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Ok. Hi, everybody. I think we'll just make a wee start here. Um So my name is Arnold Anor. I'm one of the F two doctors based currently up in Causeway Hospital. Um Today I'm just gonna take you through a perioperative medicine. Um, anesthetics. Really. Uh So II appreciate it is a very broad subject. Um We might not get through everything completely, but I'll just touch on a few things, sort of key to the topic. Um So that's just a, a brief summary of everything that I'll be chatting to you today. So I'll just be through it here just so appreciate. It's a Friday night and you are all um online, which is for plenty. So just to begin with, um those are just sort of just like the, again your objectives or conditions um for the G ND for preoperative medicine and anesthesia just included them in there for your own reference. So I just wanna start off with IV fluids. Um So I'm sure you all know the indications for the IV fluids is the five hours. So, resuscitation, routine maintenance, replacement, redistribution and reassessment. Um I've just included the fluid status assessment. It's not really coming up really. Well, I apologize for that, but it's really, you're going through the patient just to see um how they assess. Are they euvolemic, hyperkalemic or hypokalemic? And key things in those that you're going to be looking at is looking at the patient having, looking at their BP, their heart rate, look at this, you know, the JVP, listen to their lungs. Are they overloaded? Is there cracks there? You wanna feel the pulse? Is the pulse good volume or is it thread? Um You wanna look also like mucous membranes? Are they dry? Do they feel thirsty? All on down to the ankles? Have a look. Is there any pitting edema or um is the skin quite dry? Is a reduced T and then have a look at the blood? So you, and is there any evidence of an AK I um if there's a BNP available too, if it's raised, are they at risk of um overload or factor to heart failure? Also, recent echoes and chest x rays are really helpful before you consider giving anybody fluids. So there's um different types of IV fluids. Um starting off with crystalloids, you guys as F ones and all will be using crystalloids quite often. So that's your Hartman's, your dextrose, your normal saline. Um Hartman's and normal saline are both isotonic. So what this means is that they're both equilibrate, equilibrate between the intervascular and extravascular spaces. Um Dextrose is a hypotonic solution. And it's just really important to note that it has no role in resuscitation. Um Dextrose really is a way of giving basically water into the body, especially the 5% concentrations. So, you know, the dextrose is rapidly taken up by cell which leaves really the the water component in the intravascular system. So it's really, it's really ideal for maintaining hydration. But um obviously, if you give water directly to a patient, you can call the lysis and it's quite dangerous. So the only way you can give essentially water is through the 5%. Obviously, there's higher percentage dextrose that we can use with um for the likes of um DK um starvation ketosis, sorry um to try and bring down the ketones and they will commonly use the likes of 10 and 20% in statins such as ICU if the ketones are raised and there is a suspicion of starvation. The next one is colloids. Um you probably won't use these as much. Um So these are solutions with large molecular weights and it's aiming to maintain the oncotic pressure within the intravascular compartment. Um There is limited research to suggest of their benefit in resuscitation. And examples of this, you will use blood commonly, but the other one is human albumin solution. So there isn't some of you, if you have a job in gi you will be using that um which will be, you know, given albumin to people who are getting acidic taps to drain ascites. Um Other uses that you will see it very commonly is an ICU as well. So people will often get a furosemide combined with a human albumin infusion. And that will try and drop fluid from the um third space essentially into the intravascular compartment. So then the fu can then push it out of the body um but not commonly used on the wards. Really. At least I don't think it is anyway. Um And then lastly blood. So it's a type of ide um fluid as well as your pack red cells, platelets, FF PC precipitate. I've just added in really your maximum infusion for packed red cells is 3.5 hours and you can add F out for that if there's a risk of tackles and then um, platelets are 30 minutes. But any trust that you guys go to there will be guidelines that will help you along the way if you're unsure and it's ok to refer back to them. So in northern Ireland, there is a regional fluid balance chart. Um it's starting to be out outmoded essentially and we're going to this which is fluid prescribing un encompassed. So, um the likes of the, the Southeastern Belfast and Northern Trust now are all an encompass. Um and the way of ordering fluids is you'll go onto your orders, type in your fluid and then on the right hand side, there's what will come up for you in order to prescribe it. So it's really straightforward and you guys will get the hang of it if these are going to a trust with encompass. So, starting off with resuscitation. So it's chrysalid fluids only and it's your 0.9% saline or Hartman's usually 500 mils given a stop, which means it's over 15 minutes. Usually. Um you can also give lower volumes if you wanted. Um and also run it at a slower rate and these are in patients who are very risk of very high risk of overload. Um You will never use Dextros as resuscitation and never add anything