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Yes, that should bring you to the side. Um, so my name is, and I'm one of the, uh, final years and I'm also on the peer. So if you have any questions about that, um, you can email me there, that's my email address there. And then it's also, um, at the end, um, of the side show, you'll be able to email me with any questions you have about peer or if any questions about anesthetic or, right. Um, so what we're gonna go through today then is we gonna very, very quickly go through the ABCD approach, but I'm sure you've all kind of gone over it before and you have a good idea of it. But, um, it is very important and it always comes up as a force here. Um, so we'll have a really good go at it and like practice it loads, um, in preparation for that. And then I'll go through some of the peroperative medicine things. So we'll go through a little bit of a preoperative assessment. A SA grades pa score pre op medications and when, what to stop, what to, um, continue with, uh, VT prophylaxis, come up to surgery, um, complications during surgery and complications after surgery. And then we'll go through a wee bit of analgesia, specifically the P CS and the epidurals and spinal also tell a bit about local anesthetics, um, and airway management and oxygen delivery as well. Um, so we'll go through that so very quickly then through the ABCD. So you wanna go and, and chat to them, you know, are they able to talk to you And if they are, then you're less worried. So they should be airway pitt and should be ok in that way. Um, but if they aren't talking to you, then that's why you need to start listening and looking at them. So, um, some things you want to listen for are snoring, stridor or wheeze because that could, you know, show that there is a problem with, um, the airway and then you want to look inside their mouth as well in case there's anything obstructing the airway. So that's some of the things there that you might see. Um, and you can remove that either, you know, with your fingers, um, gloves or you can get one of them, the gills, which is basically like you can just move, but don't use them for anything that you can't see. So if you can see, uh, obstruction very clearly there that you can grab it with and then you can do that but don't blindly start going into their airway because you can push things down further. And so some of the interventions, then you might do it a then is to remove that, as I was saying, and you might want to stop any secretions or any vomit to sort of clear that up. And you might start doing airway maneuvers like jaw thrust or head tilt and lift, um airway adjunct, which we'll talk about later in the side show. Um And then always remember to in and if you are worried about the airway, that's when you need to get anesthetics um involved and to come and see them. Um And then any of that causes her that you can treat like anaphylaxis or any body that you can start um doing that and treat the patient. So, moving on to b then, so whenever I'm doing ABCD for each one, I go from their hands up to their arms, their face and then down to their chest. Um So if you start with their hands, you want to get their pulse oximetry and then looking at their head and see if they say no and then the tracheal deviation, like if they're having pneumothorax and then the chest exam. So a lot of people forget respiratory rates. So just make sure you do remember to do it. Um looking to see if they're using their accessory muscles. Um and then if they're equal expansion and quickly percussed and auscultated, normally, what happens in the OS is that they move you along quite quickly and they'll tell you what you hear. Um But just do remember to say that, you know, you're trying to do each one. Some of the things you might consider then is you might consider an ABG. So if they're hypoxic, you would want to get that. Um And if not, then later on you can think about doing a VBG under sea. Um, and most people will get a chest X ray if there's anything wrong with bay at all and you can get that as a portable one if they're a sick patient. Um Some of the interventions that you might do at this stage is a 15 m per minute uh non rebreather mask. Um So that goes to anyone who's um unwell at bay, you would want to start that right away and then some of the causes that you can treat there like the pneumothorax. You wanna get your asthma guidelines or CPE guidelines out if you think it's that and start giving them oxygen and hydrocortisone and all that sort of stuff. Um or it could be an opiate overdose or apa. So you want to start treating them um as you go along and then very quickly see again, going from the hands up the arms to the face and then down to the chest. So feeling their hands doing like the refill time, their pulse, um what it's like doing the BP. Um And then you want to check their G VP and then doing their chest and auscultated it and you want to listen to the lung be as well in case they're fluid. Um, some of the tests. So most people in your ABCD approach will get INOS will get an E CG. Um, and they'll probably hand it to you and it'll be, you won't have to go through the whole thing of the A B of the, of the E CG. But you'll have to sort of very quickly say what you think it is that's wrong. Um Like if it like tachycardia or something like that, I think. Um And then you want to do blood and you would say what blood you want to do. So if you want to do, if you haven't done a ABG, you might do a VBG. Now I say, you know, your full blood count GE LFT S, you might think about blood cultures then as well at this point. Um And you want Artonin, if you're worried they're having AMA, so you want to see what kind of blood you want to get. Um And then a catheter specifically if you're worried about sepsis or um fluid status. Um So interventions then you can do so you can get the white for two whiteboard IV Cannulas and get IVF going, especially if they have low BP, high heart rate. Um And if you think this person's having a hemorrhage, then you might want to activate the measure hemorrhage protocol. Um, and you can treat causes there and specifically one of the things you should probably pick up and see is if they have sepsis. So, just remember your re ses is six there. So you get the three and you take the three. and if you're querying, if it could be that at all, you're better doing that. The not and make sure you specifically say to the examiners as well, you're doing the sepsis six. Is that just um and you can treat your cause there as well. Um So disability then the way I remember this is I do aged so a for alert. So you want to do their G CS and they made us calculate that this year in the. So they do do it. It was just a patient who was sitting and talking to you. So they didn't have a G CS of that, but they got you to do it and work it out. Um They're glucose. So always remember it um because it can no be masked and always and their eyes. We wanna use your pen torch and see if they're more active. Uh And then you wanna get to see the drug. So what's wrong with the card? So specifically looking at um opioids because of one ABCD, then we can, we can get um test, you might get a CT brain if you're worried about your pupils or anything like that. Or low gcs and you might then correct your glucose or if there are any pain, then give them analgesia and then