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Thank you everyone who's showing up for today's session. Um Today we're having doctor G here to speak to us about um pre peri and postoperative care from the point of an anesthetist. Um, personally, I think it would be a very, very interesting session as it's something that's not really covered much in med school. Um Hope you'll enjoy it if you have any questions, just make sure to pop it in the chat box and we will kind of um stop and check in the middle of the session just to make sure your questions are answered. Um Thank you. Yeah, thanks for that. Um I'm Adrian, so I'm uh an anesthetic school trainee at hull er, at the moment. And uh yeah, this talk is basically on per care. Um So the pre the peri and the post and it's kind of coming from an anesthetist perspective. What I'll do is I've got three sections. It's gonna be a little bit of interactive stuff in there as well. So hopefully it's not gonna be death by powerpoint at 6 p.m. on a Wednesday. Um, and then after recession a session, sorry, I'll, I'll pause and if there's any questions and I'm obviously happy to take them and then at the end as well. So that further ado, so that's what we're going to be covering a few Bs as well, but nothing too scary or long, I promise. All right. So preoperative care. Now, hopefully with the power of mental meter, you can ping some words into a word cloud about what you think um because I'm constitute preoperative care. So what happens before a patient goes for an operation? So I'll just see if this works. I don't know if we're gonna get any responses. So if you either use a QR Code or if you use a code or menter, it should come up see if it works. Don't seem to be getting any responses. Ok. Uh So for those of you in oh hang on. Oh amazing. Oh yes, it is working wonderful. Yes. Medication reviews. Absolutely. Patient details. Yeah. Do we have any more coming through? Honestly? There's like basically no wrong answers. Patient details. Swabs. Yeah. Um ok. Yeah, definitely in your investigations. Yeah. A sa someone said very good. We'll be talking about that. Um meds review 100%. Yes. Anything else history? Yes. Thank you. Someone's put history as well which is probably like possibly the largest part um looking at airways. Yeah, perfect. Perfect. Really good stuff. Yeah. Keeping patients in by mouth who'll come on to talking about fasting rules as well. Brilliant. Yeah, great. I think you guys have yeah, covered it really well. So essentially, yeah, purpose of pre op assessment is thinking about the patient thinking about the procedure, the environment that it's happening in and then we come in and have different anesthetic techniques available. So we ask, which is the safest way of going about this. So literally, it's it is the analogy between like anesthetics and flying an airplane, it comes off over and over again with with a reason. So it is literally, can I take off safely with this patient? Can I fly them? And then I can I also basically reverse what I've done to them. So can I safely then land them? So that is the whole purpose of preoperative assessment. So you've got your general side of things, your history. So you presenting complaint ie in this case, the reason for surgery. So that's always really important. Um why the patients coming in and basically is a surgery going to be elective acute or emergency. So that's always really important to consider. Is it long term or short term problem that's led to their operation? Is it chronic? Is it et cetera? So basically, the acuity is really important to understand um past medical and surgical history. So I'm not going to go into this in great detail because I'm sure all of you guys know how to take a full past medical and surgical history. But just to point out the things that are particularly of interest to us as anesthetist. So any inherited acquire conditions, any previous procedures that involve head, neck airway, right lungs. So anything to do with cardio respiratory system is of interest and especially things like radiotherapy or surgery as well, because anything that sort of causes scarring or tethering of tissues and then also nerve conduction problems will be of interest to us because we use muscle relaxants and finally, things like arthritis. So, so basically, is it safe to maneuver the patient's neck when we do our railway procedures? Um medications someone mentioned? Definitely. So the the ones again, of most interest to us are cardiorespiratory me anticoagulants because there's rules around stopping them diabetes, meds and steroids as well. Um And then allergies and type of reaction as well as then any premedication that the patient's been being given and social history. What we we're really interested in is a patient's normal day to day activity. So, so this is think about your um things like um frailty scoring. Ok. So how does the patient function baseline? And also if they've had any problems with recent mobility, what is a resuscitation status? You know how they got respect forms, et cetera. But then also, obviously the the more salient things such as smoking, alcohol and recreational drugs. And again, that's really important to us because especially the latter two, you need typically, for example, an increased anesthetic dose to meet the requirements and then specific to the anesthetic history. So past anesthetic history, previous general local anesthesia, general, regional or local anesthesia, um previous history of postoperative nausea, nausea and vomiting. So P OB any Avis or difficulty waking up awareness. So really anything that went wrong with their anesthetic and then also previous issues with their airways as well that had been pointed out to the patient afterwards or, or if they themselves know that there had been an issue, family history wise, we were interested in inherited conditions. And then again, if they've had typically a first degree relative who's had any adverse effect from an anesthetic, because um things like malignant hyperthermia and suxamethonium apnea can run in families. So again, I'm not going to go into this in too much detail, but essentially, there are certain familial conditions someone else had. We would definitely want to know about it. And then in system review, again, we have a huge focus for us on the cardio respiratory system, always asking about pregnancy as well. And then we want to know about any gastroesophageal reflux because that tells us how we're going to secure the airway if the patient suffers from it and then period of starvation. So this is again, someone mentioned it six hours for solids and then two hours for clear fluids. Although typically this is starting to change a little bit, some guys might work a trust where on surgical or will work or will have been on placement, trust where they have sort of sip til send kind of signs up around surgical wall, that