMS 62
• FEEDBACKFORM 63
1
Introduction
Welcome to your SSC in Anaesthesia and Critical Care. We appreciate thatanaesthesia isverydifferenttotheothersubjectsyoustudy,butall thestaffareheretohelpyougainagoodintroductiontothisbroadfield.Mostofyourtimewillbespentintheatresandonthewardwithconsultants andtraineeanaesthetists,aswellascriticalcare,nursing,theatreandrecovery staff.Dobepro-activeandusethisopportunitytoseeawiderangeofcasesandlearnfromthedifferentmembersofstaff.Sometimesjustwatchingisavalidtool,butfeelfreetoaskquestionsandthinkaboutwhywedothingsinacertainway.There are freely downloadable short articles on the students section of ourwebsite at www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students that willsupportthebooklet.VisitourYoutubesite(google‘youtubeuclanaesthesia’– it’sthetoplink)forourvideos!Moretraditionalresourcesarestillimportant,andtheCruciform library has a good selection of anaesthetic and critical care books.Therearealsothelatest journalsandaccesstotheinternetandevidencebasedmedicine.This booklet is intended as a guide to your learning; use it in conjunctionwiththeatre teaching and the tutorials youwill have. Some of themain points youneedtocoverarehighlightedandthereisalsoachecklistofpracticalproceduresyoushouldgetsignedoffonceyouhaveseenordonethem.ThisSSC isagreatopportunity to gain valuable experience in airway management and IVcannulationandyoushouldtrytoseeanddoasmuchaspossible.Thebooklet includes9main topics, eachofwhich forms thebasisof a tutorial.Oneortwowillpresentasummaryofthemainpoints,butyoushouldallprepareinadvanceandbereadytodiscussthesubjectaswewillbeassessingyouonyourparticipationinthesetutorialsaswellasintheatre.Therearealsoscenariosandquestionsforeachtopictoreinforceyourlearningeitherinthebookletoronline.Therewillbeaformalassessmentattheendoftheattachmentintheformofacasebaseddiscussionorpeer topeer teaching session for theYear4 students.Thetopictutorialsandthecasereportorteachingsessionconstitutetheprojectworkthatthemedicalschoolspecifiesyoumustdotopassthemodule.
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Wearealwaystryingtoimprovethismodule:thiscanonlybeachievedwith yourfeedback.Sopleasefillintheassessmentformattheendofyourtime.Wehaveanonlinerotayoucanviewathttps://uclh.clwrota.comUsernamemedical.s1 PasswordStudent1We have a training tool in Perioperative Medicine mostly for when you're atWestmorlandStreet.Youcandotanytimeonyourown.Gotohttps://versal.comandregister.FindIntroductiontoPerioperativeMedicineforMedicalStudentsorgototheaddress: https://versal.com/learn/jgjmnk/introduction
Finally, enjoy your time here. Anaesthesia and Perioperative Medicine is anexciting field to work in and we believe you can learn a lot during yourattachmentanddevelopskillsandknowledge that will really help you as a newdoctor. If at any time you haveconcerns or need to raise an issue do get intouchwith the educational fellowAnthonyormyself,RobStephens.
Rob 07946742344 robcmstephens@googlemail.comAnthonyLizCervi
07988431346 antonyodwyer@gmail.comConsultantDrLizCerviwillbehelpingwithsomesessions
3
OBJECTIVESAt the end of your four-week special studymodule in anaestheticsandcriticalcareyoushouldbeableto:
1. Assess and prepare patients undergoing emergency and electiveanaesthesiaforavarietyofsurgicalconditions.
2. Understandpostoperativecareofthesurgicalpatientincluding painmanagement,fluidandoxygentherapy.
3. Appropriately identify patients who require a higher level of carethancanbeprovidedonthewardandneedreferraltothe intensivecareandhighdependencyunits.
4. Have an understanding of anaesthetic drugs and equipment andwhenandhowtousethem.
5. Carryoutthefollowingprocedures
! Basicairwaymanagement! IVcannulation
4
ProvisionalSCHEDULETherearefourblocks;WeekA,B,CandD.
Youwillsplitupandspendaweekineachandrotatethrough.WeekA UCHEmergencyTheatresandCriticalCareJoinTraumaandEmergencyList(Theatre1)Anaestheticteamhandoverat0745outsidetheatre1.Contacts:AnaestheticSHO&SpR(bleep4300&4600),EducationFelloworRobStephens.Trytoseeasmanypatientspre-operativelyandpost-operativelywiththeteam.FeelfreetoflitbetweenTheatres,DutySpR(4600),ICU,CPEx(CardiopulmonaryExercisetesting)andPainrounds.
Regularteachingsessions
Monday 0900 Preopexercisetestingintermittentlyallday(Pod1ClinicA–roomA4)–callon70162/emailucl-tr.CPXref@nhs.nettocheckthetimes.
1300 ICUcasepresentationsintheICUSeminarRoomTuesday 0830 JournalClubICUThursday 0800 ICUWardRoundinCoffeeRoomorseminarroomfollowedby 0830
0900CoretopicsteachingICUPreopexercisetestingintermittentlyallday(Pod1clinicA–roomA4)–callon70162/emailucl-tr.CPXref@nhs.nettocheckthetimes.
0915 ConsultantTeachingWardRoundICU 1230 MultidisciplinaryRoundICU
1300 ‘GrandRound’intheICUSeminarRoom 1600 WardroundICUFriday 0800 AnaesthesiaDeptMeeting
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WeekB NationalHospitalforNeurologyandNeurosurgery,Queen Square,TheatresandITUContacts:PleasedonothesitatetocontactDrAminifthereareanyissueswithliststoattendwhilstatNHNN.DrYogiAmin(07539-212638)orAnaestheticRegistrar(bleep8131)orMei(TheatreAnaestheticManager)02034484711Ontheatredaysarriveat07:45andpresenttothefloorconsultanttointroduceyourself.Listswillbeallocatedfromhere.