you can treat them causes this like that. So then moving on to e so exposure or everything else. Um So you want to just look head to toe, um you know, remove any kind of clothing and see if there's any like bleeding, rashes, injuries, you know, opioid patches, which could be have an opioid overdose. Um Any cannulas like our year this year in our a we had a patient who had a cannula in their hand and they had like it red around it. And that's what you were supposed to kind of realize that that was like an infected cannula. So just um keep the Irish for that because I might do that again. And then just looking around the bed like if they need catheters or drains and what their um output is like. Um our patient last year for her ABCD was a POSTOP patient. So, um they could have things like that and then you wanna squeeze your calves in if you haven't done that already to look for a DVT and then focus exam on the relevant system, for example, an ABDO exam um and everything else, then always remember your temperature and if it's a woman then do pregnancy test as well, um Just realize, oh, she's going for surgery, she's gonna need that anyway. Um So some tips, then always remember to call a senior. Um And the earlier you do that generally the better. And then if a, as I said, you worry about it, call any as well. Um And you wanna say, you know what senior you're calling. So if you're in like the surgical ward, then you call surgery, um, the consultant or who you want to call. Um, and then reassess intervention. So example, if someone has low BP and you're giving them the IV fluids, you wanna come back in and check if that BP is increased. So check if what you're doing is working and then at the very end when you've done ABCD eight, then go back to A and start again and then if you can find out what's wrong with them, it's ok. Like don't panic and a lot of people didn't really know what was going on with their last year, 11 to 100% sure, but it's ok because as long as you go through it in the system and you fix things as you go along, that's where the most of the marks are. So you'll be ok. Uh, so just, um, you know, remain, um, relaxed here in ABCD E is amazing. Um, and they might combine it with other specialties as well, like last year for the final year, they combined it with, uh, and did A PP and so just be aware of that, it's just something is a common example. So they might have like sepsis. And then you have to find the source of it hemorrhage like any of that. As I said, the P PPH um anaphylaxis is another one or asthma or CO PD, which is quite easy for them to do. And you can have to go through your um approach with that. They could be having ama hypoglycemia, opioid overdose or the topic and this is just a wee screenshot of um the medics like a stations you have to pay for it. But I actually found it really, really helpful this year and I would really advise people to get it. I thought it was very useful and I thought it was a lot more useful than the ques Ay bank. Um So if you're thinking about buying, I would say this one's very good and one of the things they have is these ABCD um approaches. So if you're getting together in like a full of um in pa or you can examine each other on this, you know, have someone be the patient and someone else examine them and then they'll tell you at the end, do you know what kind of things you should be looking for? Um for that patient? It is very good that way. So I would advise you to look up over that if you're looking for something. Uh So I moving on to the pre op assessment, so unlikely they would get you to do this, but just so you have like a basic idea and what you really want to do is just find out, you know, what, why they're in hospital, like, what are they having done? And then if they've ever had surgery before and how that went, for example, if you know, they have a problem getting intubated or something, then you would kind of want to know about that, be prepared for a difficult airway. Um They also kind of want to ask about their family history of problems with anesthetics because some of the problems which will come to you later are inherited. So you want to be aware of that. Um And then just how they got on afterwards, postop as well uh for any previous surgeries and then dental work as well, that's in case they have any like loose teeth or anything that you might, you know, whenever you're intubating in the airway might go loose and then they might um and if, if they're fasting or not, and then just a past medical history. So there's different kind of things that you wanna know about that they had before going into um theater. So for example, if someone has gout or hiatus hernia, they're going to be at increased risk of aspiration. So you might choose to do, you know, intubate that person instead of just putting in an L or something like that. So that would be good to know. Um and some with, you know, the cardiovascular and respiratory is, you know, how likely they are like to have problems during or straight after the operation. Uh, for example, if someone has, you know, asthma, then they might be at increased risk for your, um, intubating and vent them during the, uh, surgery or afterwards coming off it and then endocrine specifically about, um, diabetes, how it's controlled the most recent HBA1C. And we'll go through a little bit more about that later. And then also under that, you know, if there and on any, um, or have any me, any endocrine problems that they need like steroids for you. I know about that as well. Um, and then M SK is neck problems. So if you're thinking about whenever someone's in surgery, you're moving their head quite a bit and you want to get their neck in quite a specific place to put in any kind of tubes or anything. So you wanna be aware if they have something wrong with their neck that you, you know, are aware of that, that you're not moving your neck in certain ways that could harm them. And then the drug history is specifically steroids. Um, I know you're on medications that, on that they might have to stop or that you'll have to continue or do anything with, um, coming up to your surgery. Um, so just a quick note about fasting then, so they can have food up to six hours beforehand, clear liquids up to two hours beforehand and then they're nil by mouth after that. And that is just to prevent their risk of, um, a reflux and aspiration. Um, after. So that's that and then I'll move on to a SA grades. So this is the first three. So it's 1 to 6. The first one is a very healthy patient who doesn't smoke and either doesn't drink or drinks very, very little. Um And then a SA two is most people in questions. So if you're coming on question and you're not really sure what A SA they are, I would be picking to just the majority of people are too. Um So there are people with mild disease and that is pretty, can be pretty mild. For example, someone who smokes, even people who socially drink alcohol would be considered a SA too if you're pregnant obese, if they have well controlled diabetes or high BP or the name mild lung disease, for example, well controlled asthma A SA three then is more severe. So their diabetes are high BP, poorly controlled. If they have CO PD, they're morbidly obese with a BMI over 40. They have Hepatitis alcohol dependency, a pacemaker, moderately reduced uh ejection fraction or this is an important