just means a bit of water, sipping away until they get taken down for surgery or taken to the theater for surgery is fine as well. So it's a bit of shift on that. So, examination wise, so yes, airway is definitely where we start. So we want to have a look inside the mouth always. So this is the ma and PA score and essentially um none of these scores in, in themselves are indicative of unnecessarily how difficult the patient's airway is going to be, but sort of putting it together gives you an image. So ma and PA is kind of where you start and you look at if the patient fully opens their mouth, how much of essentially the back of the mouth um or the back of the um larynx you will be able to see. So class one is a really clear view, full view of the uvula. Class two is typically a um full view of the uvula, but obviously less. So you can see that and the distance that you're getting between the tongue and the uvula is less. And then class three is only the base of the uvula. And then sort of class four, you're only seeing the soft pallet light at the top of the mouth, you're not seeing the uvula at all. So again, that's kind of a worrying sign in terms of being able to see their airway and manipulate the airway and intubate mouth opening. There is a screen sharing kind of pop up at the bottom that so just brought up. Could you just click hide? Oh, sure. Sorry. Yeah, absolutely. Sorry about that. Thank you. So, yes. So mouth opening again, if, if you can imagine if someone's got like for example, TMJ dysfunction is a function of the, of the joints, either side of the mouth and they're not able to open their mouth beyond like typically two finger widths is what we, what we look at as a, as a bare minimum. So again, that would be quite worrying um if they've got dentition problems, so a lot of people have poor dentition or just sort of um missing teeth, wobbly teeth. So again, you don't want to damage that. Um if we've touched on it previously, the patient's got arthritis. So the head and neck movements, you know, you can't really manipulate the head for fear of damaging anything. So that's an issue as well and also receding jaw. So all of these things put together. So these are sort of just to illustrate some of the um aspect of the patient that we would worry about when it came to their airway. So anything from sort of massive, massive lumps to the lady in the picture with the receding drawers is definitely something that we worry about b teeth or dentition. Um obesity, especially centralized or pressing up towards the neck, short neck and, and that's actually in the bottom right corner picture of Quincy. So there is a small abscess at the B but also very, very prominent tonsils. So all of these things put together, tell us about how sort of difficult or easy it might be to manipulate and um and the instrument, the airway further examination. So we are interested in BMI but more than BMI, we're interested in body habits. So for us, it's more about how it distributes. So for example, you can have someone who's pregnant, but you know, their BMI isn't necessarily all that high, but because they're late into their stage of into their pregnancy, they'll have quite prominent breast tissue and obviously, they've got baby bump as well. So just all of that will be pressing up towards the neck. So you can imagine that that that might be something that we would worry about and we're trying to intubate any associated cardiovascular disease go from sort of metabolic syndrome from BMI would be something that would worry about the airway problems and difficulty with venous access as well. So there's a number of reasons why we're interested in the BMI, but more than the BMI, which is a bit antiquated really is the body habit is that we're looking at and then finally, systems again, I'm not gonna go into too much detail on this cardiorespiratory narrow as needed. Um Investigation wise, obviously, you've got uh bloods, definitely. So, hematology wise, full blood count clotting and then I've put up a picture of uh Teg, so Teg er stands for thromboelastogram and some of you might have seen this and work with it. But it's actually a really, really helpful tool that takes a little blood samples, pokes a little needle in it and then essentially like aggregates the blood sample around it and you get this nice sort of wine glass shaped readout and the different, the different sort of segments of that wine glass correspond to different deficiencies in clotting. So it's much more um um if, when you have something like a major hemorrhage, it's much better at telling you what the patient in front of you there and their knees or what their actual functional coagulation status is like as opposed to, you know, what you just get from your A PTTP T, you know, cova sample that you send off to the lab. So this is becoming more and more prominent across hospitals and, and definitely in the northeast at work. So you guys might come across it as well, but basically as a table suggests. So if there's a problem with our time, you want to be giving the patient F FP K time and alpha angle cryoprecipitate. Um And then sort of looking at the amplitudes, you'd be doing platelets or the lysis time you'd be treating with thic acids. It's a very neat way of figuring out what a patient who's blood needs in terms of products, um biochemistry wise. So obviously, liver and renal function, we're interested in electrolyte imbalances. And these are not just potassium and sodium, but we also tend to look at calcium magnesium phosphate. So sort of the whole range of them and then obviously glucose as well, especially in patients with diabetes, ECGS echo. So again, pretty self explanatory and preexisting, arrhythmias, ischemia, pacemaker, Alvear disease. All of those bits we'd be interested in if, if relevant imaging wise, again, same goes and then more and more these days, we're tending towards performing CPE testing. So CPE is a form of in vivo functional cardio respiratory testing. So basically, we take patients with them on a on a sort of indoor bike like an ergometer and just say, you know what their sort of two max is or what they tend towards and it correlates quite well with sort of mortality morbidity outcome. Um in terms of them having surgery, why? Because surgery is a huge sympathetic insult on the body and having an anesthetic is a huge sympathetic insult on the body as well. There's so much stress involved with it. So seeing how they respond to that stress and just sort of doing a little bike test is a quite good indicator of how well their body will cope with the stress of surgery and having an anesthetic. So again, someone mentioned the A sa grading. So a sa comes from the American Society of Anesthesiology. Um and this is there's six grades to it. So a, a ones are your normal fit and well and healthy patients to mild systemic disease. Three severe systemic disease, but