Monday: TheatredayTuesday: TheatredayWednesday: TheatredayThursday: Arrive 08.30, find registrar on SurgicalITU, Identify and clerk a patient to
present onwardroundat10.00Friday: Arrive0900,MedicalITUwithDr.Amin
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WeekC PerioperativeWeek:UCHTheatresatWestmorelandStreet&UCH
Thisweekcombinestime:
• withthePerioperativeFellowsatWestmorelandStreet(WSt)ITU,(TheoldHeartHospital)
• atPre-operativeAssessmentClinic@UCH,
• Seeing“atrisk”patientswiththePERRTteam
• Followingathoraciccaseortwofromsurgerythroughtopost-operativerecoverytounderstandindetailthepatientjourney
YouarealsoexpectedtocompletetheOnlinelearningmodule:PerioperativeRiskandSafetyforMedStudents,atwww.versal.comthisisfactoredintothetimeallocated(seebelow).Youcancreateanaccountforfreeyourselfwhichallowsyoutoaccessthismodule.Ifyouaredoingthisweekasapair,pleaseallocateyourselftoStudentAorStudentBrolesasthiswillmakesureyougetthemostoutofthisweek.Contacts:AtWestmorelandStreet:1stfloorCriticalCareUnit,PerioperativeFellowbleepholder2261orDutyConsultantatWestmorelandStreet(bothavailableviamobileviaswitchboard).AtUCHRobStephensorEducationfellow.PERRTteam–pleaseemailPERRTUCH2@uclh.nhs.uktoconfirmwheretomeettheDAYbeforeyouarerosteredtobewiththem
Monday: StudentA:@UCHPre-assessmentclinic:Peri-operativeRiskOnlineLearningpmStudentB:PERRTteammorning@UCH:Peri-operativeRiskOnlineLearningpm
Tuesday: StudentA:@WStCCUWRShadowPerioperativeFellow-reportforhandoverat8am,level1.OfficeatfarendofcriticalcareunitStudentB:@WStThoracicTheatreslevel1,0730-0800ameitherTh1orTh4,followpatientthroughtorecovery/post-anaestheticcareunit/ITU
Wednesday:StudentA:@WStThoracicTheatreslevel1,0730-0800ameitherTh1orTh4,followpatientthroughtorecovery/post-anaestheticcareunit/ITUStudentB:@WStCCUWRShadowPerioperativeFellow-reportforhandoverat8am,level1.Officeatfarendofcriticalcareunit
Thursday: StudentA:PERRTteammorning@UCH:Peri-operativeRiskOnlineLearningpmStudentB:UCHPre-assessmentclinicam:Peri-operativeRiskOnlineLearningpm
Friday: StudentsA&BWestmorelandCriticalCareTeaching8am–reporttolevel1
Afterthisyoucandomoreofwhatyou’vemostenjoyed:attendtheatresformorethoraciccasesorseearoboticsurgery,followthepainnursesorfollowtheperioperativefellow,andmakesureyouhavecompletedyouronlinelearning!
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WeekD UCHTheatres
Checkthemedicalstudentrotaforsuitabletheatrestojoin(availableontheUCLAnaesthesiasite:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students)Trytojointheanaestheticteampre-assessingtheirpatientsbeforetheatrestarts.Contacts:DrRobertStephens,EducationFellow,AnaestheticSHOorRegistrar(bleep4300 and4600)ordutyAnaesthesiaConsultant(07944139718)Trytoattendsome“outoftheatres”lists,e.g.Endoscopyonlevel2tounderstandthechallengesofanaesthesiaoutsideoftheatrePleasealsofeelfreetoattendjournalclubwhichisonThursdaysat2.30pmintheanaestheticcoffeeroom.
AdditionalActivities
Duringyourtimehere,wecanalsoarrangeforyoutoattendorspendtimewiththefollowing:• PainTeam–usually2roundsaday(c9:30and1:30)• Obstetricanaesthesia• CPET:CardiopulmonaryExerciseTestinginSurgicalPreassessment/K-POD• CriticalCareinT3• Staylatewiththetheatre7teamonceuntil(eg2300)• Potentialtoseesomecardiacanaesthesia–pleaselettheEducationFellowknowifthis
issomethingyouwishtodoasapandwewillattempttoarrangeit
Tutorials
Tutorialsshalltakeplaceatdifferenttimesduringthe4weekswithdifferentsupervisorsandthedetailsshallbeemailedtoyou.Whicheverallocationyouareon,youshouldallprepare forandattendthetutorials.
Website:Wehaveawebsitewithasectionformedicalstudents,withdownloadableteachingmaterialaccessibleat:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students
IfyouhaveanysuggestionformoredownloadableteachingaidsorchangesintheSSM pleasedo contact Rob Stephens on robcmstephens@googlemail.com - we are always looking toimprove!
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PRE-OPERATIVEASSESSMENTLearningObjectives
! Realisetheimportanceofpre-assessmenttotheanaesthetist.
! AnunderstandingasyourroleasasurgicalFYinpre-assessment.
! Theabilitytorecognise,investigateandreferappropriatehigh riskpatients.
Pointstocover
• Anaestheticconsiderationsinthehistory• Fastingguidelines• ASAgrading• Importantanaestheticconsiderationsintheexamination• Airwayassessment• Premedication• Relevantpre-opinvestigations
Webresources:
YoutubePodcast:Anaestheticpre-operativeassessmentandthepre-operativevisit
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KeyTutorialLearningPoints
• Pre-assessmentbyAnaesthetistestablishestherapeuticrelationship
withthepatient,andallowsdiscussionofchoicesofanaesthetictechnique.
• Astructuredapproachshouldbeadopted(applicabletoallmedicalspecialties!)withattentiongiventothepatient’shistory,examinationandrelevantinvestigations.
• Particularattentionshouldbegiventotakingasystems-basedhistorywithemphasisondetectingconditionswhichmayinfluencetheconductofanaesthesia(especcardio/resp/renal/GI/musculoskeletal)
• Astandardphysicalexaminationformspartofallanaestheticpre-assessmentbutattentionshouldalsobefocusedontheairwayassessment.
• Investigationsmayincluderoutinebloods,ECG,CXRand/ormorespecialisedtestse.g.Echocardiogrambasedonpatientshistoryandphysicalexamination.
• OverallAnaestheticimpressionofpatientshealthgivenbyanASA(AmericanSocietyofAnaesthesiologists)gradeafterassessingpatient.
• AirwayassessmentshouldberecordedinbasicformbyaMallampatiscore,butmoreadvancedassessmentse.g.“Wilson’sscore”maybeusefulinthosewithasuspected“difficultairway”.
• Fastingguidelineswillgenerallybeoftheorderof6hoursforsolids(includesmilk)and2hoursforclearfluids.Thismaybealteredbydelayedgastricemptyinge.g,Pain,opiates,autonomicneuropathy.
• Pre-medicationislesscommon-placenowadaysbutstillusedincardiacsurgery,paediatricsandtheanxiouspatient.(Pre-medicationmayalsoincludeanalgesics,pro-kineticsandantacidsratherthanjustanxiolysis!)
• Referralforfurtherinvestigations/furtherassessmentshouldbebasedonapatient’smedicalstatusattimeofpre-assessment.