to the bag such as potassium in Mastin as well. So just going to kick off, start getting you thinking a wee bit. Um So the first case, um want you all to put in your ideas into the chat if you want, if not, you feel free to listen. So Mrs Robinson's 33 year old female, she presented to Ed with lower abdominal pain and syncope. She had a positive pregnancy test seven weeks ago. Her shots are 98 on room air. Uh heart rate, 100 and 25 systolic BP, 82 and respiratory rate. 18. So what fluid um and what rate would you guys consider prescribing this lady? So feel free to put your answers into the chat if you want or speak up, it's up to yourselves. If not, I can be it on and to be the answer. So I'll give you a feedback into just to get it. Have a think. Ok. Yeah. No. Uh, that's 100%. Yeah. So she's a young woman. There's no real other history here. Um. Oh, sorry. Uh, so, yeah, 100%. I would be thinking of giving her 500 mils of normal Saline that, um, or you can also go Hartmans either or it doesn't matter in that, that I mean, the risk benefit of she needs, she needs fluid resuscitation. So that's 100%. So this wee one just requires you to think a wee bit more and we're turning a couple of other things in with it. So, Mister Jones is a 74 year old 60 kg male. He presented the Ed with new onset confusion and Rs his stats are 96 and rumor heart rate 100 and 30 systolic bp 60 1039. His family's f he thinks they think he has a bad heart and an echo two years ago shows an ejection fraction of 50%. So first question is what fluid would you prescribe? And what rate for this gentleman? So has to pay particular attention to his age, his weight. Um You know, the whole history with his heart. OK. Uh I was like I just with the interest of time and I have a lot to go through. Um Yeah, no absolute. That's perfect. Yeah. So for this gentleman, I wrote 250 of Normal Saline or Hartmann Stat. But over 30 minutes is also perfect as well. Like you, you know, you can kinda with a smaller volume you can give, you can always give more. You can't always take it back for people who are really high risk. You can try and um, you know, you can, after every bag you can assess. So every bag of fluid you're prompted to reassess the patient to make sure that what was the effect of that fluid? And if you're given a smaller volume, you're reassessing and it's quite safer that way. So, yeah, 100% anything else that you would want to do in this situation? So I'm just gonna be on. So they, what you want to do if you want to get a brief history and examination and I'm saying brief there is because from that case, um, description, this guy is pretty unwell. So you don't want to be spending too long on getting a history. You want to try and start your management really quickly. At the same time, we've given him the IV resuscitation fluids, we've done the sepsis six. And because he's an older man, the likelihood of him being on a rate of medications is quite high. So you wanna go through that list to make sure there's not any antihypertensives or any other drugs that would, um, precipitate or, you know, worsen au AK I um or make the situation worse than you actually needed to be. And I've just included the we acronym, you know, stop the Dam drugs, which is the drugs that you would need to consider. Stopping if somebody has evidence of an AK I also include your set is six. I'm sure you all know it by this stage. Um So you have your antibiotics, fluids, oxygen cultures, lactate and then urine. Um, antibiotics is quite important. You have to get that within one hour of the patient presenting a septic and also obviously take your cultures before you get these antibiotics. But with this man, um obviously, you'll go by your trust guidelines with what choice of antibiotic you'll go to most trusts in Northern Ireland anyway, will go with IV Tazo, but they'll also have regimes for if they're kind of allergic. Um So the trust I'm in at the moment, the Northern Trust, they will generate the microbiologist will say because he is showing signs of hemodynamical instability. We'll also add gin for um gram negative cover. So it's just really important to keep to the trust guidelines and just a wee F II just sort of on the back of that. So a lot of people think with Hartman's because it has Lactaid in it, this would precipitate and worsen Lactaid acidosis. But actually, it's the way Lactaid is in Hartman's. It's the only way that we can get bicarbon to the body in a bag of fluids. Um So in the actual sense, it might actually help with an acidosis if there's great volumes of apartments given which you're realistically not gonna do in most patients. But um, the overall pointed that it will not worsen an acidosis. So, moving on to back to our case. So Mr Jones, he's been given 2 L of fluids. He's noted to be fluid responsive to this. However, after some time following fluid administration, his BP drops again and his map is less than 65. So just a wee site note in anesthetics ICU, they will go by maps and their target usually is 65. So if it's less than 65 they'll be starting to want to do something about that to target about this. You've also noticed Mr Jones becoming more short of breath with new oxygen requirement of 2 L on nasal specs and as your eyes begin to tail off. So, what would you do now? Oh, ok. Oh, sorry, I've just jumped on. Yes, for this gentleman. He's got refractory hypotension. So this will be then prompting you to do an IC ICU referral or consider it at least if it's appropriate for this man for vasopressors or inotropes. So, vasopressors inotropes you your adrenaline, you're no adrenaline and you can also these, these sorry are actually given through a central line which