typically still controlled. And then sort of from for onwards, you start really questioning whether or not the patient is fit for surgery because they have disease that is essentially constantly a threat to life. Um A SA fives are the ones that often sort of crash into sort of emergency department resource and essentially they will definitely die without, without an intervention. And then A SA six is essentially only useful in organ retrieval because that's, that's um patient who's been declared brain dead and they're just in the operating phase for the purposes of their organs being harvested. And and the scale really does go from like the very top young fit healthy athlete, you know, runs every day, kind of level of patient to lor Doris down in the bottom right hand corner who's 92 and sort of pushes around with same frame and then she's fallen over and broken her hip. So and and the way you deliver and you tailor your anesthetic to your different patients is influenced very much by, well, their A SA grading, obviously their functional status. But again, with a sa grading, there is very much a correlation with morbidity and mortality, right? That is the end of the first section. Any questions that have popped up in the chat at all. Not at the moment, just move on to the next section, the next section. And so, so Perca, so again, um if you guys wanted to pop in a few answers in terms of a work, now, I'm just going to start this one on Monday, uh as well. And what are the sort of what thoughts then come into mind with respects to the perioperative period? So this is essentially during surgery. If you will see if we can get a few responses. Lovely. Yeah. Monitoring. Yeah, absolutely. Trends 100%. Yeah, BP monitoring. Yeah, we're definitely um very keen on that. Yeah, 100%. Yeah. Any other thoughts? Yeah. Lots of people saying about monitoring. Yeah. Yeah, absolutely. That is, that is spot on. That is basically the, the largest portion of the work is what we do is monitoring in various forms. Yeah, 100%. So just to touch a little bit on the anesthetic technique, um I'll start with the general anesthetic. And what I was always told as a med student is that anesthetics is a very postgraduate study, which it is whilst pretty much everyone will work a surgical job in somewhere during their F one F two, quite a few people end up working sort of an anesthetic placement. And even when they do is typically a supernumerary role. So it is none of this is really essential at this stage in terms of how to give an anesthetic. Um What I thought I'd just make it a little bit more interesting by adding in these bits. So essentially what is an a general anesthetic it comes in. It's got three components to it. Induction maintenance. And then the recovery of the patient induction happens with this essentially by wanting to treat the triad of anesthesia, which you can see there's unconsciousness, analgesia, immobilization. Typically we start with analgesia and we start by giving the patient a very, very strong opiate. So typically, we give them fentaNYL IV to start with. And this is obviously, once we've got the patient into the theater position, consented intravenous access. So all of this prep has been done at this point and now we're really on to getting this patient off to sleep. So, preoxygen, whilst we're pre oxygenating the patient, we will start off with giving them a very strong opiate, like I say fentaNYL typically, um then we use again on adults, typically an intravenous uh agent to drive them off to sleep. So you guys might have come across um propofol or um or thiopentone or um or um ketamine, for example, uh would be the ones that we would use. Uh And then the third step is then the immobilization, which is not always a must. So we don't always paralyze our patients, we don't have to, but they definitely need paralysis if they need to be intubated. And I'll come on to what exactly intubation is a little bit later on. The option here is to do a rapid sequence induction. So, if essentially, um, you've got someone who's had a massive curry and then fallen down the stairs and broken a leg and they need to have an operation. Obviously, that curry is still sat there in their stomach, right. So the, the worry about them regurgitating and hence aspirating is quite significant. So what you would do is use a AAA variation of induction called the rapid sequence induction, where you essentially you was in the, the intravenous agent very quickly followed by a very quick muscle relaxant. You put pressure on the throat to essentially with the idea being that if you press down that you're including the esophagus behind and you intubate them as quickly as you can. And it's quite scary to do that. It needs to be very, very quick and you, you are at serious risk of your patient regurgitating and aspirating whilst you're doing it. So that's quite scary. Maintenance of anesthesia can be uh achieved. Um Sort of obviously, at this point, you've got some form of airway for your patient, be that a laryngeal mask or an endotracheal tube. So again, we'll come on to that in a bit, but just to clarify intubation means that your patient has an endotracheal tube. That's the definition of it. Um And then the maintenance can be either with uh intravenous substance. So we, we can use a method called Tiba, which is total intravenous anesthesia. So it can be just an infusion, for example, propofol or more typically, what you guys would have probably seen as inhalational agents. So you have, have them breathing, they have them connected to ventilator when you have them breathing the anesthetic gas that keeps them asleep. Now with the gas, you monitor something called mac. So that is a mean alveolar concentration. So you monitor the amount of gas uh of anesthetic gas in the patient's lung and that tells you how asleep your patient is. And if you're using TIVA, then you use eeg dots on the head and you have an EEG monitoring and again, that sort of generates a read out and that number tells you how, how asleep your patient is. So that's how we monitor for awareness with the different types of maintenance that we do and then monitoring. Yes, fully. So this is there is full respiratory and cardiovascular function as well as like I mentioned depth of anesthesia. But we'll be monitoring gas content that they're breathing in and out. If they're on a volatile agent, we'll be monitoring, obviously BP, heart rate respirate capnography. So if you wanted to look at all the monitoring, there is guidance on it from the API but anyway, but yeah, essentially lots of monitoring and then finally recovery is where we reverse on that. So operations over we want to make sure that the muscle relaxant is reversed. It's quite scary when you first start waking up patient by yourself because what you worry about is that they're still paralyzed but they're awake because that's a