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Scenario1
Mr Tolu ALIKI a 65 year old gentleman is attending the pre-assessment clinic prior to hisscheduledrightinguinalherniarepairoperation.Hetellsyouthathehashighbloodpressureforwhichhetakesa‘watertablet’andthathegetsshortofbreathafterclimbing2flightsofstairs.HisBPtodayis170/87.He isa lifelongsmokerof20cigarettesadayandhasachronicproductivecough.He livesaloneinaflatonthe6thfloorbutcopesindependentlyforallhisactivitiesofdailyliving.Heisverykeentohavethisdoneasadaycase.Questions;
1) Ishisbloodpressureadequatelycontrolled?2) Whatarethecriteriaforpatientstobedoneasdaycases?3) Isheasuitablecandidatefordaycasesurgery?Why?4) Whatwouldyoutellhimaboutbeingdoneasadaycase?
1.
2.
3.
4.
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Scenario2MrMartinBruce,67 isa retired constructionworkerwhohas come in for a right totalhipreplacement.Hehasahistoryofchronicrenalfailureandhashaemodialysistwiceaweekathis local hospital. He has hypertension secondary to his renal disease but this is wellcontrolledon50mgatenololoncedaily.Questions;
1) Whatthreepreoperativeinvestigationswouldyouorderforhimandwhy?2) Whichhospitalteamsshouldbeinvolvedwithhisperi-operativecare?3) Shouldhehavepre-operativehaemodialysis?4) Whereshouldapatientlikehimrecoverpost-operatively?Explainyouranswer.
1.
2.
3.
4.
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AIRWAYMANAGEMENTLearningObjectives
! Reviseairwayanatomy
! Beablemanageanairwayusingsimplemanoeuvresandaids
! Anawarenessofthedifferentequipmentinvolvedinairwaymanagement
! UnderstandtheprinciplesinvolvedinendotrachealintubationPointstocover
• Airwayassessment• Facemaskventilation• Oropharyngealairways• Nasopharyngealairways• Laryngealmaskairways(LMA)• Endotrachealtubes(ETT)• Laryngoscopes• Gradesofintubation• Difficultintubations• Tracheostomy
Webresources:
• ‘TheAirway’• ‘Howtoinsertanemergencyairway’• UCLCentreforAnaesthesiaPodcaston ‘ManagingAirwayObstruction’on
youtubeAllinvia:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students
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KeyTutorialLearningPoints
1) Mallampatiscoreofbasicairwayassessment.
2) Recognitionofthosewithlikelydifficultairwaysi.ePre-existingconditions(AnkylosingSpondylitis,Rheumatoiddisease,thyroiddisease,morbidobesity)andacuteconditions(facialfractures,c-spineinjuries,epiglottitis.)
3) Basicairwaymanagement(headpositioning,jawthrust,
chinlift)
4) Simpleairwayadjuncts(oropharyngealandnasopharyngealairwaysandhowtosizethemforeachpatient).
5) Moreadvancedairwaysi.etheLaryngealMaskAirway
(LMA)andindications/contraindicationsfortheiruse.
6) Indicationsforendotrachealintubation(pre-existingconditions/typeofsurgery/acuteconditions).
7) Gradingsystemoflaryngoscopyandrelevancetofuture
anaesthetics.
8) “Difficult”airwaysexistandifanticipated,meticulousplanningmustbeusedtoensuresafeintubationoftheairwayi.eawakefibre-opticintubation.
9) A“failedintubation”drillexistsandallAnaesthetistsmust
befullyconversantwithit.
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Scenario1YouarehelpingaConsultantanaesthetistwitha68yroldmanwho isscheduled tohavealaparoscopichemicolectomyundergeneralanaesthetic.Heweighs98kgandis1.6mtall.Hehasapasthistoryofrefluxandofaduodenalulcerforwhichhetakesranitidine150mgbd.Otherwiseheisfitandwell.Hehasbeenappropriatelystarvedpre-operatively.Questions;
1) Whatproblemscanyouforeseewithhisairway?2) What threepiecesof airwayequipmentwouldyouprepare for use to anaesthetise
himandwhy?3) Whatairwaytoolsmaybeusefulinmaintainingapatentairwayonceheisasleepbut
notyetintubated?4) What twootherpiecesof equipmentwouldbeuseful for laparoscopic procedures?
Why?
1.
2.
3.
4.
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CONDUCTOFANAESTHESIALearningObjectives
! Anunderstandingoftheprinciplesinvolvedinadministeringgeneralanaesthesia
! Anawarenessofthevariousclassesofanaestheticdrugsused
! Anunderstandingoftheequipmentused
Pointstocover
• Monitoringrequirements• Induction• Rapidsequenceinduction• Maintenance• Wakeningthepatient• Criteriafordischargefromrecovery• Potentialproblemsinrecoveryandtheircauses• Post-operativenauseaandvomitingcausesandtreatment
WebResources
• ‘BasicsofAnaesthesia’atwww.ucl.ac.uk/anaesthesia/StudentsandTrainees/students
• RecommendationsforstandardsofmonitoringduringAnaesthesiaandrecovery:4theditionatwww.aagbi.org/publications/publications-guidelines/S/Z
• Podcaston‘ConductofAnaesthesia’-Youtube
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KeyTutorialLearningPoints
• Classesofanaestheticdrugs:Hypnotics,analgesics,muscle
relaxants.
• Minimumstandardsofmonitoringduringinductionofanaesthesia.
• Indicationsforrapidsequenceinduction(RSI)of
anaesthesia.
• Maintenanceofanaesthesia(Gaseousandintravenous).
• Depthofanaesthesiamonitoringand“awareness”duringanaesthesia.
• Wakingthepatientfromanaesthesia(awakeversusdeep
extubationandindicationsforboth).
• TransfertoITUforhighrisk/sickcases.
• Equipmentfortransfertorecoveryandmonitoringwithinrecovery.
• Treatmentofpost-opnauseaandvomiting(PONV)in
recoveryandcriteriafordischargefromrecoverytoward.
• “Analgesicladder”fortreatmentof acute post-operativepain.
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Scenario1
YouaretheA&ESHOoncall.MrNazımYılmazattendsA&Einfastatrialfibrillationwithaheartarateof168bpm.ThedutymedicalregistrarwantstoattemptDCcardioversionbackintosinusrhythm.Youtalktotheanaesthetisttoarrangeageneralanaestheticforthisprocedure.Heasksyoutosortoutsomemonitoringforthecardioversionprocedure.Questions:
1) Whatispurposeofmonitoringthispatient?2) Whatmonitoringmodeswouldyouliketocommenceonthepatient?3) Whatequipmentwouldhelpyoutoachievethis?4) Whataretheshortcomingsofeachofyourchosenmonitoringmodes?
1.
2.
3.
4.