is usually inserted into the neck in one of the, um, juggler or juggy veins on either side, excuse me. But you can also give um peripheral, you know, aedine to kind of tie them over until a lot is done. Um You can also go uh bedside echo as well. Um If they're trained in point of care echo or point of care ultrasound, some people will be able to do a bedside echo just to check the ejection fraction. Um an ABG and a repeat chest X ray is also very helpful here, especially an ABG. If his urine is starting to tail off, your ABG, will not only tell you about the oxygenation of this gentleman, but it will also tell you if he's acidotic and if he has impaired renal functions in his U and, and he's also acidotic, you would also maybe be considering as well. Um An I CUAC RT, which is a form of dialysis that is delivered acutely in ICU. And for your IC referral, it's very important to get a collateral baseline functional history from the relative if you, if it is appropriate at that time, you know, and you have time and the patient is safe and stable and or there's other doctors with them. So they are just all the questions that ICU would really like to know. Um and that will help ICU sort of guide their treatment, they could put limitations on if they feel appropriate. Um So it's quite, it's quite useful and they'll also see if there are a good candidate for ICU with those questions as well, moving on to routine maintenance. So um there's a lot there in that slide, you know, you're aiming 25 to 30 mil per kg per day of um water as well as one M mol per kg per day of both sodium and potassium. And generally the rule is you can only, you can give maximum of 10 million moles an hour of potassium. Um And the max concentration in bags available on the ward is 40 millimoles. There's also 20 milli m bags available. Uh You'll never add it to Hartman's as well. Um Glucose requirements is about 50 to 100 g per day and just to kind of give you a wee bit of context. Um One bag of 5% extra, sorry is there's 50 g in it and included the one salty two sweets. So if patients are going for surgery and they're fasting, sometimes surgeons will also like that one salty too sweet. So it's one bag of normal feeling followed by two bags of 5% dextrose. Um And then you would want to check your fluid balance charts. So in the fluid balance chart, it's quite important to note IV medications as well as enteral or para enteral feeds are all included in your totals. And whenever you're on the wards and you know, or you're in a ay or something and you're being told to uh, prescribe routine maintenance, you wanna ask why this person needs um maintenance fluids. Um You wanna see if there's enough being occur, it can be achieved from a encourage and oral intake. Not possible. Obviously, if they're no by mouth, you wanna see also if there's a reason to uni for this person as well. So another case, um we have Mister Morgan, he has been admitted to the stroke board. Um his follow has not yet been assessed by the Salt team and therefore he's, you know, by mouth. He is a back round of type two diabetes hypertension and CKD one. He's 82 kg and a recent year is uh shows no electrolyte abnormalities, but his renal function is slightly reduced. What maintenance fluids would you prescribe him? Mhm. I'll give you a minute just to have a rethink and then I'll just go on with it. So there's quite a few options you can do for this. So there's a couple of options there you can give for this gentleman. Um So you can, again, it's a mixture of 5% Dextro. So there's your two salty ones sweet at the top. Um You can also give but not the volume, sorry. Um You know, they're not giving a liter, a liter, a liter. So make sure your volumes is matching that gentleman's body weight as well because 2 L of fluid to someone who's 82 kg is completely different to someone who's 40 kg getting 2 L of fluids. So just be very mindful of your volumes whenever you're prescribing maintenance fluids. Um, there's one salty, one sweet or you can have your 5% dextrose normal saline on Hartman's mixture as well. So you've got a few options there. Um, so just a quick note about replacement and redistribution. Generally, the rule is if you have upper gi loss is like vomiting, you're replacing with normal saline with or without potassium. Um, lower gi losses are normally replaced with Harman's and you want to check first if the potassium is ok. Um Just to make sure they don't need additional supplementation of this and you're aiming to do this over 24 hours. So this is quite a difficult case. I appreciate, but um we'll, we'll go through it nonetheless. So Mrs Johnson is a 56 year old female who has day six post laparotomy um for subtotal colectomy, his, her oral intake has been poor. She's been getting IV fluids, daily urine. I put approximately 25 mils an hour and you've noticed her and that her sodium has been dropping every day. So what would you do next for this lady? So just a wee note on hyponatremia. So obviously you would have the game guidelines or the other trust guidelines, whatever they want to go by in each trust. Um It can be classed into generally hypovolemia, euvolemia or hypervolemia hyper hyponatremia. Um For these patients, you wanna get, you know, your urine, electrolytes, urine, urine parts urine, um urinary and serum osmolality. Sorry, and that will help you guide, you know, and your fluid assessment. Sorry, that will help guide what type of hyponatremia this person is. And that's quite a good what I find that really kind of summarizes it all up for you. Um Don't be worried either. I'm sure. I think you've got these slides so you can go through this again at your own pace. So, hyponatremia. So