really, really scary place to be it as a patient. Like imagine like being awake but still having like being fully aware that you've got like a tube in and not being able to move. Like it's really terrifying and it's one of those like awareness scenarios that you don't want your patient to get to. So anyway, uh you want to make sure that your patient is properly relaxed and there's ways of again checking that with sort of um twitches. So you stimulate muscle movement and you check how well your muscle relaxants worn off and then you basically want to get your patient awake enough that they probably won't remember this, but they are obeying commands. So they're, they're squeezing your hand, they're opening their eyes to command as you bring them back through those pains of anesthesia. Um, it's an alternative uh trial of anesthesia that some people have proposed, which consists of coffee sitting down and silently judging my part. I don't silently judge, I kind of just sit there and internalize some panic at times, but anyway, I'll just leave it at that airways. So laryngeal masks, they sit above the lary, they do not go past the vocal cords, ok. Er, and they do not offer definitive airway protection. That, so that means that your patient can aspirate with a laryngeal mask. So they're not suitable for emergency surgery, but they're suitable for shorter, less invasive surgery. So think about like your arthroscopies or like knees or orthopedic, shorter procedures, that sort of thing, younger patients, et cetera. So that they would get a laryngeal mask and the good thing, good thing is you don't, you don't need to relax them for a, so you don't need to paralyze them for a laryngeal mask, endotracheal tube. However, that's the only definitive airway protection. Why? Because um it goes and sits underneath the vocal cord. So you put it into the trachea and if you can see it on the image just um on the endotracheal tube, just on the left hand end of it, there is a small balloon and you inflate that balloon over there and that literally sort of like sits in the trachea, trachea and doesn't allow anything to get passed. So it avoids any soiling of the airway and soiling of the lungs. Uh You definitely need that in emergency surgery any time you're going into the abdomen, anything, anytime you're inflating the abdomen, like for example, with laparoscopy, um it is um so it's more suitable for invasive longer surgery, but it does require your patient to be relaxed. So you can't intubate someone unless they are relaxed. I eat paralyzed. So, stages of an anesthesia. Again, there's four stages that we talk about and this sort of stage three end up towards the lighter end of it is where we want to be. So this is what we're tending towards and this is what sort of our monitoring reflects as well. And then when you don't go to sleep, essentially, ie you don't have a general anesthetic alternatives can be regional sedation. So, sedation is sort of a low, typically a an injection or infusion that sort of goes in and it just makes you a little bit sleepy and it helps with irritation, agitation. Um, and typically a patient will be sort of dozing. But if you were to shave their shoulder or call their name, they would wake up. So that's kind of the level, but they're quite relaxed, even though they're sort of hammering away at their knee or something like that. And then regional nerve blocks can be all neuraxial procedures can be. So and procedures or use for pain relief in combination with a general anesthetical sedation. And then your neuraxial procedures, you'll probably, uh, if you do obstetrics at any point in maternity labor ward, you will see spinals for your cesarean sections and an epidural is just for um, the pain relief and liquid. So it's very, very commonly used there, anesthetic drug. So, again, just a very, very quick overview of what it is that we keep in our cupboard. So you've, we've got our IV anesthetics. So these are your induction uh more maintenance agents. So propofol can is the one that can be used as either just uh an induction agent or as an infusion. It can, it can be used to keep someone as asleep with fever, like we said, muscle relaxants, opiates uh and um naloxone. And then you've got sort of uh your miscellaneous group, but then on the other side, you've got your vasopressors, antiemetics, anticholinergics, benzos, local anesthetics and then further on, over onto the right, you've got your inhalational drugs. So, sevoflurane, for example, or isoflurane are probably uh in the UK, the most commonly used volatiles, right? Any questions about that section at all? Yeah. And we have three at the moment. So I'll reach out to you. Um, someone asked if we use an inducer like propofol and before G A. Yeah. So Propofol is one of the induction agents. So yes, you would get um either propofol or uh one of other. Well, we in the UK, we have license for uh four different induction agents but Propofol is by far the most common. So yeah, typically you will get Propofol. Yeah. Cool. Um Another question about fasting time for clear fluid before elective surgery. Yeah. So clear fluids. It was two hours. So you can have sort of um um up until two hours before your operation. You can have clear fluids. So nothing with milk in it but you and nothing fizzy. But you can have like for example, just like plain squash. Um, because, you know, uh, that's, that counts as clear fluid. Yeah. Cool. And last one is about like, um, nasal cannulas just asking if that's ever used in surgery. So, not for, uh, so nasal cannula are not used when delivering a general anesthetic. They are typically used. We use them in, um, either if someone's having sedation and because they're a bit too sleepy, they're just sort of a little bit breathing a bit too shallow. And we want them to have a little bit of extra oxygen, but essentially they're maintaining their own airway and we don't have any concerns. They're just dropping their sats a little bit, we give them a little bit of oxygen to breathe. So that, that will be one use that we, we have for a nasal cannula and the other one is really in recovery. So in recovery, people will typically be on nasal cannula or on a sort of hugs and just a simple face mask to get a bit of oxygen. And again, that's just to help that recovery process while they sort of get back full control over their breathing. All right, all the questions for now. So perfect. Thank you. So we'll crack on. So we're on to our post locker. So same as before, if you guys wanted to just pa few words or phrases as to what comes to mind, um, with respect to the post operative period. So now that your patients had their uh operation, they've emerged from their anesthetic. They're sort of in the recovery area. What would be your considerations? Very good. 100%. Yes. Love it. Pain management. We all do it so, so poorly. Every hospital can. Uh every like literally everywhere you work there will be scope to improve pain management. 