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Scenario2
MsJuliaHarrisisa23yearoldballetdancerwhopresentswithasuspectedruptured ectopicpregnancy.You,thesurgicalSHO,areaskedtoassessherpriortohercomingtotheatreasanemergency.Whenyouseeheron theward she lookspale, sweatyand is ratherquiet.Herobservationsare:BP 80/40HR130SpO293%onroomair
Theanaestheticregistrarhasaskedyoutoputanintravenouslineintothepatient.
Questions;1) Whatfurtherassessmentwouldyouliketomakeonthispatient?2) WhattypeandsizeIVcannulawouldyouuseinhercase?3) WherewouldyouideallyplacetheIVcannulaandwhy?4) Namethreecomplicationsthatcanensuefromperipheralvenouscannulation.How
canthesebeavoided?
1.
2.
3.
4.
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Oxygen Delivery
Learning Objectives
! Anunderstandingofthevarioustypesofoxygendeliverydevice,theirapplicationsandlimitations.
! Revisedthebasicaspectsofrespiratoryphysiologyandrealised their
relevanceinclinicalpractice.
! Understood the causesof postoperativehypoxia andhavea rationale fortreatingthem.
! Anawarenessofthelungasarouteofdrugadministration.
! An awareness of the importance of humidification, pulmonary toilet and
physiotherapyinclinicalpractice.
Pointstocover
• Differentdevicescanbeusedtodeliveroxygen• Definitionofhypoxiaandclassification• Oxygencascade• Oxygencarriagebyblood• Ventilation/perfusionmismatchandshunt• Effectsofanaesthesiaonoxygencascade• Post-operativeoxygenrequirement
WebResources
• Article“Oxygendeliveryandconsumption”.
www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students• Podcasts-‘Hypoxia’and‘ABGinterpretation’
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KeyTutorialLearningPoints
• 4classesofhypoxia.(Cellular/cytotoxic,anaemic,stagnant
andhypoxaemic).
• Deliveryanduptakeofoxygentothepatientisbasedonbasicphysiologicalprinciples(oxygencascade,ventilation/perfusionandhaemoglobinuptake/delivery).
• Causesofhypoxaemiaunderanaesthesia(pre-existing
causesandfactorsrelatedtothetypeofsurgeryandanaesthesia).
• Waysofimprovingoxygenationunderanaesthesia(
increasedFIO2,effectsofPEEPandincreasingminuteventilation).
• Waysofgivingsupplementaloxygenontheward(Venturi
principles)andrecognisewhentorefertoITUforfurtherventilatorysupport.
• Howtoprescribesupplementaloxygenforwardpatients.
• Howtointerpretrespiratoryfailureonbloodgasanalysis.
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Scenario1
Youarehelpingtoanaesthetisea36yroldman,whoisfitandactivewithnomedicalhistory.Heishavinganelectiveinguinalherniarepair.Hehasundergoneanuneventfulgeneralanaestheticandhasbeenstablethroughout.At theend of theoperation the consultant anaesthetistwaits until he is awake and removes theLMA.Sheasksyoutoescortthepatienttorecovery.Onarrivalinrecoverythenurseasksyouaboutoxygentherapy.Questions;
1)Whydoesthispatientrequiresupplementaryoxygenintherecoveryroom?2) Howmuchoxygenwouldyougive?3) Howlongshouldhehavesupplementaloxygeninrecoveryandhowwouldyou
monitorhim?4) Whatdevicesareavailableforoxygendeliverytopatientsinrecovery?5)Whichdevicewouldsuithimbest?Why?
1.
2. 3.
4. 5.
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Scenario2You are bleeped toA&E to see an asthmatic girl.When you arrive you find the 16 yr old,Emily,lookingpale,sweatyandanxious.Sheisextremelyshortofbreathbutshemanages totell you her name and address. The nurses have put some monitoring on her and haveobtainedthefollowingvalues:Pulse120bpm Respiratoryrate35minBP140/90 SpO292%Questions;
1) Whatotherinformationwouldbehelpfulinassessingher?2) Whatisyourfirststepinhermanagement?Why?3) AnarterialbloodgasshowsherPaO2is8.5kPa.Isshehypoxaemic?4) Whatsubsequentstepsinmanagementwouldyouinstitute?5) Howwouldyouassessherresponsetotherapy?
1. 2.
3.
4. 5.
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1.
2.
3.
4. 5.
Scenario3Youareaskedyoutoseea78yroldladyontheward.Shewasadmittedtwodaysagowithaninfectiveexacerbationofherchronicairwaysdisease.Sheisnormallyonhomeoxygenandiswheelchairbound.Shehasnotimprovedwiththerapysofar.Youwanttotakeasetofbloodgasesonthiswomanon28%oxygen.Questions;
1) Howareyougoingtoensurethatsheisbreathing28%oxygen?2) Whyisitimportanttotakethebloodgasesat28%oxygen?
HerABGsare:pH7.39pCO28.0kPa,pO27.5kPa,HCO334,BE+2.4.
3) Isshehypoxaemic?4) CommentonthePaCO2andHCO3.5) Howmuchsupplementaloxygenshouldshenowhave?
1.
2.
3.
4. 5.
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Scenario4Cmdr Walter Smith is a 68 yr old retired naval officer who was a heavy smoker untilhestoppedtenyearsago.Hehasapermanenttracheostomysincehehadatotal laryngectomysevenyearsagoforacarcinoma.Hehasbeen admittedwitha chest infectionasa result of sputumretention. Hehasbeentreatedwith intravenousantibioticsandsupplementaloxygenviaatracheostomymask fortwodays.Althoughheisimprovingtheprogressisslow.Questions;
1) Whyissputumretentionaprobleminthiscase?2) Whatothertherapeuticmanoeuvresmayspeeduphisrecovery?3) Whyshouldhissupplementaloxygenbehumidified?4) Whatmethodsarethereforhumidificationofoxygen?
1.
2.
3.
4.
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PERI-OPFLUIDTHERAPYLearningObjectives
! Revisethebasicphysiologyofwaterandelectrolytecompositioninadults.
! Anunderstandingofthecompositionofvariousintravenousfluidsandbloodproductsavailableforuse,andtherationalefortheiruse.
! UnderstandtheNationalInstituteofClinicalExcellence(NICE)5Rsof
prescribingfluid
Resuscitation RoutineMaintenanceReplacement Re-distribution Reassessment
! Asimplerationaleforprescribingfluidtherapyintheperi-operativeperiod.