we, we, we had a look at the guidelines for the management. We did a clinical uh hydration assessment and we found that she's euvolemic. Um We check what fluids she's been getting and it has, it seems to be a lot of dextrose, but there's some sodium being given. We checked the urine output and we wanted to see if there was any IV any response when she was getting IV fluids. And by this, I mean, when she got IV fluids, did her urine output go up a bit which would tell us, you know, is she responded to this. Um But no, she didn't, her urine output has remained 25 mils an hour on average. Um We sent a serum, her, sorry, we sent a her serum and urine hospitality as well. The urine for electrolytes, we found her urinary sodium is less than 20. So spot diagnose. Who thinks what, what, what's this condition this lady has? So if you wanna think of it, she's POSTOP um urine output hasn't changed with IV fluids. Her urinary sodium is less than 20. Anybody wants to have, I'll go back to the slide if anybody wants to have a wee guess at what we think this lady has. Mhm. So this lady has si A DH. Ok. So it is, it is, it can happen postoperatively. It's quite important to kind of be mindful of that um, in POSTOP patients, especially if they're post laparotomy. It was just big enough in, in uh surgery and the management of this is through fluid restriction. So whenever you have somebody with SI A DH, you wanna keep a crude eye on their urine and see how much urine they're cutting out an hour. And basically you want to match the rate, the rate of your fluids is going to match the rate of the urine coming out. Um And then it's also important if they have a A DH or signs of this with the hyponatremia, one of your other um, investigations to rule out any other causes of it. So, malignancy. So, you know, lung cancers, you want to do um CT CF or an MRI and then another treatment of it is you can also give to. So, moving on to our preoperative assessment. So what is involved? Obviously, your history examination, your assessment, your baseline investigations. Um And the key ones in that is your F PP, your EC A N FT S also gripping holes as well. Would be very useful if, if we could get them, if it's not an emergency situation, all of this will then help guide what the A SA grade is. Um we'll then have to assess the surgical severity and then have a medication review. So that's a big massive busy slide of all the histories that would be involved in an anesthetic, preoperative um history. So again, if you should be getting these slides, have a wee look at that in your own time and quite useful as well for um I imagining so your airway assessment, so things that we'd be looking for for this is the mouth opening, the job protrusion like involvement. Um You want to do assess your mampy score and this will predict the ease of intubation and there's it on the right hand side there. So it's basically assessing how big really the the soft palate uu uvea. Can you see it at the back of their mouth? Um And then dentition didn't have any dentures in cause they need to come out. Um And also a key thing to warn patients when they're going for operations that there is a risk of injury to their teeth um moving on to the A SA grading. So there is, it's from 1 to 6 and it is basically deemed on how fit and healthy the person is. The more unwell. Basically, they are the more comorbidities they, they all have the higher the score becomes um, obviously at number six, that person is brain dead, um, or they're confirmed brain dead by brain testing. Uh, again, this a very busy slide, which is kind of a we look at it in your own time. So it's basically, um, you'll, you'll assess the person based on your history for the A SA grade. You will then go, these are the nice guidelines. You'll then go to the A SA grade accordingly and see if there's any investigations that you make sure you have done before the operation, your surgical severity. So you have minor intermediate major complex. So your minor is just like in the brain ab uh breast, abscess, skin lesions, very, very minor. Um intermediate is, you know, your excis fans, inguinal hernias. Your major complex is your intraabdominal surgeries, like your laparotomies, your, your spinal, your total joint replacements. It kind of self explanatory as well to some degree those just your guidelines with fasting. So you have two hours before anesthesia, you're completely nil by mouth and then from 2 to 8 hours, there's different things that you're allowed in those time frames before your procedure. Um It's quite important to make sure patients know this before they are scheduled for um operations completely delayed or I think, or the patient doesn't get the operation at all and they make for very unhappy people and moving on to the uh medications. So I've summarized it all as best I can in this slide. So starting off with the PTE every there is a regional assessment tool in the card on, on, it's very self-explanatory, it's basically a tick box. Um And it kind of assesses is this person, you know, high risk of bleeding or low risk of CT, are they um you know, high risk of BT, low risk of bleeding and so on and forth. Um And that will help you to see if you consider pharmacological prophylaxis, if there is an increased BTE but low grade bleeding risk. And this is for enoxaparin. So everything I should tell enoxaparin is very important to know their weight. If you don't have their weight, it's ok to try and guess and just err on the side of caution in some patients if you're really unsure and um look at the renal function as well. Um because I'll show you a wee side next, that will show you um a good breakdown of your oxy