100%. Yes. Pain, yes. Waking opening bowels. Yeah. Nausea, vomiting, nausea, vomiting, definitely going for a wee passing urine. Yep, nausea, vomiting. Very good. Yeah. Again, monitoring of um sort of of the patient observations. Very good. Yeah, brilliant. So definitely coming on to some that I'm going to be talking about. So, yeah, there we go right off the bat analgesia. So everyone knows the who analgesic ladder. It's very, very simple. It's very easily accessible and yeah, pain relief is, is so poorly managed in hospitals. So a again, ii, this is very, very simple stuff. Simple analgesia plus minus and it's paracetamol. Every everyone should have um regular paracetamol um adjusted for their weight. So, ensuring that obviously patients, less than 50 kg are at risk if they can get the full 1 g qds. So weight adjusted regular paracetamol if there is no contraindications. Um So they typically, you know, they've got good renal function. They don't have asthma don't have any other reason why they couldn't tolerate an NSAID ibuprofen and Diclofenac is brilliant. Again, regular um diclofenac if you ever come across a patient with renal colic and there's no contraindication. You give them Pr diclofenac, they will cry with joy. I have seen it happen. It is nothing else touches that horrible herbal colicky pain. But pr diclofenac does and they, they literally, they, they just completely turns them around and it makes them so much better anyway, weak opioids. So again, your patient, if there's no contraindications to it, um they should be on some form of regular weak opioid POSTOP. So this could be codeine dihydrocodeine traMADol. So again, traMADol is better because it's less constipating, but it causes more sort of essential confusion in the elderly or a bit more sort of um drowsiness. Codeine does that less so, but it's very constipating. So for some people, so again, but one of those weak opioids should be prescribed regularly, which one is most appropriate for your patient. And a strong opioid, this is where we get into the sort of territory of Pr Ns. So as and when Mo or Aor, ok. So that's really important to have that or oxyCODONE. And that's uh that's again, sort of typically dictated by their renal function, which one you go for reaching into towards fentaNYL. So I wouldn't expect you as sort of foundation doctors to be prescribing it or giving it. There is scope typically in recovery for nursing staff to give a little bit of fentaNYL, but it's a very anesthetics l drug fentaNYL. So I wouldn't expect you to have much to do with it. Similarly, patients often come up with P CS. So patient controlled analgesia, epidurals, peripheral block infusions, pain pes, you might see all of these or may have already seen these on surgical wards. Again, these are overseen by specialist pain teams, but especially with PCA, your patient's compliance with it might be poor. So if you get asked to see a patient in pain and they do have a PC. And it's really important to sort of see whether or not they're using it or using it well enough. So I literally had a patient the other week was simply not, they thought they were pressing the button, but they actually weren't because they just needed to press a bit harder and they didn't realize that they weren't actually delivering themselves like any doses, nausea, vomiting. So again, very, very, very common uh postoperatively. Now, just very, very quick reminder of the vomiting center of vomiting is a very complex physiological thing. There's a lot of things that contribute towards it. So, um just a very quick recap of the different sort of types of receptors that um antiemetics can act on. And really this is, this just goes to illustrate that multimodality is really good uh to utilize with postoperative nausea, vomiting. So I typically, I'll always have onda and again, cyclizine if there is no um no contraindications to it. And then you can try with prochlorperazine, dexamethasone works well, but we typically only give it sort of once the patient is already asleep because it feels a bit, it feels a bit nasty. So, um so essentially what I'm saying is um multimodal um management of postoperative no vomiting fluid balance again, done very, very poorly. And it is very difficult to get an accurate flowing and balance chart on patients on wards, it is very, very difficult but just to start with some very basic physiology. So your BP is your cardiac output times by your systemic vascular resistance, right? That is just S law, right? OK. So V equals I times on OK, BP equals the cardiac output times by the resistance. Now, cardiac output in turn is a heart rate times by the stroke, volume, stroke, volume. How much volume leaves the heart and heart rate? How many times a minute does that volume leave the house? So there's total volume permanent and the system um think ways of assessing fluid balance, right? So ways of assessing how well the system is working is through again, cardio respiratory measures. So your heart, like you guys mentioned, monitoring heart rate, BP cap refill and just generally sort of the the h how peripherally filled and and fuse your patient is in front of you um blood. So obviously using his renal function lacta but then arterial ph as well and fluid balance shots, like you said, they it's really really helpful if you can get up to date and accurate fluid balance shots. But on, on the walls, it is often difficult to, to get that. Um now resuscitation wise, right? So typically the bit that you guys will be dealing with is a stroke volume. Why? Because you'll typically be dealing with patients who are hypovolemic and that means that their preload is less, therefore, their afterload is less and afterload corresponds to stroke, right? So the the the the hypovolemic there's less coming into the heart, hence, there's less coming out of the heart. OK. So this is the stuff, this is the side of the equation that you'll be able to manage with your um with, with your fluid challenges. So, Crystal Oil Hartman's or, or 0.9% saline blu is 500 m over 15 minutes. Again, tailor it to your patient. If it's tiny little Doris who weighs 40 kg, don't give her a full 500 to give her sort of 250 at a time. But essentially that's kind of your ballpark of having her um resuscitate with fluid boluses. And the ones who've kind of addressed resuscitation and me the needs of the patients having said that if they're bleeding. Now, the best replacement for blood is blood. So there is definitely cause to transfuse a patient who's drop their hemoglobin and is bleeding. But that's a separate discussion. But once you've essentially met the resuscitation needs of the patient, you come on to your routine maintenance. Again, there is always a temptation. You see the flu's patient chart, you're on your way home. It's literally 10 minutes past five. And the, the nurse goes like, hey, did you want flus for this patient? And everyone does it. I've done it. We just copy whatever the previous person wrote and it's really bad practice and it happens time and time again, especially surgical or you just see sodium chloride after sodium chloride, after sodium chloride being infused into the patient. And it's not good. Why? Um Well, it's really because it doesn't address any of the electrolyte needs of the patient. So water, that's straightforward. 