one to remember. And I'll show you in the next slide as well. If they have endstage renal disease, undergoing dialysis, there are three. But on the next slide, you'll see if they're not undergoing regularly scheduled dialysis, there are four. So if they're on dialysis, three, not on dialysis for, um, so just remember that one cause that can we, that and then if they have had, uh, you know, myocardial function or stents or anything like that and then over three months ago, so this is 4 to 6. So, um, four is, you know, a severe disease that's a constant threat to their life. So, if someone has recently had ama or a ta or stroke, they're at quite a high risk of something like that happening again. So there will be a four, um someone with severe valve dysfunction similarly like that uh severely reduced ejection fraction or septic or the D IC, they would all be for. And then as I was saying there, the NSAID renal disease not undergoing um regular dialysis and it is considered more uh a sa five, then someone who isn't expected to describe without that operation. So someone comes into you who's like severely, severely unwell, um they will be considered a five. Like if someone has a ruptured Fibria or a massive trauma or an inial bleed, it will be a five. And then a six is someone who is dead and they're just having their organs removed and to make them. So most people, you know, majority of people will be a two or three and then you will probably be able to pick out five that they're just extremely unwell. Um So yes, that's just kind of a, you just kind of have to learn that. And then I think pasted and Quest have very good, you know, questions on it that you can go through and you can just kind of get in your mind the more common ones that happen. So the most common ones would kind of be, you know, people with lung disease or um, obesity would be, or a recent ma or something would be the most common ones that will come up. Um, and then I think I have the MCP here. So, um, a 45 year old nonsmoker is due to undergo an elective cholecystectomy. She has well controlled type two diabetes and her BMA is 41. So if you think to yourself does her a SA grade. Mhm. That, so she would be a three. and the reason for that is because her BMI is 41. So if we go back to this here too, so, a SA three BMI of 40 or more, she also has the type two diabetes and it's well controlled. So if she didn't have the BMI of over 40 she would be a two, a lot well controlled diabetes. Um, so hopefully that makes sense. And then there is another one. So a seven year old boy has been added to the list for an elective, uh, tonsillectomy. He has a history of well controlled asthma and he takes two puffs of BD bate and he has no other past medical history. So, what is his, he can answer the shot if you want or, or his is a two. And the reason for that then if we go back to our um in here, so he has a mild systemic disease because he's only on um a steroid inhaler twice a day. The pain is considered mild. So he is a, yeah. And that's also, yeah. Oh yeah. So the next one then is the ma and pa score. I don't think they would really expect you to know a lot about that as long as you know, that it's used to predict the ease of intubation. So if you think about it, if you can see someone's airway really clear, then it's gonna be easier to get a tube into it. So if someone is like one here, you can see their whole soft palate that behind their um uvula. So that person's be really easy to get a tube down their throat. Whereas someone who's me four, you can't see their. So at all. So if you think about it, their tongue sitting like a lot higher and you're not gonna be able to get that tube down their throat as easily. So, as long as you know, it's to predict the ease of intubation one really easily again or a bit more difficult. Um So as long as you know, that there, I think you'll be grand. Ok. So pre op medications. So, these are the ones that you should stop. So, uh, hormones is an important one to know. And they do ask you about this here one a lot. So, the combined oral contraceptive pill and the H RT, you need to stop four weeks pre op. And that's because that increases your risk of PTE. Um, afterwards. Then I think it's the H RT can start as soon as they start immobilizing and then the cop is two weeks after they start immobilizing. Um So it's just important to know that you're stopping four weeks beforehand to reduce the risk of clots. Um So some potassium sparing drugs then, so ace inhibitors, Arbs and potassium sparing diuretics. You wanna stop that one day before their surgery and that surgery reduces the risk of uh achy eye or hyperemia, then during surgery or after and then lithium, you wanna stop the day before and check their US and T FDA S and, and so that's one you really need to know to stop. One that is very, very important to continue is um prosol antianginals, antiarrhythmics, um Digoxin and then just for digoxin, remember to do a pre op ecg and G just in case there, there are wonderful things going on there. Um Respiratory wise, you want to do broncho bronchodilators because if you think about it, you don't want someone you know, having like bronchoconstriction, like if they have asthma, you don't want their or um constricting while they're intubated. Uh So just continue them on that as they normally would. Uh gi ways then. So you want to continue on them, them on their antacids and their PPS. And that's because you're trying to reduce the risk of them having any, you know, reflux and then aspirate, not so continue them and then all your like anti epileptics, anticonvulsants, antipsychotics, antidepressants, except for MAOIs purely because they interact with a lot of different drugs. Um Parkinson's medications, you always need to continue them. They are like a critical met. Um and benzodiazepines you want and then any thyroid drugs. So like levothyroxine, continue it and then steroids is very, very important that you continue that and the majority of people will need an increased dose of that because their body needs to be able to react to that stress response um using steroids and they can't do that themselves. So you're more than likely gonna need to give them. Uh So just that very important to remember and then tamoxifen normally continue that. Normally a very it breast cancer more than likely gonna continue or not. Ok. So um anticoagulants and antiplatelets then, so the wax, you stop them a couple of days beforehand. Um Warfarin then is kind of a tricky one. So you stop it five days beforehand. Um You want to have a good look at their inr. So um whenever they're in the hospital, they'll get it done every day. Um And you want to make sure that that's um quite low and then you might need to bridge them with a low molecular weight heparin or an oxy um from the night before. Um And if it's an emergency, then you check their I NR and then depending on that, you can give them prothrombin comp, prothrombin complex concentrate. Um and that would, can reverse the effects of both uh Warfarin and will um stop that. So that's important to remember as well. Um Aspirin, you stop seven days beforehand, unless a very high risk and you would be like kind of just comes up with, you know, cardio, your anesthetics, then you continue them on that. Um because you don't want them even during surgery, uh clopidogrel and stopped seven days