doses. Um, blood thinners, all of them have different time frames of when they need to be held preoperatively. So your an oxy, if it's a prophylactic dose, you usually hold it about 12 hours. So they usually get their, if they're scheduled for surgery, say at 10 o'clock the next day, their last dose of enoxaparin will be at 10 o'clock the night before. Um, if they're on treatment dose, um CeleXA, you want to be holding it for 24 hours. Dabigatran is 18 to 96 hours that may change. It might be, you might give it a wee bit longer to come out of the system and this will all be based on your renal function. You pick the Band river guidelines also 18 to 96 hours, but usually it's 48 hours and that's if they're getting like a spinal block, for example, Warfarin is five days and in that five days, you're bridging that person with enoxaparin. Um You want to keep a wee eye on the inr s and all too aspirin clopidogrel tore. Uh proo is all January 7 days when you uh there's guidelines on steroids as well. If they're taking, if this person is on, say 5 mg per day of steroids, they don't need additional steroids in surgery. Um But if they're taking more than 10 mg a day, they may need additional steroids and it all is dependent on the severity of the surgery that they're going for. Uh There's quite simple guidelines as well there to what to give that person if they're going for minor, moderate or major surgery, other medications need to be considered and stopped your uh contraceptive pills or hormone replacement therapy. So you want to give these to four week, um lithium as well is 24 hours before major surgery. Uh You want to keep a wee eye also on the UN and the T FT S because lithium can have an effect on these as well, they can cause a dip in the renal function and hypothyroidism. Um, ace inhibitors. ARB S, potassium sparing medications also need to be reviewed before operations. Generally. Um, I was on the trauma ward, um, in the F one and generally we use just held the ace inhibitors and ARB s on the morning of surgery, but every anesthetic, um, or anesthetist will have their own preference and would usually specify this. Um, mis just caution with these because they're very, um they have a lot, they can react with a lot of other drugs used with in operations and then herbal remedies generally two weeks before. So this is what I was talking about about the PTE prophylaxis and an oxy. So this is the Southern Trust guidelines and I thought they were quite useful because it breaks down, you know, um the dose for PTE prophylaxis based on their weight. Um And then also what would it be if their renal function was impaired as well? And what, you know, you know, the EGFR less than 30 is generally the, the threshold and then also the PTA treatment. So it's a very helpful guidelines. Every trust should have them. Um But it's all that include this because the Southern Trust is pretty easy to follow. And again, um if you wanna go down to the wee preoperative patients there, it kind of gives a wee guideline on how to manage risk in preop patients. So, again, another wee questions just to kind of keep you following um for emergency surgery, anticoagulation produced by Warfarin can be reversed by using a fresh host and plasma B injectable vitamin KC. Prothrombin complex concentrate D factor eight concentrate or E oh, I try to pronounce that, but it's a monoclonal antibody. So, which one do you think ABCD or E? Yeah, it's safe. So, prothrombin complex concentrate. It's a big word. But if any of these are on the ward and I've heard the term octaplex, um that's what that is. So it's a very expensive um, medication. Usually you'll be talking to a hematologist to kind of get the, the dose, the dosage is usually in units. Um And when you get it, uh you have to make it up but there's like instructions in the box. Um but it's a bit of pressure making it up cause it's quite expensive. So if you, if you break it, that's uh like a couple of grand or something, a bottle. So no pressure. Uh I just wanted to include a wee bit as well on the massive transfusion protocol. Um So whenever I was F one scarily enough, II used this a couple of times. Um and I found this, it was quite useful. Um So it's the seventies of the massive transfusion protocol. So every trust will have their sort of procedure normally is you're ringing switchboard emerg in an EMG on the emergency line. Um You're saying massive transfusion protocol telling them where you are. Um the switchboard will normally alert the porters and the labs and then that will start your, your your transfusion protocol. So number one is your trigger. Um So a lot of people are quite scared when to start the massive transfusion protocol. So this is quite simple or kind of breaks it down. So two or more um penetrating mechanism, two or more of each of these. Sorry. So it's either the penetrating mechanism. Um, systolic BP, less than 100 or heart rate greater than 100 and 20 if they're losing more than 33 or more units in one hour, if their shock index, which is heart rate over um systolic BP is greater than one. And then also if there is, it's, it's also very fair if you're very concerned that this person's losing a lot of blood. So say if they're passing a lot of Melina and you're really worried that this person's losing a lot of blood, they, they're gonna become unstable completely fine to set it out to, you're better safe than sorry. Number two is your team. So like I said, it's your porters, your labs, um staff, nurses and doctors should all be there. So your nurses should be getting set up with the kit. Doctors are there assessing your porters to run into the lab and the labs getting the blood made up for. So TX