25 to 30 mil per kilo uh per, per day. Sorry, that's a typo, I'll write that. Um and then the sodium potassium chloride. So just a quick reminder, Saline has no sodium, sorry, no potassium in it whatsoever. So if you're just infusing Saline into your patient constantly, they're literally not getting any potassium and the potassium is if anything diluted and then add in a patient who is on top of that, having diarrhea or vomiting because they've had some horrible colorectal. Um they're then going to be getting rid of even more of that potassium. So before you know it, you've got like a hypokalemic patient on your hands because they've never been replaced. So if you think about it one minimal per kilo per day, sodium potassium chloride, that means that your potassium really to your like textbook 70 kg patient, they should be adding 70 millimoles of potassium, they just as maintenance and then finally, uh glucose typically again. Um So it's uh and if, if you're thinking about infusing glucose into your patient because your patient is not eating, then maybe it's also time to think about alternative ways of feeding patients. So again, patients often say 10 days, two weeks, however long having just intravenous fluid after intravenous fluid, instead of someone taking a step back and saying actually, should we be putting in a nasogastric tube and feeding this patient like actual well food replacement. So again, the the the glucose is yes, short term wise, your 5% dextrose is a good way of replacing it. But if it's kind of going on for a longer period of time, then again, there is course to think of alternative ways of getting nutrition into the patient, right? Um VT prophylaxis, again, this will be something that will be your bread and butter in in foundation BT risk assessment. So everyone who comes into hospital as an inpatient needs to have a risk assessment done at some point. And typically that risk assessment then gets redone if they have any intervention or say like surgical procedure or anything that might change things. And there are non pharmacological measures. So basically looking at uh patient factors. So um hydration and immobilization, um mechanical. So this is your compression stockings, boost heads if you ever tried Flowtrons, you'll know that there is no sleeping in them whatsoever because they keep going up like every other minute. And it's the most annoying thing in the world, but important to know to be avoiding your peripheral vascular disease patients. So they're the ones who shouldn't be getting sort of their veins even more compressed by these devices. And then your pharmacological measures, which I again, I'm sure you've come across your low molecule weight heparins, which might need again, dose adjustment and then you're on fractionated heparins, which you typically historically use in renal impairment. But these days, we we, we tend to at least where I work, adjust our low molecular weight heparin type and dose in renal patients postop complications. So again, it will be very, very common to get bleed to the ward. Once the patients come out of recovery, they've been sent back to the surgical ward because they were well enough in recovery. And now it's suddenly like 10 at night, the patient had their operation like at some point in mid afternoon. And now it becomes your problem because they're starting to develop a complication of their hypertension. So, hypoxia be that POSTOP pain, nausea, vomiting be that they've not weed in a while. That's a very common one to get bleeped about as well. They're more confused or they're increasingly in pain. Now, pain other than it's not pleasant for the patient, it can have physiological knock on effect. So if you think about reduced mobility because of pain, you're high risk of DVT. If you're not breathing because you're in pain, then you're splinting your abdomen, you're suffering atelectasis and you can, you're much higher risk of getting a pneumonia in the hospital. And also if you're vomiting because you're in so much pain again, it's just electrolyte in disturbance. So treat your patient's pain because obviously you want to be nice to them. But also because you don't want to have to deal with what happens if you've not treated the pain. So yeah, um don't panic any of these things. So just basically shout for help, ok. Ask for help, talk to your senior, but also just assess your patient. OK? So this, this is literally a a carbon copy of the a to look for your listen measure um table that I was given as 1/4 year medical student, which is a little while ago now, but I've basically just stuck with it um throughout like my foundation program throughout like um core training. Whenever I have to do an ATV assessment, I fall back on this. Um I understand the size will be distributed in exchange for feedback. So don't worry about like writing it down or anything you can have access to it, but it is in a sense as simple as that. It is just really scary to do sometimes. So definitely get help, ok? But don't panic, get help do your at fine, lovely. Now we're on to the SBA S any questions before we start the SBA S? Yeah, there are a few questions. Actually, um someone wants to know about kind of the consequences of like respiratory rate and heart rate, dropping post surgery or during surgery. So during surgery, it, it really depends. Um So it depends if it's um happening in conjunction with something else. It depends on the trend. It depends on why you started in the 1st, 1st place. So if, for example, um the, the most common, the most often for heart rate, let's say what's happened is that I've uh my patient had a low BP. I've gone and given them a vasopressor. So I've squeezed their vasculature and as a result, they developed a reflex bradycardia. So I go like, oh, that's my fault. I kind of saw that coming. So then I'm going to go and treat their um uh they're low heart rate with an anticholinergic. So this is typically your glycopyrrolate or your atropine. And I'm gonna bring that up so often. It's iatrogenic. It's, it's what we've done to the patient. Respirate is a, is an interesting one. So, respirate, typically, we control for as long as the patient is paralyzed, right? Because it's the ventilator controlling it. And as long as the patient is syn well, with ventilator, which means they're well paralyzed and they're deeply anesthetized. They, they are comfortable now where respirate