beforehand. Um Trag is five days and then if someone's on that, like if they had, you know, a recent um stent put in or PC done, uh you just discuss them with cardiology um because you need to weigh up the risks and benefits of that. So, um just you wouldn't have to decide that, you know yourself. Um So that would be like a shared decision between anesthetics and cardiology. Ok. So then um diabetes. So a couple of weeks later on this. So they should be the first ones on the operating list. And that the reason for that is because you want as little disruption to their normal routine for diabetes as normal or as possible. So, um, put them first on the operating list, um, preferably in the morning as well. Um, and you want to do their HBA1C beforehand to see what it's like to see how good their glycemic control is. And if someone's going for elective surgery and they have a very high HBA1C, like at 70 then you can, if you can wait, it would be better to wait until it's better under control or if it is urgent and you need it done like surgery done within the next, you know, couple of days you put them on V ri which is variable rate, insulin infusion. So, um that's a very important thing to remember for diabetes around uh um surgery. So if someone's noninsulin dependent, then, so as I said, they're above if, if the perm control and they need the surgery done, like if their blood glucose is great in 12 or if there's a high HBA1C, then you're gonna put them on the variable rate. Um And then for the oral hyperglycemic. So I'll show you this, we uh table here for you. So, um basically all of them, you just take as normal the day before the surgery. So there shouldn't be any disruption there with that Metformin. Then um if they're taking it once a day, you take it as, or taking it twice a day, you just take it as normal, it's fine. But if they're taking it three times a day, you just don't give them at lunch time. So basically, if someone's on Metformin, they're getting it either just in the morning or morning and evening, but nobody's getting it at lunchtime. Um, Sulfon Urea, then for example, Gliclazide, same again, you take it as normal day before and then there's a slight difference if they have their surgery in the morning or the afternoon. So if they, um, have their surgery in the morning and they take it once daily, then you admit it and see them with, if they have their, um, surgery in the afternoon, you want to omit it in the morning. So basically anyone with self gonorrhea who, um, is going for surgery will not get it in the morning time. And then if they're on the morning, but they're get, if they're getting their surgery in the morning and they're taking a BD, you only omit the morning dose so they can get their afternoon dose. Then basically you want to stop it before the surgery. So whenever they come back from the surgery, you can give it to them again. So it's ok. And if they have it in the afternoon, basically, if you think about it, you want to stop the Sulfon Urea, they have before the surgery. So if you take, they take it OD in the morning like that. If they take it b you omit that. So basically the Sulfon Urea, omit it before the surgery and then whenever they come back from the surgery, they can continue it. So if they have it in the morning, they will really come back from that. Take it as normal. But if their surgery is, then you're gonna be omitting both because it's ok. So then the next one is the DPP four inhibitors and it, and the, um, GLIP one, analogs are both very easy cause they're just, um, so you don't need to worry about it as much. And then SC LT two inhibitors take it as normal the day before, but then the day of you on it and the reason for that is because of the um risk of uh hypoglycemia or of um ach OK. So, um pre-op medications then for diabetes. Uh So if they're insulin-dependent, then, so there's a bit of a difference here. But um the Belfast uh have like a protocol for this, which is on this here slide. Um So this is basically just, yeah. So the day before you want to reduce their long acting insulin to two thirds of the dose. And then the day of the important thing to remember is to stop the short acting insulin because you don't want them to one hypoglycemic. And then if they're very high blood sugars, same with the noninsulin um dependent, you start them on that variable rate of insulin infusion. If they're missing more than one meal, again, you do the variable rate of insulin infusion. But if they're only missing one meal, then you can um, continue some things on as normal. So they get their once daily insulin as two thirds of the normal dose. Or if they're on a twice daily insulin, like novomix, they get half the morning dose with meal following procedure. And then if they're on basal bolus insulin, you'll make the breakfast rapid active insulin because as I was saying earlier, you stop short acting insulins and then you can do two thirds of their normal dose, basal insulin. So basically, the important thing to remember there is stop short-acting insulin if they are high blood sugars or if they're missing more than one meal to the variable rate and then most other things, you know, so the once daily and then you just gonna divide that down by two thirds. Um, or if they're on the twice daily, then you're just doing half in the morning. Um, so that's it again there. So this is from the Belfast protocol for this. Um So if you look on the day before the surgery, the only difference they have there is the long acting incident is two thirds the normal dose the day of the um, surgery, you wanna just keep checking the blood glucose. And if it's more than 12, then, um, that's when you start the IV insulin infusion. I know this is quite blurry. But, um, that's right there. And, um, then if there. That's basically just said they won't be on the morning list. And then here, if you're gonna miss more than one meal, you put them on a variable rate in then, and if your, your glucose is 12 or more, then you want to put them on a variable rate. And then this is just what happened last three. I wouldn't get too bogged down on that whole, you know, deciding what to do with that. It's unlikely they gonna ask you any, you know, big questions on it. But I would say the more most important things to know is to stop this and if you know, some people will go on the variable rate and, ok, so hopefully that makes sense. Um, so a few M CQ on this side, um, so a 55 year old patient is due to undergo an elective cholecystectomy, which of the following medications should be held prior. Mhm. Ok. So the answer is to hold hernia chart. So you'll be holding that for from four weeks before, um, the surgery. And, um, then the next one. so a 65 year old man is due to undergo an elective hernia repair. He has type two diabetes which is well controlled with BD Metformin. His most recent HBA1C is 43. He is placed first on the operating list for the morning. What should be done with regards to his Metformin on the day of the surgery? Ok. Ok. So that one is take abnormal and the reason for that is because he's taking the B Metformin. Um, so if I go back to the table here, um, someone who's on Metformin B, you just take it as normal. And then the reason why the rest of them are wrong is, um, so you don't do this with Metformin. Um, and then he's not gonna be placed on the, a variable rate because he