A um So there was, I think a study that shows that every, I think 15 minute delay in given T Xa in a massive transfusion protocol, um increases mortality or morbidity by 10%. So it was quite, quite scary figure. So um basically you would be given 1 g of bonus of acid, acid followed by another 1 g bonus. Um or you can give 1 g bonus and then a 1 g in patient over eight hours or if you're in ad GH um you maybe want to give this person 2 g. If you're transferring this patient out, you want to test early. So you want to be doing your F PP. Um, you might need to send off more gripping hose group and crosses. I want to see what your transfusion targets is. Generally it's greater than 80. Um and then temperature management. So the big risk of transfusion loads and loads and loads of blood is hypothermia. So you want to aim the temperature of greater or equal to 36 degrees. Um So if it's dropping, you might, nurses might put on a wee bar hugger or something to circulate warmer around the patient. And then s you want to think about when you want to terminate the code. So there's just general guidelines on for blood transfusions. So if you're under 65 it's usually less than 70/65 less than 80. Um I think there's been a slight change to the guidelines but um usually if there is additional risk factors such as cardiovascular or cerebrovascular, a lot of doctors and consultants will still aim 90 for hemoglobin. And if there's significant active bleeding, you want to be aiming greater than 100 for this for these people. Uh, quick jaunt about diabetes around uh surgery. So it just depends on the duration of surgery. Um, the fasting, uh you know, and all the other comorbidities, these patients are usually scheduled to be first on the list. So they're not missing a lot of meals. Ok. So again, every trust has their guidelines for this. So if they have, if they're on insulin and with a good control, with the HBA1C, less than 69 and it's a minor surgery, it can be managed during the operation by the adjustment of the regime. Um, if they are an insulin with poor control, there's a long fasting time and they're gonna miss more than one meal, one meal on the day of surgery. You wanna be starting a viral rate IV insulin infusion. Um, so again, at the side, there, there is a few medications there that, you know, um, and a bit of guidelines of what you can do for the day of surgery. For example, um, Metformin day prior to surgery, you can take it as normal, um, on the day of the surgery, if you know, you can take it as normal as, as well. Um, most of them, you can usually take as normal. But again, if you're unsure, I would definitely run it by a senior or by the pharmacist as well. So, moving on to anesthesia induction. So there is a triad, sorry. Um So there's a triad of anesthesia. So there's your analgesia, um your hypnotics and your muscle relaxant, so very quickly gonna run through this. Um So your anesthetic agents, usually what's used is the likes of propofol, which I'm sure you guys all came across and your volatile liquids such as your flurry. Um If a patient is quite hemodynamically unstable anesthetics will tend to use ketamine to induce um anesthesia because propofol, a big side effect propofol is, it can cause hypotension. And if somebody is hemodynamically unstable, going for emergency surgery, it is um if you give them propofol, you'll just type them. And so ketamine a good, a good uh good trait of ketamine, it, it doesn't tend to do this as much. Uh So muscle relaxants. So that's your suxamethonium and roro are like the two you probably hear about suxamethonium is not generally used, it's used for rapid sequence induction, but a big risk of this is malignant hyperthermia. Um uh So this is an auto autosomal dominant condition and it's the lack of the acetylcholinesterases. Um So it's quite, it's quite, it's quite an important one to, to note, but they don't really tend to use it as much the other one that they tend to use is rocuronium. Um So what this will do, they will give the rocuronium whenever they're about to insert an et tube. And basically the rocuronium will reduce the risk of uh bronchospasm. Er and whenever they're starting to wake somebody up, they might give SOGA AEX to this person to try and reverse the rocai. So if you see that in the, that's basically what it is. Um Roni basically paralyze basically paralyzes the muscles. So um you want to wait until the patient is completely out of it before you're given this drug because it can cause quite um distress. So for assessing su successful intubation, so if you look less and feel, you want to look for chest rising, you wanna look for ming up your mask, check for an end T CO2 and then you want to listen to the lungs, both lungs to make sure you haven't went down one bronchi and the other. Um and also listen for it or leak. You know, the tube might be changed, the cup is probably not fully inflated in the UT tube, intraoperative monitoring. You'll see them monitor the likes of the heart rate, they'll monitor the map. Um So this is done by normal BP or if they're quite high risk, they might do an arterial line in these people as well. And the arterial line are very useful because that will give a continuous BP monitor. Um They can also assess temperature. So theater is quite, uh it's very cold. Um And so ear probe, temperatures might not be as accurate. So what anesthetics can do is they can put a temperature probe down the et tube or basically down into the, the mouth to kind of accurate, accurately measure um, the temperature. They'll be monitoring the oxygen SATS and they'll be monitoring ABG S if the patient is unstable or they're undergoing emergency surgery. And this is