Pointstocover• Normalfluidbalanceanddistribution• Howthenormalbalancecanbeaffectedperi-operatively–inparticular
losses• IVfluidsandBloodproductscommonlyused• Howtoassessfluidbalanceincludingperi-operativeacutebloodloss
WebsiteResources
• BasicsofFluidandAnalgesia• Article:“Howtodo:BloodTransfusion”• Article:“HowtoprescribeFluidTherapy”• NICEGuidanceward-basedfluidguidelinesalgorithm2013• NICECompositionofFluids• NICEDiagramofongoingLosses• “Hypotension”–brieflearningsheet
Allfoundat:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students
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KeyTutoriallearningpoints:
• Distributionoffluidsintointracellularandextracellularcompartments.
• Understandhowfluiddistributionbetweencompartmentsrelatesto“Starling’sequation”(influenceofhydrostaticandoncoticpressures).
• Understandhowdiseasestatesinfluencethedistributionoffluidswithin
compartments(heartfailure,sepsis,nephriticsyndromesetc).
• Understandthedifferencebetweencrystalloidandcolloidsolutionsandhowtoprescribefluidtherapyforthepost-oppatient.
• Understandindicationsforbloodtransfusionperi-operativelyandhazardsof
transfusion.
• UnderstandtheuseofbloodproductssuchasFreshFrozenPlasma,platelets,cryoprecipitateinthetreatmentofperi-operativecoagulopathy.
• Understandclinicalassessmentoffluidbalanceintheperi-operativepatient(
BP,pulse,capillaryrefill,jugularvenouspressure,urineoutput)andhowtoresuscitatethehypovolaemicpost-oppatient.
• Understandthatfluidadministrationmaybeguidedbyinvasivemethods
(centralvenouslinepressuremonitoring,oesophagealDopplercardiacoutputassessment)inthecriticallyillpatient.
• Understandtherelationshipbetweenguidedfluidadministration(i.eviacentral
venouspressuremonitoring)andcardiacoutput:Starling’slaw
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Scenario1
MrsKiranBalhasbeenadmittedwithsuspectedcholecystitis.Sheistoreceiveanalgesiaandundergo further investigations.She is to be kept nil bymouth until the investigations arecomplete.Sheis1.56mtallandweighs80kg.Shehasnosignificantpastmedicalhistory.
Questions;
1) Whatareherestimatedintra-vascularvolume,extra-vascularvolumeandtotalbodywater?
2) Whatisherlikelymaintenancefluidrequirement?Howdidyoucalculateit?3) WhattypeofIVfluidswouldbebestformaintenanceinhercase?4) Writebelowanappropriatefluidregimeforherforthenext12hoursbearinginmind
yourpreviousanswers.
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Scenario2
Mr John Wilson is a 58 year old gentleman who had an elective hemicolectomy thisafternoon.Heisonthepost-operativesurgicalwardbuthasnothadanyIVfluidsprescribedforhim.Thewardsisterasksyoutoprescribehimsomepostoperativefluids.Questions;
1) Whatfurtherinformationyouwouldlikeaboutthispatient?2) Howwouldyouestimatehislikelyfluidstatus?3) Whatwouldyouexpectthisfluidstatustobeandwhy?4) Ishelikelytohaveanelectrolyteimbalance?Ifso,whatandwhy?5) Onthechartbelowprescribearegimeforthenext24hours.
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Scenario3
Dr Jane Summers is brought intoA&Ewith amassiveante-partumhaemorrhage. She tellsyouthatshewoketofindthebedcoveredinblood.Accordingtotheparamedicsshehaslostatleastafurther2litresofbloodintheambulance.Asyouaretakingahistoryfromhersheisbecomesvagueandgoesquiet.Youcanonlyfeelveryafeebleradialpulse.Questions;
1) Whatwouldyourfirststepinhermanagementbe?Why?2) Howwouldyoucalculateherpercentagebloodloss?3) WhatIVfluidswouldbebesttoimmediatelyreplacethelostvolumeandwhy?4) Howmuchfluidwouldyougiveherandhowfast?5) Howwouldyouascertainwhethersheneedsabloodtransfusion?
1.
2.
3.
4. 5.
35
Scenario4
MrsRoseAcornisa64yroldlady,weighing75kg,whohadatotalabdominalhysterectomyyesterday. Her postoperative haemoglobin (Hb) is 7.6g/dl today. Previously her Hb was13.5g/dl.Shewaswellpreoperativelyandhasnospecificcomplaintsatpresent.Questions;
1) Howcanyouestimateherbloodloss?2) Doyouthinksheneedsabloodtransfusion?Explainyourreasoning.3) Howwouldyouobtainbloodfortransfusionifyourequiredit?4) Nametwocomplicationsassociatedwithbloodtransfusions.5) Whatthreeprecautionswouldyoutakebeforeadministeringbloodtoanypatient?
1.
2.
3.
4.
5.
36
PAIN&ANALGESIALearningObjectives
! Revisethephysiologyandpharmacologyofpain
! Understandhowtoprescribeeffectiveanalgesia
! Basicknowledgeofacutepainmanagementinperi-operativepatients
! Understandingofyourdutyasadoctorinprovidingeffectiveanalgesia.
Pointstocover
• Painreceptors• Painpathways• Analgesicladder• Mechanismofactionofparacetamol,NSAIDs,codeine, tramadol,
morphine• Mechanism of action of gabapentin, ketamine, TENS, local
anaesthetics• Side-effectsofthedifferentanalgesics• Patient-controlledanalgesia• Epiduralanalgesia
WebResources• Article:“HowtoprescribePerioperativeAnalgesia”• Article:“HowtolookafteranEpiduralontheWard”• Podcast:“Mechanism of Acute Pain”
Allfoundin:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students:
37
Keytutoriallearningpoints
• Painmaybetargetedatanypointinafferentpathwayfromperipheralreceptortohighercorticalcentres.
• Understandbasicclassesofanalgesics(NSAIDS,opiates,paracetamoland
adjunctsi.eketamine,amitryptiline,gabapentin).
• Allanalgesicshaveside-effectsandanalgesiamustbetailoredtotheindividualpatient.
• An“analgesicladder”shouldbeconsideredinthepost-operative
treatmentofpainforallsurgicalpatients.
• Painmayalsobecontrolledpost-operativelybyperipheralnerveblocksorcentralneuroaxialblocks(epiduralorspinalinjections)performedbytheAnaesthetistintheatre.
• Centralneuroaxialblock(spinal,epidural)havecontra-indications
incertainpatientsandconditions.
• Patient-controlledanalgesia(PCA)mayprovideanalternativeformofanalgesiawherepainissevereorifneuroaxialblockhasbeenunavailable.
• Epiduralanalgesiashouldbemonitoredcloselypost-operativelyforsigns
ofneurologicalcompromisewhichcouldindicateepiduralabscessorhaematoma,whichareemergenciesrequiringimmediatetreatment.