is well controlled and his HBA one C is 43. So we're happy enough with that, but he can go on with surgery. And similarly with this, we wouldn't reschedule it because his HBA one C is ok as well as well. So we're happy enough with that. Right? And then the next one. So this one's picture here. Um, so it's 65 year old man has been admitted for emergency cholecystectomy due to uh cholecystitis. The patient is first on the list for tomorrow morning. She has type two diabetes and takes BD Metformin. Her HBA1C is 95 admission blood show normal, normal renal function. What should be done with regards to her diabetes management period. So, um, the answer here is to start the variable rate and the reason for that is because she has a very high HBA1C and she, um, it's an emergency procedure back, it's here. Um, so she's a non dependent and, you know, she's a high HPC. So it's 69/69. Um, So we're gonna put her on the, um, and it can't do, you know if it was an elective procedure, you could just wait until it's improved but because it's urgent. Um, so that is that I, I'm just gonna pause this for me a second. Uh So hopefully that one's clear, but if it's not let me know and I can have a chat with you about it. Um So if her HB A1C was normal, we would go with the, but, um, and then we do with anybody and then we can schedule it because it is emergency. Um And what will we do? Ok. So that makes sense. And so then the next one is VT prophylaxis and this is pretty straightforward when you, if you look at a cardi and look at page two, it, it is very, you know, straightforward, you just tick box and not actually have a and I would definitely, if you go through this because it has come up from before in Queens where they just get you to fill this in and it's really easy if you know what you're doing, but it's not, you've never seen it before. So this is not here. So, um, what to do patient and first and then you just go straight. Yes, and you just, which ones are relevant to the patient and then also bleeding risk, you wanna see what with that? And then they have a high risk of uh or bleeding risk and you decide what. And then on the next page is where you do your, if you look, it's already written there. So um you just put your dose. Um So it's very important, I would advise you to go through that. Um Most people will just get 40 mg of an oxy. Um They do ask you sometimes about the doses we would ask in M CK in fourth year, about what dose of um an oxy you would give somebody. So it is important to remember them. Um But some important things as well is that if they're at a low weight or if they have a Pernal function, then you want to half the dose they're getting or if they're very high weight and you um would give them 60 mg and then if you're unsure about it all you would. Um And then you don't give it to people who take Warfarin as they're within their therapy range. So if you're helping with that, and then another important thing is do not give it to people who are on a full anticoagulant therapy. So if someone's not having their anticoagulants doctor or if they're on one minute, don't give them an oxycontin as well. And that was on one of our exams that she was MC or PSA. Um and quite a few people give a patient who was on epon um an oxycontin when you come into the hospital and that was wrong So, just remember that one as well. Um, and then most people as well when going to surgery will get 10 stoping or? Ok. Um, and this is just some of the things that would increase your, uh, clots. So, the lung, um, surgery, if it's in your pelvis or lower limbs, um, if it's an acute admission or in, you have something going on in your tummy, uh, or if they're expected to not be moving around as much and that would all increase your risk, then some things that can happen, um, during surgery then, so one of them being malignant hyperthermia uh passed is very, very good at going through this. And you'll probably get a lot of questions in past me about this. Um And basically, it's just, everything starts like increasing it. Um So they just get a metabolic response to that and it's a genetic thing. So it's also more dominant. Um, it's more uh common with suxamethonium or ce flaring. And then as I said, everything increases. So their temperature goes up, they become rigid, their heart rate goes up, they get increased, um, co2 output, their potassium goes up and then they get mastotic as well. So they're doing a in this patient and then what you do is you remove the trigger. So major reason and you get the medication called dre. So you did that and then the more important one is a succinum apnea. So that's basically where it's just a prolonged period of paralysis. Um So it's normally inherited or can be just spontaneous. Um And it's at the end of the procedure, then we just don't really start breathing on their own and you just ate them and ate them and they will begin to. Uh, so you just, ok, so some POSTOP complications. So the most common one that you probably will get asked about is postoperative, nausea and vomiting. Um So some of the risk factors, women are more prone to it. Um If you have a history of travel or motion sickness or POSTOP nausea and vomiting, in your opinion, uh opioids, increased risk of it as well. Um Volatile anesthetic patients that will increase it nitrous oxide and then certain surgeries as well. So G A ent neuro or um ophthalmic surgery will all increase your estimate. And then just a wee side note that propofol actually reduces your risk of it. And so that's one of that. And so what they do normally to prevent this happening is they give intra um ants. So Ondansetron is 11 they normally use. But if you give any of these, you can give them all together. Um and they use, you know, they're used in combination then so they um and some of the worst things you can do is um whenever you start up to like over in their stomach because they follow up. Um uh So I'm just not like more. Um And then some, so with the postop anorexia. So I think about the four s so the wound. So if it's leaking or if it uh infection at the wind, so respiratory, so it could help them prevent that are associated pneumonia, the water. So they could have a uti after because people get catheterized during surgery. Um, and then what we do, so that would give a blood trans, um, and then more of a surgical kind of thing, but postop immune and give them the food. And so, uh, POSTOP pain management as well is a very common thing in, um, anesthetic questions. So you can give it in many different ways, you can give it orally IV um through the patient controlled analgesia, um, an epidural, a recti sheath catheter which is inserted between the surgery, um, or a wound, a catheter or a peripheral nerve block, um, which they do the surgery and they get with the ultrasound and then you put local anesthetic in and around that nerve. And so it just really reduces the pain in that, which is very good. Um, and it prevents you from having this morning the side effects. So what you wanna do anytime you're taking more of pain, you do your pain, I'm sure you all this, but basically start off with your lower and second part. But with a lot of, you know, big operation that you're gonna have to start the higher and because you're, it is very, very painful. So it's gonna be sore. Um, so you might there as well. And so then it's just the right PC. So you can