to basically assess how they're doing on the ventilator and see if they're becoming acidotic and taking off by the surgeons. Um If they're getting induced or anesthetic, is there volatile gas such as people fleury? They'll be using a Mac which is on like all the, the ventilator or anesthetic machines in theater. Um And then there's also biz moderate. So it's a modified eeg. So the higher the score, the more weak the person is. Um but you know, they can, they can monitor the score and try and get them to a certain level to make sure that they're appropriately. Um anesthetized. Another question for you guys. Um John is going to surgery for during the operation. He has muscle spasms. Um His heart rate is 100 and 12. He's a great temperature of 38 9. The anesthetist remembers the patient mentioning about her uncle going to ICU after surgery. What is this complication? Anybody has an idea? Yes. Yeah. So it's malignant hyperthermia and bonus points. Do you know what the reversal agent of this is. What would you give to someone if they have malignant hyperthermia? Is it DD? Yes. Yes. It's D yeah. Correct. Hold on. So, moving on quickly. I know. Sorry, I don't wanna keep this too long on a Friday afternoon or evening and especially before Christmas. So, moving on to postoperative management, postoperative management. So there's suffering sort of aims. So you want to maintain the normal physiology and this is just with monitoring through their normal news, you want to be giving them fluids, you want to be um considering nutrition, um and then also restart existing medications as well, very important analgesia. And then also this will relate very closely to prevention of postoperative complications. So, immobilization, um especially for example, if you've had a hip replacement, they'll try and get them patients up as quickly as possible. You have physio. Um and these physiotherapists, especially if they're after a laparotomy, they can start the likes of incentive spirometry to try and reduce postoperative pneumonias. Um And pt prophylaxis is quite important as well and just monitor very closely for complications. So I've just listed a r of postoperative complications. This list, obviously, I probably haven't even got a lot of them on here, but family ones you'll probably see is infection, you'll see patients with fever. Um And that would be maybe the most common thing that you'll be presented with, you know, oh, this person's day one, POSTOP um, or day two POSTOP, they have a fever. Can you come and assess them? So you want to kind of think is it, is it just normal physiological response to after an operation? And if it's within the 24 hours after surgery, it probably is. And if they're otherwise well with it, um, if it's a wee bit, a couple of more days after the operation and they have a fever and they're maybe a wee bit grumbly. We wanna go through the five W. So that's wind water, walking wound BDRs. And then just what, um, each of those kind of relate to you want to think of, especially if it's a laparotomy. Is there any collections that could be forming if they're specking a temperature? Um, if they're really tender in the abdomen, um, anastomotic leaks again, sort of like a collection. But it's, um, for example, I've seen a patient who is very, very unwell and very critical with an osmotic leak. Um PTE. So, uh, is there a DVT or is there pe pneumonia is quite common, especially if people whose pain relief is not appropriately, uh monitored or managed after surgery. Um, there could be failure of surgery just depending on what the type of surgery they were going for. Um, leading is another one and I've also included sarcopenia, which is um, muscle loss. So a lot of people can, um, develop sort of sarcopenia which they will, their muscles will basically waste away and this could be related to poor nutrition. So it's quite important to keep patients, especially those, for example, elderly people going for hip replacements or repair a femur fracture. Quite hard to get these patients on sort of high protein diets because their albumin will naturally reduce after um the operation and that's kind of like a stress response. So um high protein diets is basically what you want to be aiming for these patients. So, analgesia. So you have your multimodal kind of modeler, it's paracetamol, non opioids. So, paracetamol, aspirin. So paracetamol just be very cautious in people who less we than 50 kg and have liver impairment, nsaids as well. Kind of key things to remember is the renal function or the history of gastric ulcers. Um asthma as well. Step two is weak opioids so that your codeine your traMADol and then you're moving up to your stat three, which is there really strong opioids, which is your morphine oxyCODONE fentaNYL. And very important side effects of these is um re respiratory depression, sedation and constipation as well. Um and the reversal if there is concern of respiratory depression. So things you'd be looking for in opioid toxicity is to pinpoint pupils, respiratory depression really, really flat. Um You might want to be considering naloxone. Um and when you're given naloxone, just be very careful in the doses that you give. So if you're reversing say somebody with cancer pain, um give give smaller doses. So usually they'll say give 400 mcg, but you could start a bit slower because if you refer to that person's pain altogether, they'll just come round and be in agony. So you want to sort of do it at a slower rate. If you're concerned, the patient's going to wake up, um, screaming in pain. And then I've included your, um, your adjunct to your analgesia that we discussed. So that's your rectus sheath catheter. So this basically