• Anypatientreceivingopiateanalgesiashouldbemonitoredfor
respiratorydepressionandknowledgeoftheadministrationofnaloxoneforrespiratoryopiate-sensitivityshouldbeheldbyalldoctors.
39
Scenario1
Youarereviewingpatientsonthepost-operativeward.YouareseeingMrRogerEvanswhohad an appendicectomy earlier today. He is to remain nil by mouth on IV fluids for thenextfewdays.Hehasnosignificantmedicalhistory.Questions:
1) Whatanalgesiawouldyouprescribeforhimfortoday?2) Whatisananalgesicladder?Howaretheyusefulinpainmanagement?3) WhatanalgesiawouldyouprescribeforhimonDay3postoperativelyandwhy?
1.
2.
3.
4.
40
Scenario2
MrsAbeoKuti , 78yrsold, is scheduled tohavea left total knee replacement forosteoarthritis.Sheisveryworriedaboutpostoperativepain.Shealreadytakescodydramoland‘ibuprofen’regularly.Sheasksyouaboutoptionsforpost-operativepainrelief.Questions;
1) WhatareCodydramoland‘ibuprofen’?Howdotheywork?2) Wouldthesedrugsbehelpfulinmanagingherpost-operativepain?3) Whatotheragentsandoptionswouldyoutellheraboutformanagingpost-operative
pain?4) Whataretheadvantagesanddisadvantagesofeachofyouroptions?5) WhichoptionsdoyouthinkwouldsuitMrsKutibest?
1.
2.
3.
4.
5.
41
Peri-operativeComplications,RiskandSafety
Learningobjectives:• Understandtheincidenceofmortalityandmorbidityassociatedwith
surgery
• Recognizetheimportanceofidentifyingkeyriskfactorsforpost-operativecomplicationsinapatient’spastmedicalhistory
• Theabilitytoidentifykeyopportunitiestopreventpost-operative
complicationsinthepatientjourney
• Specificandassociatedcomplicationsofanaesthesiaandsurgery
• UnderstandtheconceptofEnhancedRecoveryAfterSurgery(ERAS)pathways
• UnderstandtheconceptofRisk&CommunicatingRisktopatients(Online
Course-Week3)
• Scoringsystemsforriskinanaesthesiae.g.P-Possum,SORTsurgery(OnlineCourse–Week3)
• Definitionofa“NeverEvent”inaccordancewithNHSEnglandassociated
withAnaesthesiaandSurgery(OnlineCourse-Week3)
42
PointstoCover• Riskfactorsforperi-operativehaemorrhage• Definitionofoliguriaandclassification• Causesofpost-operativepyrexia–“thesevenCs”• Classificationofpost-operativeinfections• Virchow’striadandWellsScoreinDVT/PE• Effectsofanaesthesiaandsurgeryonbowelfunction• Post-operativedelirium• RoleofchecklistsinSaferSurgery• ERASpathwaymodel
WebResources• Article“IntroductiontoPost-operativeComplications”
www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students
• OnlineCoursetobecompletedduringWeek3:PerioperativeRiskandSafetyforMedStudents,www.versal.com,accessedviaGoogleChromebrowser.Passwordstocoursesupplied:contactcfrith@doctors.org.ukifyoudonotreceiveyoursbyWeek3.
44
BASIC&ADVANCEDLIFESUPPORTLearningObjectives
! RevisethecurrentBasicLifeSupport(BLS)andAdvancedLifeSupport(ALS)guidelines
! Anunderstandingoftheaetiologyandoutcomefromcardio-respiratory
arrest
! An understanding of the differences in BLS andALS algorithm for adultsandchildren
! Anunderstandingoftheuseofadefibrillator
! Arationalefortheuseofdrugsincardio-respiratoryarrest
Pointstocover
• BLSandALSalgorithms• Paediatricresuscitationguidelines• Reversiblecausesofcardiacarrest• Anaphylaxismanagement• Drugsusedinresuscitation
Webresources:
• ALS:www.resus.org.uk/pages/als.pdf• BLS:www.resus.org.uk/pages/bls.pdf• PaediatricBLS:www.resus.org.uk/pages/pbls.pdf• PaediatricALS:www.resus.org.uk/pages/pals.pdf
47
Scenario1
Youarealoneonatrainplatformapartfromanelderlymansittingaloneonabench.Suddenlythemanclutcheshischestandslumpsoffthebenchtothefloor.Questions;
1) Whatshouldyoudointhefirstinstance?2) Ifheshowsnoresponsetoyourinitialactionwhatisthenextstepyoushouldtake?
Whatistherationaleforthis?3) Whatdetermineshowlongshouldyouremainwithhim?4) Whatwouldyouaskthefirsthelperonthescenetodo?5) Whatisthesurvivalratefor‘outofhospital’adultcardiacarrest?
1.
2.
3.
4. 5.
48
Scenario2
Youareoutsideanewsagentwhenashoutforhelpfrominsidetheshopcatchesyourattention.Intheshopyoufindayoungboyappearstobechokingandisblue.Youcanfeelapulseofaround40bpm.Questions:
1) Whatisthefirstthingyouwilldo?Why?2) Isthereanyusefulassessmentyouwouldmakeatthisstage?
Helosesconsciousnessandstopsbreathing.Youcanstillfeelapulseof40beatsperminute.TheshopassistanthandsyouthefirstaidboxandtheAED.Theambulanceisthreeminutesaway.
3) Whathelpwouldyourequestfromtheassistantandbystanders?4) Whatinformationwouldyougivetotheambulancecrewwhentheyarrive?5) Whatfurtherhelpcantheambulancecrewsupplyontheirarrival?
1.
2.
3.
4.
5.
49
Scenario3
Youarethemedicalhouseofficeroncallatyourhospital.WhilstontheCoronaryCareUnitMr. Cesar Frank,who you admitted last nightwith unstable angina, collapses. The cardiacmonitorshowshimtobeinventricularfibrillationandheisunrousable.Questions:
1) Whatwouldyoudofirst?2) Whathelpandequipmentwouldyouaskfor?3) YoudecidetogivehimDCshocks.After2DCshocksheremainsin ventricular
fibrillation.Whatdoyoudonext?4) Wouldyougivehimanydrugs?Ifso,whichonesandwhy?5) WhatarethecurrentUKsurvivalratesfor‘inhospital’,witnessedcardiacarrest?
1.
2.
3.
4.
5.
50
Scenario4Youarethemedicalhouseofficeroncall.Thecardiacarrestbleepgoesoff.Youhavebeen inpostfor5monthsandthemedicalregistrardecidesthatyoushouldleadthenextarrestaspractice.YouarecarryingouttheALSaccordingtocurrentprotocol.Duringthearrestthepatienthasthesethreerhythms.Questions:
1) Identifyeachrhythmandstatehowyouwouldcontinuewithresuscitationfaced witheachrhythm.