give it IV or you can give it epidural. So this is one here and as you can see there, it says epidural use only. So that's going to, um, and then there's a mix of things that we call it. So this one has fentaNYL and give the ski. Ok. Um So that would be the um and then this is this box not has the um drugs in it. And then this is the we uh remote that goes to the patient and they press this little button and it will deliver uh the either set up. Um And then it goes into this period. Um And that's prevent them from that. And then this screen for shows the nurse how often they're pressing it and how much they've gotten and things like that. And then the nurse will do that specific news chart. Uh So you can see how much um analgesia person has gotten over the time. Um And the very important thing to remember is you don't prescribe any additional opioids. So if you are called the patient like this, who is still in pain, don't be writing them up for more morphine or anything because you put them a very increased risk. Um And these ones are these normal be under care of the pain team. So um the nurses will come around the nurses and uh review them every day to make sure that they're not going too much. And as at home as you shouldn't be changing the. Yeah, so um next one then is uh spinals and epidurals. So, um this is the difference between the spinal and epidural here. So this uh injection, which is, you know, so um this is the spinal one. So this is like an injection and it's going actually into the spinal area. So it's going into your uh CSL. So you need quite a low amount of opioids for that because it's already in the CSF. Um and it's placed at L3 or L4. And the reason for that is because that's after the end of the spinal cord. So if you're inserting this needle right into someone spinal cord, you don't want the in certain. Yeah, because you could do a lot of damage there and spinal cord. So you wanna put down here to see uh il four, that's a one off injection that you normally get before surgery. And whereas epidural van, so it sits in the epidural space. So that's the epidural catheter there and it's just sitting in here and you normally need a higher amount of it than you would in spinal because it has to cross over the gerra to get into the spinal column. So you need more of a, have a um difference um, and it's usually a mix of a local anesthetic and opioid in the last third side of the, uh, PC. And it's normally a catheter placed and they get the continuous infusion of, um, whatever it is they're getting and, um, you can get that for a long period, you know. Um, and then you'll also probably see this one where you're in, um, uh, getting will get, that's probably the most common place you'll get. Um, but you might also see a big difference for pain relief and um, surgeries like C A options sometimes get um, so complications and so uh postural uh headache and basically after you've punctured, so you reduce the emergency range in their brain. So they get a little pressure headache and a very dull headache. Um, it normally gets worse whenever they set up. So you wanna flat and getting a bit of paracetamol and it will go away. Um But it's just very annoying for patients. Um, and then analgesia might not work properly. So, um there's a lot of like horror stories about um women getting these around the time of labor and they only working on one side and stuff. And so that is the risk of it. Uh You, they can get hypotension and that's because you're blocking their sympathetic nervous system. And so be aware of that. You can obviously down in your spinal cord because you're running a needle. Now, there is like a lot of things that they do to prevent that. So they get them to bend really far forward and to increase space between that their, uh, vertebra and the needles have like a dull end on them. So if they do go in there, then it's not really gonna do much damage. And so, but it is obviously ok, so then a wee bit about local anesthetics. Now, um, so one of the important things to know about is the additional adrenaline. And the reason you do that is because adrenaline, as you would know is a vasoconstrictor. And there's two reasons why that's good with local anesthetic. It's because it reduces the amount of lidocaine that's gonna be uh absorbed into the systemic um site. So you can use a higher dose of lidocaine that can stay around that area that you injected it. Um And then because of uh causes that vasoconstriction, it will also be less bleeding. Um which is good for you um in somewhere you don't wanna. So that's good things to remember. But the very important thing is that you don't use adrenaline and per so if you think that if you put your adrenaline to someone's finger, you've cut off the both do that and it could go. So you don't want the doses. Um There are because there's loads of different uh local anesthetics. There is a highly different doses you could remember. But the two that I would really remember is the lidocaine and lidocaine with the. So lidocaine is 3 mg per kilogram. And the lidocaine with the one is 7 mg per kilogram. So I would try to remember them. So there's other ones you can learn and stuff like that there, but I would say they are the three that are most likely to come up. Um And then it's also important is that after the obese you use and then this 1% solution. So this can be quite tricky for some people to remember. But basically, if you think about it, what that means that 1% solution means that there's 1 g of the drug like the lidocaine and 100 g of the solution. And then 100 g is the same as 100 MS of that solution. So if you think about it, then if you multiply if you, so there's 1000 mg in 1 g. So that means that there's 1000 mg per 100 mills. And then if you divide these by 100 you get 10 mg per milliliter. So 1% of the solution, 1% solution mean it's 10 mg per milliliter. So if you remember that, um then you can work out how many mills to get something off of the anesthetic. So um that's just a couple of different few questions. So if you want to sort of think about that, um so 1% 0.25% and 0.5%. So concentration of that. Yeah, that's in there. Basically what you're doing. So if you think about the 1% solution is equal to 10 mg per milliliter, basically what you're doing is you're 10, so 0.1 or probably 10 is one so on and so on if you even remember it like that. Um OK. So then the local anesthetic system toxicity and this is very important to remember. Uh So basically, if the local anesthetic gets absorbed into your systemic system, um it can cause a lot of problems. So for example, if you don't go by this and you give them too much anesthetic, this could happen. So this is some of the signs and symptoms of it. So it starts out sort of mild with the tingling and that the headache, uh lightheadedness. Um and then it becomes more serious with the convulsions, coma and loss of consciousness and they die from it. Um And the important things you need to remember is how to manage it. So you get this lipid rescue kit and it has this um intra 20% intralipid um by that. So you wanna obviously stop the local anesthetic if it's still going call for help, get your fingers. Um do your supportive management like it's some oxygen. Um and then you want to do like if it's any, you know, bad nutrition, for example, someone's pain, um things like that. And then the most