is very, becomes a very po, so a chap who's not needed to be paralyzed, he's having his knee operated on, he's just got a laryngeal mask in because, you know, he's not needed anything more invasive and then he starts hyperventilating on me under the influence of an anesthetic. So he's breathing at 30 you know, a minute. Then I say he's probably in pain, right? That's what he's trying to tell me. So then I give him more morphine for it. And typically, again, I see that's happening now. So it really depends what it's very difficult to comment on those things individually. But I kind of, you look at it as part of the whole picture, the patient in front of you. Yeah. And we have another question on why anticoagulants are discontinued before surgery? Why uh because of risk of bleeding. So typically we, um so again, I'm not going to go too much into the guidelines, but um your antiplatelets are typically discontinued uh for uh either seven or two days. And it's literally, it just got to do with risk of bleeding, especially if you think about, for example, if your patient needed epidural for pain relief, if you go and put an epidural needle in, right? And you go into the epidural space, you feed a catheter happy days. If you, if the patient starts bleeding into their epidural space because they were, their blood was thinned, you're not going to know that until they present with an emergency, neurological condition, which is an epidural hematoma. And that's, again, that's a scary place to be. So, essentially bleeding is why you discontinue it. Yeah, one more question about Hartman versus Saline. Um, just like what drives the position to use one or the other and who's responsible for making that choice? So who's responsible? I think so in personally, I, and I think if you ask most anesthetists, we opt for Harman's. There is no perfect physiological fluid. We wish there were or I wish there were. Well, there is an Hartman's is a slightly more physiologically accurate than Saline, which is literally just salty water. There is nothing else in there. Whereas Hartman's is sort of a compound, um lactate um crystalloid, it does have some potassium in it. Not very much, it's only five mol liter, but it is physiologically a little bit more accurate than Saline. So unless basically the only time I would avoid using Hartman's is well, a if I wanted to give more than five millimoles of potassium. So if I wanted to stick in an extra 40 because the 40 mol or 20 mol of potassium comes in sodium chloride. So that would be one of my reasons. The other reason to avoid hormones for me would be possibly hyperkalaemia. But even I, I've spoken to some renal doctors who even in hyperkalaemia say that actually the potassium content is so low that they prefer Harman's to be given because the other thing that saline does 0.9% saline is acidic, it's got a ph about 5.5. So they rather they wouldn't, wouldn't make their renal patient acidic and give them a little bit more potassium than the other way around if that makes sense. So personally, in my practice, I always reach for Harman's unless I have a very specific reason not to anything else. That's all the questions for now. Perfect, lovely. So a few questions, um I realize the time is um coming up to seven. So we won't spend very long six questions. So essentially, um I'm just gonna let you guys read through it and then hang on. I'm just gonna skip ahead and start. So again, it's just a little voting system. Um 79 year old child preassessment clinic, biomass knee arthroscopy, PMH of hypertension, high cholesterol and benign prosthetic hypertrophy is his E CG. What are you gonna do? He's, he's coming in for a for an elective operation. So I'll just give you highs just a few seconds longer to read the answers and then we'll skip on to the next page to look how you voted. Same. OK. So we've got one for C and one for A. OK. So either postpone or it's first degree heart block, right? So this patient has, so C is the correct answer here because this is total heart block and I do apologize. It's not the best quality um ECG, but this is, if you look closely, there is um no uh pattern between P waves and Q Rx complexes. So, um so this is a case of total heart block. So especially for a an elective operation, you wouldn't want to proceed with that. You would want to postpone it obviously apologize to the patient, but I explain that is the safest thing to do and get them sorted by cardiology before sort of real listing them for their um um knee up at a later date, right? Ok. Next 1, um 54 year old lady who is to have a laparotomy. So that's long midline incision, right? Um To get a, a large pelvic mass removed, what are we gonna do for this procedure? What how are we gonna go about making her safe? Say again, sorry, I'll start apologies. I'll start menting me to as well and I'll just show you the answers again. So again, I'll just leave you guys a bit longer and then I want to be, oh, second. Um sorry Adrian, could you share the QR code again? I think someone is asking about how to vote. Yeah. Um So the QR code um I'll just scroll back to sorry, this page here. So if you grab the QR code from there and then this is uh and then if you go, it should come up with SBA two, someone's voted. So two people have voted. Excellent. So so far we're thinking e I'll just give it a few more seconds. Let's see. Fine. 11 a day, one for c another one for baby one for OK, fine. So the correct answer here is E so those of you who said be so laryngeal mask airway is not appropriate because this is a big intraabdominal operation. So there is significant risk of regurgitating as, as a result. So anything that happens in the abdomen, basically, we would never use a laryngeal mask because of that, of that um of that risk. And then for anyone who says c so using a a gel airway, so the gel is a small little stubby thing that sits in the mouth. We never use it for a general anesthetic. We only use it when we're pre oxygenating someone but that's it. So this, this woman definitely needs AAA definite uh a definitive airway, right? Um So yeah, gel, we only use in pre oxygenation but it, it you wouldn't use a gel to keep it whilst your patient is asleep because it's, it's not an appropriate um airway at all, even though some films and television series make you think that it is, but that is incorrect just um for the record. So, yes, absolutely intubate. Keep her airway safe, 100% and appropriate intraoperative analgesia. Yes. Um Question three again. Let me just start menting. Sorry about that. So, here we go. This is a 75 year old gentleman recovering after a knee replacement. Um Oh sorry, that's meant to CO PD. Um just got my letters the wrong way around. CO PD gets around without help. No home oxygen. He is overweight BMI 34 and now he's saturating at 90 but doesn't have any oxygen prescribed, but otherwise clinically seems ok. Um, just a bit