2) Regardingrhythm1,whatassessmentwouldyoumakeofthepatient?Why?3) Regardingrhythm2,whatdrugswouldyouuse?Why?4) Whatinvestigationsorassessmentwouldyoumakeifthepatientwasinrhythm3
Rhythm1:
Rhythm2:
Rhythm3:
51
Scenario5Youareattendingapaediatriccardiacarrest inA&Eyouhavehad2attemptsatperipheralintravenous canulationwithno success. The2year old child still doesnothaveapalpablecardiacoutput.Questions:
1) Whyisitimperativetoobtainvenousaccess?2) Whatothermodeofaccesscouldyouorthepaediatricteamattempt?3) Whataretherisksassociatedwiththisprocedure?4) Canyousubsequentlygivedrugsthroughthisroute?
1.
2.
3.
4.
52
SICKPATIENTSCENARIOSLearningObjectives
! Revisebasicaspectsofrespiratory,renalandcardiovascularphysiology
! Recognizetheimportanceofbasicphysiologicalmonitoring
! Theabilitytorecognizeunwellpatients
! Astepwiseapproachtothemanagementofthecriticallyunwellpatient
! Knowledgeofwhen,howandwhotorefercriticallyillpatientstoPointstocover
• Shock• Sepsis• Hypoxia• HowtointerpretArterialBloodGasses• GlasgowComaScore
WebsiteResources
• Article“recogniseCriticalIllness”• Briefdocument:“BasicsofIntensiveCare”• Briefdocument:“BasicsofRenalfailure”• Podcast“recognisingthecriticallyillpatient’
www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students
53
KeyTutoriallearningpoints:
• Takingabasichistory,examiningthepatientandrequestingpertinent
investigationsallowsidentificationofthecriticallyillpatientinneedofsupportfromIntensiveCare.
• ManywardpatientssubsequentlyrequiringadmissiontoITUwillhave
demonstratedseveralhoursofdeclineintheirwardobservations.
• Basicphysiologicalwardscoringsystems(NEWSetc)havebeendevisedtoallowearlyidentificationofpatientdeteriorationandsubsequentreferralforprompttreatment.
• ITUmayprovidesingleorganormulti-organsupportforpatientsunableto
respondtosimplemeasures(i.efluidresuscitation,supplementaloxygenetc)ontheward.
• IntensiveCarepatientmanagementisbasedonasystems-basedmodelwithstrict
attentionpaiddailytopatientCVS,Resp,GI,Renal,Neuro,Microbiologicalandpharmacologicalparameters.
• Inadditiontobasicobservations,patientsmayreceivemoreinvasivemonitoring
toguidetherapysuchasarterialbloodpressurerecording,centralvenouspressurerecordingandcardiacoutputmonitoring(OesophagealDoppler,thermodilutorymeasuresi.epulmonaryarterycatheterdevices).
• Circulatorysupportoftenrequirestheuseofinotropesand/orvasopressorsanda
thoroughunderstandingofcardiacphysiologyandpharmacologyiscentraltopatienttreatment.
55
Scenario1
Awomanwhoappearsinher40’swasfoundonthestreetunconsciousandbroughtinbyanambulance.Whenyouseehersheislyingonherbackinresus.Sheisunkemptandsmellsofalcohol.Sheopenshereyeswhenyousqueezeher fingernailsbutpullsherhandawayandgroansincoherently.
Herobservationsare,BP140/90,P110,SpO296%,RR8andT35.8C.
Questions:1) WhatisherGlasgowcomascore?Whyisthisassessmentrelevant?2) WhatwouldyoudoinresponsetohavingassessedherGCS?3) Whatassessmentandinformationwouldbeusefultoyou?4) Whatdoyouthinkisthemajorproblemwithher?5) Whatshouldthenextstepinhermanagementbe?
1.
2.
3.
4. 5.
56
Scenario3
Scenario2YouarethesurgicalFY1whoisaskedtoseeoneofthepost-operativepatientsbythenursingstaff. He is a 72-year-old man who had a laparotomy for an elective resection coloniccarcinomathreedaysago.HeremainsnilbymouthandhasbeenhavingIVfluidssincetheoperation.Whenyouseehimheisdrowsyandcannotrememberwhatdayitis.Hisobservationsare;BP80/60,Pulse120,SaO294%onair,Resp28andTemp38.6oC.Questions:
1) Onthisassessment,whatarethemainissueswiththispatient?Isthereanythingthatyoushoulddoimmediately?
2) Whatotherinformationandinvestigationswouldbehelpful?3) Whatdoyouthinkisthelikelydiagnosis?4) Whatisthispatients’qSOFAscore?5) Doeshehavesepsis?6) Whereisthepotentialsourceofinfection?
1.
2.
3. 4.
5.
57
Scenario3You are asked to see a 62 yr old man who had an elective total knee replacement doneyesterday morning. He has no urinary catheter in situ. He is bed-bound because of theoperation andhas thereforebeingusing abottle. Thenursing staff are concernedbecauseaccordingtothe24hrfluidcharthehasonlypassed68mlsofurine.Questions;
1) Whatisthe24hoururineoutputexpectedtobeinahealthyadultman?2) Givethreepossiblereasonswhythecharted24hoururineisonly68mlsinthisman?3) Whatinvestigationswouldhelpyoutofindoutthecause?4) Doesheneedacatheter?Explainyourreason.5) Howwouldyouensurethathehasagoodurineoutputinthesubsequent24hours?
1.
2. 3.
4.
5.
54
Scenario4YouareaskedtoseeMrsFlorenceHarper,a78-year-oldwoman.Shehasbeenadmittedwithbreathing difficulty. She has been increasingly short of breath for four days and has beendiagnosedwithachestinfectionandhasstartedantibiotictherapy.Whenyouseeheronthewardshelooksdistressed,herobservationsare,BP150/90,Pulse92,Resps20,andTemp36.8oC.HerarterialbloodgasonairshowspH7.36,pCO24.5kPa,pO27.8kPa,Bicarb34,BE2.0Questions:
1) IsMrs.Harperhypoxic?Explainyouranswer.2) Whatshouldyourfirstinterventionbe?Why?3) Arethereanyfurtherinvestigationsyouwouldaskfor?4) Howcouldyouassessifyourinterventionwasmakinganimprovementinher
condition?5) Doessheneedventilatoryassistanceatthisstage?Towhomshouldshebereferred?
How?
1.
2.
3.
4.
5.