important thing is that and that's how much you need to give and then you get the infusion. Um and this has that in it and also has um and stuff in it. So this is just a wee N CQ on the aesthetic. Um So a 68 K meal requires citing of a wound on the forearm. You decide to use lidocaine 1% solution. What is the maximum dose in millimeters that you can use for this patient? Give me a second, get the answer to the doctor. So the answer that is the um and the reason for that is because of the we back here, we said lidocaine is 3 mg per kilogram. So write that out and then three months later by 60 60 mg is 100 and 80. So that's how many milligrams you wanna give them. And then it is a 1% solution. So as we were saying, a 1% solution is 10 mg per milliliter. Um So then if you divide 100 and 80 by 10, you get 18 millimeters. Um important things to look out for is if they change us to a 2% solution, then um it just means 20 mg per millimeter. So just be aware of that. It's not always that and then if it's um uh if there are on adrenaline for as well, it's not 3 mg per kilogram. It's um um so just remember that as well. Um We can get you on uh there's a good bi of questions on this, on the medical portal. Um Have a, we think about it at the end if you go on to year four and then go to emergency medicine, I think it's called like the Teaching. Um And towards the end of it, it's very, very long documentary. So I wouldn't be intensely reading all of it and there's some things that pretty much into, uh but there's a good bit about it on local anesthetics. Um And they have a good section of where you can work out the doses. Um And then it gives you the answers to them. So you can see how you're getting on with. That's why I really advise you to go to that and sit and work out the different doses on that um every month. OK. So then um moving on to the airway miniver. So I say all that like, but um this is something that could definitely get you to in an o to and so the head to lift everybody know you got there. And um so this is it here. And basically what you want to do is you want to move their tongue out of the way it airway. So you're open up their airway and um open urine. Um And the important thing is it's contraindicated, but you want to keep your neck as straight as you can. So if you're movement, then with your head tilt and you can cause a lot of problems, so don't do them. Um And then a jaw thrust, as you can see here, you keep the head neutral and you're just pushing the jaw up. Um And you want to do that in, right? Um If you, in, in, you will be able to do your uh jaw quite a bit and then are very good and I'll be able to show you gen right along, you know. Um So I would definitely do that. Um, and then airway devices. Um So there's four different ones will go through each of them. So there's the, there's the oropharyngeal nasopharyngeal slo airway devices, which is the LA or an HL um um or a endo so, um this is the nasopharyngeal and the oropharyngeal. So this is the nasopharyngeal uh here. So, um, as you can see, you're me then from the person's tragus to um their tip of their nose. Ok. So it's soft, it, so, so from here to here, um, but you can get different sizes of each of these. So that's how you me, um because if you think about you're doing it the way it's gonna sit, but if you know it's gonna go that way, so just make sure. Ok, and then, so you do not in, if you think someone has ac and the reason is because if they do it's gonna go up, so you really, really do not want to do that or if someone has trauma to their nose. And so I know you do not want to put it in or if they're bleeding in the nose or if someone's no one to have like, um, very polyps or if you shove up and pee up there, you could end up and then cause a lot more problem. Um And that, um, so you lubricate it and then, um, so hopefully you should we go that. Um, But it's very, very easy. You literally just, um and then, uh or oropharyngeal or sometimes called the, um, so the way you measure these is again, if you think about the way that it's gonna sit in there, right? It's gonna go like that. So what you do is you go from their incisor to the angle of the jaw that when you measure it up. So these are the three different size here. So it's gonna be one of these is gonna pick up. Um So you put this bit, this bit goes through the mouth and then this bit is the of the jaw. So, um if you have something like that and you'll know what um size is or its right side. Um So if someone's like conscious, if you show that into their mouth, they're gonna start choking on it. Um So you don't want someone who conscious there. It's actually, if you're, if you can put an op in someone like them digging it or pulling it out, it's a really bad thing with that person very well. Um And we really need to contact and so it quickly to come to see that person. Um And then anyway, put it in so you put it in upside down. So you put it in like this. So if you think that it's sitting like that, would you put it in like this? Enter a man? Turn a so, ok. So um other airway devices and so the Slavi Airway device, so the most common form of this you'll see is the el which is this top one here and you get it in three different sizes. So the orange, the uh green or the yellow one. and basically the way they work is that they, the bit that sits in the bottom, which is the thicker bit and the whiter bit um it, it's just above your uh s and it's like a squishy kind of gel. So it, whenever it sits inside the person and then it'll start to like melt a little bit. Um And then it'll form like a see then around their airway. So that's the way it works. So they're very, very easy. Can literally just shove it in um with the RF and you um and the bigger bit is gonna go. Um So that's where you put it in. Um And then the older version, this is a laryngeal mask airway. So this is in here. So they have this cuff um and with a wee line up here and basically you just put in, there's we in line and you just take a wee 10 M range and you attach to that and you push in on, in. Um So you might see them a large as well and people using them and they can, they can also be used for sure you do that. And, and so yes, size based to patients with. So it normally say here this black right here, which you would choose. And so people um and then they have like a week. Um So yes, they, you take them out of this plastic piece as well. So don't, don't. Um And it's not, so it's not the same as endotracheal goes down beneath the epiglottis, but this is a um so it's, it's not the best for someone if you think. Um ok, so then yes, some of the pros and cons are already um talk with the list. So it's very easy in, shot in. Um And it's very good that you can use in the emergency and cons uh you're likely to infect their stomach, which mean afterwards they're doing a lot of and there is there and it can cause spasm and there leaks. Uh I just say there's because you're not completely away. Um And this is just some fast because there and, and base the pregnant under the because of the risk. Um No ab and or increase is OK. So then this is the last of them, the airway device. So the endotracheal um intubation. So this is it here if you can see this. So this is the endo here and this is the way it sits in patients. So this puff sits outside and you inflate it off air and then it will in this little so that