of pain after his op. What would you do? All right. So yeah. Um II appreciate it is seven o'clock, there is four more questions to go. So if any of you guys uh wanted to leave, please feel free to do. So obviously. Um But we're just gonna finish up. It shouldn't take more than about 5 to 10 minutes tops, right on me. Four. Yeah, very good, excellent. So all of you said e uh very good. So, absolutely. So 28% via ventura. So CO PD definitely wants a controlled amount of oxygen going in D is not a bad shout. So D looks like it could work. The only problem really with D is the 6 L per minute because if I put nasal kindly on you and whack up the flow to 6 L is gonna feel like, you know, you've, you've got flaring nostrils, right? So it's really uncomfortable and it really dries out the membrane. So really um nasal cannula, the flow through them shouldn't really exceed 4 to 2 to 4 L a minute. If you're needing to go beyond that that's, that's also a good idea to be reaching for a venturia mask at that point. But yeah, other than that perfect fourth question. All right, let me just starting on that one as well. So, um patients are always assessed for their risk of thromboembolism and admission with respect to et prophylaxis, which would be the most appropriate of the following statements. Give you guys a minute to read it. Ok. Let's see what you're saying. No, no answers just quite yet. OK? I'll just leave it a few more seconds and then just bring up the answer. So, finish up soon. Oh, lovely. We've got three for perfect. Which is the correct answer. Absolutely. So, yeah, so like you said before, may needed uh low molecular weight heparins do need adjustment based on patient's weight, um renal function. Absolutely. Um I think there was no other answers. Yeah, everyone's gone with that. Perfect, brilliant uh question five. Uh You're asked to review a young patient on board because they're complaining of severe pain six hours after a knee arthroscopy now shows you that there's been no analgesia um prescribed and they've not had anything since they're off. So what would be more management again? Very, very common scenario, unfortunately. Um where you sort of bleed hours later saying, oh, patients in pain? Ok. All right. Let's see. What's uh you guys are saying? Ok, so there's a bit of a spread fine. OK. Most people are saying c OD. Yeah. All done B or E. Oh yeah. Ok. Fine. So a bit of a spread of answers. No problem. That's good. So the answer here is, is, is e so be, call the orthopedic, uh call the anesthetic and as this is an orthopedic patient and they should prescribe it. So that's if you think about sort of along the lines of S JT, that's, that's not very good pain, that's not very good team working. And this is not something that is beyond you as the f one on the wall to manage. So yes, was the, it may or may not have been the anesthetic registrar who omitted the prescription in the first place. It may be the case that there was another drug card and it got lost. But escalating the straight back to the anesthetist is before you've done anything about it is not appropriate. Also, they might be in theater. So they, you know, they might be five hours because they've just started a massive case. So that, that's not the right answer. See, 1 g paracetamol and so 1 g paracetamol is not going to touch it if they're in severe pain. And we are saying in one hour, if they're in severe pain, like if, if you've ever had an off and been in a lot of pain with it, like you might know that 1 g paracetamol is probably not really going to touch it, but in conjunction with other agents. Yeah. So we'll, we're, we're getting there, do write of regular paracetamol and Ibuprofen Rey in 30 minutes. So that's, that's not incorrect. So that's sort of tending towards the right one. But e is again, single best answer. What, which one is the best e is the best. So you write up your regular paracetamol and Ibuprofen and your P RN oral morphine. Absolutely. And then ensure that all of these are immediately given. And then at some point you come back and have a look ideally probably I would say within the next half hour or so if you uh unless you sort of get bleeded off your feet. But yeah, so C is starting to tend in the right direction. D is better. E is best. OK. Next one, Let me start ment and then this is the ABG that you presented with. So essentially, you're the f one nurse actually to look at um the uh ABG of the patients that she's been concerned about past few hours. What can you see on this gas? OK. All right. Let's see what you guys are saying. Yeah. OK. Yeah, 100%. Yeah, that's what it is. Perfect. Respiratory alkalosis with no, no compensation. Probably your patients in pain and they're hyperventilating and they're blowing off CO2 and that's why they're alkalotic. Yeah. Compensation, renal compensation is not likely to happen. So that quickly. So that's why there is no compensation for it. Just yet because it takes longer. But, yeah, absolutely. They're in pain, they're hyperventilating, they're blowing up gas, uh they're blowing off CO2. It happens a lot fine. And then that's it. Oh, only had six. Lovely. So, um thanks very much for all of you who came. Here's all the references and resources. So, if you're interested in anesthetics or peri op care, so, a lot of the er, content that I use, including the, the SBA S come from the UCL students site for anesthetics. So they do a really, really good bunch of resources and typically as the year four bits that you want to be looking at, I've included the QR code here to the site. So that's really, really good. It's the same resources I was using back when I was a student and found it really, really helpful. I used anesthesia at a glance when I was doing my elective in anesthetics and it's only like 90 pages. It's a small book, like an a, a full size like book, but really extinct and very appropriate for the level of medical student because everything there's e-learning modules that you can do. So if you set up an account ele for healthcare professionals, you can access all of the Royal College of Anesthetists modules for free. If you wanted to double in that I, if you're interested in at some point applying for anesthetics, I did a um you do that webinar a few years back. So again, give that urge just in terms of how to apply for the specialty, what to expect. And then also if you're thinking along the lines of applying at some point in your foundation, and there is a mentorship program as well that you can sign up for and you get allocated with a, with a trainee to help you through the process of applying for anesthetic training. So again, that becomes more relevant to you guys once you r you sort of F one F one F two time. But yeah, that's it from me any further questions on the chat before we finish. Mhm. Doesn't seem like there's any, so I think we can wrap it up there. Yep. Perfect. Brilliant.