Things todo in theatre thatwillmakeyouamoreconfidentandcompetentMedicalstudentAND….FY1.Therearelotsofopportunitiesduringcasesintheatreforyoutolearn/practicesomeskillsthatwillbeinvaluableforyouinfinalsandmakeyouabetterFY1!
• DOasktoperformcannulationsonasleeppatients.ThereisnobettertimetolearnthisessentialskillbeforeyoufindyourselfoncallasaFY1.
• If thepatient requiresurinarycatheterizationdotakethisopportunitytolearn(getpatientconsentfirst!).
• Look at the different types of IV cannulae, their gauge andmaximumflowrates(hasbeenaskedinfinals).
• Discuss blood gas results and define respiratory and metabolicacidoses/alkaloses.
• Look at common IV fluids given in theatre and discuss theconstituentsofcrystalloidsandcolloidswiththeAnaesthetist.
• DiscusswiththeAnaesthetisthowbloodisprescribedandadministeredandhowitisrequestedinemergencysituations.
• Fillinaroutineprescriptionchartfortheward.Gothroughprescribinga sliding scale for insulin and how to prescribe warfarin andantibiotics(whichwouldneedmonitoringoflevelssuchasGentamicin).
• Discuss prescription of “maintenance” fluids for a ward patient andwhatfluidstoprescribefor“fluidresuscitation”.
• Discuss DVT prophylaxis for the surgical patient and prescribe it onthedrugchartwhereappropriate
• Set up monitoring for transfer of a critical patient and practicetransferringpatientstorecovery.
• Discuss prescription of post-opoxygen for the surgical patient. Relateoxygen prescription to pre-existing conditions i.e COPD. Look atdifferentdevices(i.eVenturimasks)forgivingoxygen.
• Prescribe post-operative analgesia and discuss the “pain ladder” ofanalgesicprescription.
PROCEDURESCHECKLIST
Procedure Seen Done SupervisedbyAirwaymanoeuvres/maintenance.
Bagvalvemaskventilation
InsertionGuedelairway
Insertionnasopharyngealairway
InsertionLMA
Oraltrachealintubation
Nasalintubation
Fibre-opticintubation
Rapid-sequenceinduction
InsertionNGtube
IVcannulation:22G20G18G16G14G
Arterialline
Centralline
Runthroughfluidgivingset
PreparationIVdrugs
PreparationIVdruginfusions
Attachandstartmonitoringpre-induction
Aseptictechniqueforprocedures
Pre-opassessment
Spinalanaesthetic
Epidural
Nerveblock
WHOchecklist
Cardiacoutputmonitoring
Intra-hospitalpatienttransfer
Cardiacarrest
ATTENDANCECHECKLIST
Week1 Location SupervisorsignatureMonday
Tuesday
Wednesday
Thursday
Friday
Week2 Location SupervisorsignatureMonday
Tuesday
Wednesday
Thursday
Friday
Week3 Location SupervisorsignatureMonday
Tuesday
Wednesday
Thursday
Friday
Week4 Location SupervisorsignatureMonday
Tuesday
Wednesday
Thursday
Friday
Tutorial SupervisorsignaturePre-opAssessment
AirwayManagement
ConductofAnaesthesia
Peri-opFluidTherapy
OxygenDelivery
PainandAnalgesia
Peri-operativeComplications
BasicandAdvancedLifeSupport
SickPatientScenarios
CASEBASEDDISCUSSIONStudentName:
Module:Date:AssessorGrade: Cons
SpR
TrustGrade SHO PRHO
Setting: OPClinicPatient: Age:
IPSex:
A&E GPsessionM F
Pleaseusethemarkingguidetohelpwithyourassessment Belowexpected
standard(tick)
Achievingexpectedstandard(tick)
Exceedingexpectedstandard(tick)
Domain 1 2 3 4 5 6 NotassessedHistory
Examination
DiagnosisandManagement
Overallclinicaljudgement
Insightintoaspect(s)ofcase
Recordkeeping
TotalMark:Pointsofgoodperformance:
Pointsforaction:(pleaseindicatespecificproblemsifassigningamarkof1-2)
Signed: Assessor Student
Bysigningthisform,theassessoraffirmsthatthestudenthasbeengivenfeedbackandthestudentagreesthathe/sheagreeswiththeresultoftheassessmentandthefeedbackgiven.
1 2 3 4 5 6
History Verydeficient incontent
Lackingindetail Systematic.Fewomissions
Good.Allaspectscomplete
Verygooddetail Superbandcompletelyaccurate
Examination Unableto elicitordescribeanyfindings
Unabletoelicitordescribemany aspects.Manyomissions
Relevantexaminationperformedbutwithfewomissions
Goodexaminationwithgoodunderstanding
Verygood andableto discussmeaningofabnormalityeasily
Excellent.Completeunderstanding oftheexamination
Diagnosis /management
Noattemptmade
Onlylimiteddiagnosis,differentialormanagement
Adequate.Identifies majorprobablydiagnosesandmanagement
Good. Identifiesmost probablydiagnosesandmanagement
Verygood.Identifiesallprobablydiagnosesandmanagement
Excellent. Identifiesallprobablediagnosesandmanagement withcompleteunderstanding
Overalljudgement
Nounderstandingofpatient’sdiagnosisorproblems
Limitedunderstandingof patient’sdiagnosisorproblems
Reasonableunderstandingofpatient’sdiagnosisorproblems
Goodunderstandingofpatient’sdiagnosisorproblems
Verygoodunderstandingofpatient’sdiagnosisorproblems
Completeunderstandingofpatient’sdiagnosisorproblems
Insight /reflection
Noreflectionundertaken
Reflectiveaspectconsidered verybriefly
Abletodiscussareflectiveaspect
Goodinsightintoa reflectiveaspectofcare
Detailed insightintoa reflectiveaspectofcare
Comprehensiveandprofoundinsightintoareflectiveaspectofcare
Recordkeeping
Deficientincontent withmanyomissionsorillegible
Lackingin detail.Notsystematic
Coversmainpintsand nomajoromissions
Gooddetail andnoomissions
Verywellrecorded andclearly aboveaverage
Superb,excellentandcomprehensive
FEEDBACKFORMDateofModule:
Week Rating1-5(5Excellent1Poor)
Comments
UCHMainTheatres
UCHEmergencyTheatre
PerioperativeWeek
QueenSquare
Tutorial Rating1-5
(5Excellent1Poor)Comments
Pre-opAssessment
AirwayManagement
ConductofAnaesthesia
Peri-opFluidTherapy
OxygenDelivery
PainandAnalgesia
PerioperativeComplications
LifeSupport
SickPatientScenarios
Whatwasthebestthingaboutthismodule?
Whatwastheworstthingaboutthismodule?
Isthereanythingyouwouldhavewantedinstead?
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