you're seeing off that person's um airway. So then if they ref up or not into their lungs, um And this is a laryngoscope and that is how you, uh and most of them camera at the end so that they can actually see things inside airway and a lot easier. So this is the only defend of secure airway. So this is the most secure one of them all and gonna protect you from the aspiration and, and avoid CG and it also really o so, ok. Um And um, and it's a more so person. So, um, or someone who been this, uh these are some of the complications. So, esophageal intubation, that's if you go into their esophagus and instead of into their uh trachea, trachea, then you're going to inflict basically the whole stomach and that, and that's obviously not what you want. Um Because then they're not getting into their lungs and you'll know that that's happened because they're um, will just be from, the patient will be rising, um, and breathing. Ok. So that's something you know, would be by and just take it out, make sure. Yeah. Um, endobronchial intubation. So you put it in too far, you'll end up going down into one, bronchus and not the other. And the way, you know, that is because you have all rights of the chest because one e, one side is getting pretty much and the other is getting numb so that the chest, um, and your nose well as well. Um, and then that's, yeah, but the main problem, yeah, so oxygen is delivery then. So there's a cannula, I'm sure you have all seen this in the ward that's sort of the most basic one. and you can deliver quite a low uh flow rate of oxygen through that 3 to 4 L per minute. And the problem that it is cause it can cause your um nose to dry out quite quickly. Um So it's patients that they on like 4 L for a long time, then the hot and face mask is just 5 to 10 m. That's just the basic um face mask and then this is a non breather mask. And so you'll see these are in EDA lot. Um and they're up to 15 L per minute and that's what we use for someone who's very unwell, as I was saying, ABCD. So if you A B and someone is very, not good with their oxygen, um and the important thing is that you fill the bike, so they'll be able to tell someone has used this before very quickly by if you know that or not. And the way you do it is you take your index finger and you place it inside the mask and there's a little valve that just sits on top of that and you just press down on the valve and it will then fill the b with the here so that they're not getting centimeters. So there's no point in using breather if you're not gonna fill. So that's important to say that. So then another one. So venturing mask. So I never learned the um different colors. So different colors have d have different sizes and different amounts of oxygen that they let you get them to a patient, you know, uh per minute. So this is the different colors here and you know, like the blue gets 2 L per minute, the red gets tenter per minute. Um They're supposed to be used in CO PD patients who retain um CO2 because you can get them at a fixed rate of oxygen. Um Whereas those in the previous side, these are all variable because you can change on the about the amount of oxygen you're giving this person, but these are very fixed that it will only deliver that amount to them. Um You can learn these on the top but it just the, you know, the oxygen is gonna different. Um You can learn these if you want, but I don't think we've ever been examined on them. And they're not used very commonly in northern Ireland either. So, um, you can watch but, but we haven't been, um, and then the hy on nasal oxygen is like the air. So that's an example of it down on the corner there. So, this was used quite often for people who had, uh, COVID way back then. Um, and it's just warmed, humidified air and it goes through like a bubbly, you'll hear it because it's like go through, I just straight out so dry out there was basically, um and you can get some serious, which is a lot more than like any of these ones. Um And it creates such positive end exploratory pressure so that in the lungs and keeps them open. Um And that's why we do it. Ok? And then um just the, so you're not, you're not breathing. Um So yeah, you were seeing one COVID patients. Um But everything else may need more. Um Yeah, and then if I buy golf mask, um you could definitely get us to do this in. Um we haven't, but it has come up for over many years. I think the year above us whenever they were in fourth year, they got in the airway station where they um had to use the bag valve mask. So they had to show them how, you know, first of all, how on a man and then the jaw thrust and then the bag valve mask and talk through what they were doing and show their technique. Um and F and B and then they talk through like an NP um the Super Air. So we need to know what they were doing um for each of them, how to use them. So that could definitely pop again. Um And you can find a fee on that, on, you know, the on the portal. So we see you back, not, not last year, but the year before. Um So, but some bi bi this and so you hold it either like that, your right there man or you can hold it like that. I'll show you the next side of your thumbs over the um sides of your leg, the leg. Um um So yes, these people who are unable to brace themselves um for example, if someone you know, was in cardiac arrest and, and you can connect the uh and you can use it with the airway. So you have some of the um given by. Um And then it depends on the, which is why you like to not very good, they're not. So this is how to do it here. So this is one of the options. Um You can do it or you can do your or you just, and then this is just a red um uh 12 mask here. So this is that in your life. Um And then it's connected on to this uh this and you don't want to press all way down really quickly because that's not, if you want just a bit like that there and small. So about half way down and just very slowly. Not that, um, because you get more pain, um, because you're just kind of air into their uh, lungs. Um, so this is that how you did and, um, yeah, you can connect it to the. Ok. So, um, and so this is the additional resources. So as I said, and I think that it is actually very good specifically for anesthetics. But there is some, it's like a very long document. I wouldn't be sitting doing an intensely reading at all. Um But there are parts of it that are very, very useful. Uh And then oscopy stuff as you show is very, very good and then page 100 and 72 has a bit on it. And so I would go through that, you know, in grip it can make scenarios for each other or not. And then as a scenario, but the, the rest, um there's a couple of things I haven't covered like um tracheostomies now, but they very, very rarely come up. Um And then next year before you become an echo, that sort of thing. Um But whenever you're stuck, I just anesthetics or, or both and basically, you just start taking things out um and never put a new in and because you or anything, so just even just So you start taking part. Um and then yes, certainly not. So that is me II see on here, I'll send him into the chart and then if you fill that in and you'll be able to get the um, so it's on that off. Yeah, and if you have any questions you yeah, or me right into the shot or yeah, you can send a mental or you can yourself or whichever what? Thanks so much. Thank you. Thank you. Thanks.