um gives a continuous sort of flow um of like local anesthetic between your t seven t 11 levels. And it's commonly given to people who have had laparotomies. Um People can also get P CS amitriptyline can be used as well as pregabalin and gabapentin so quickly on to nerve blocks, epidurals, and spinal blocks. So you have your peripheral nerve block, which is basically local anesthetic around the nerves. So there's different indications that you can use this. So if they're having um hand surgery or they're awake, um you can give it for hip surgery, um they could be done under general anesthesia to help control pain. Um So that's, you know, your rectus sheath catheters as well. So, basically a good thing about the local anesthetics for nerve blocks. It reduces physiological stress and improves postoperative pain. And as opioids burn, if you don't get the, the negative effects of opioids, another quite important use of nerve blocks if somebody comes in with multiple rib fractures. Um So there is I think a guideline uh developed or being developed that, you know, for appropriate analgesia for people with multiple rib fractures. Um and one of those is given a nerve block to these patients because it reduces any further complications related to infections. For example, later down the line epidurals. This is local anesthetic into an epidural space. And this is a mixture of bin and fentaNYL which they both have a synergen synergistic action. These are used in labor or postoperatory, mostly labor. Um So basically, the local anesthetic will work on the smaller diameter fibers first. Um and then they'll also work on the autonomic fibers first and then move on to sensory and motor. Um So you have, you can have your sympathetic block which can cause hypotension. There's a sensory block which you can have pain relief. Uh urinary intention blocks the heat and cold sensations. There's also motor blocks with this which is paralysis and urinary retention. So it's quite important things to sort of look out for um when epidural is given and then obviously, the complications of them because they, they aren't without risk. So obviously, you've got your hypertension and um so and risk of M I renal failure, stroke, access fluid administration, and it's due to the block being given a bit higher. So you've got, you've lost the sympathetic nervous system. Um There's reduced mobility. So every patient who gets an epidural will need a catheter. Um There is motor weakness, um And if there is motor weakness that you would be considered anergic anesthetic review. Um So, and then your complications that could be poor, partial unilateral or failed. Um So it might not work as well as it intended to. There's also a post dural puncture headache. Um So these needles are quite big that's going into the epidural space. Um, so you can have CSF leaking out, which will cause a reduction in CSF pressure and it basically will give uh a headache when these patients sort of sit up. Um You can have transient neurological damage, um which is very rare, albeit. Um you can have permanent neurological damage again by low risk but still possibility. And you can also have a hematal uh epidural hematoma uh and quite a complication of this. It can cause spinal cord compression and obviously, with every anything going into the body, there's a risk of infection, the benefits of it. Um you can give, it can provide great pain relief. It again, opioid resin, there's some reduction in respiratory complications. Um But then the side effects again, like we discussed, there's, it's, it may not work as well. There's maybe hypotension, you know, you've got your pro Gerald headache or you can have um neurological damage, moving on to the spinal ducts. So, these are used in C sections, transurethral resection of the prostate and hip fracture repairs in patients who are very high risk and, and the theists don't really want to sort of um anesthetize them completely. So basically, these patients are awake and they have a um local anesthetic into the CSF within a SA space. Um It's only used in the lumbar spine. So that's your level of L3, 4 or 45. And they will provide numbness and paralysis below the level of injection and it'll take about 1 to 3 hours to for it to wear off. So, again, a wee question for you guys. So this is a 22 year old lady who undergoes spinal. Um here goes epidural, she had an epidural for a cesarean infection. Everything was on a vent. She was able to walk again when the epidural was coming off. About half an hour later, she was complaining of back pain, it was radiating down to her legs and she had an episode of bladder incontinence. You have said her, she had loss of sensation at multiple lower limb dermatomes as well as hyperreflexia and increased tone bilaterally. So, what would you be worried in this lady? Is it called equina meningitis, epidural hematoma nerve damage or conversion disorder. So, in this day, you'll be worried for an epidural hematoma. So all the symptoms that's been described, there is quite concerning for spinal cord compression and this is an emergency. Do you wanna be contacting quite, quite urgently? So, again, local anesthetics, just give you a wee bit more background on it. So these block voltage gated sodium channels um and basically results in a reversal block of the conduction along the nerve fibers. It's examples that are commonly used as lidocaine bicain and Levo. Um you have adjunct such as your adrenaline and there's great effects of the adrenaline being used along with local anesthetic. So it can prolong the fact the effect of it. Um it can also reduce bleeding by causing vasoconstriction. And there's also reduced systemic effects. But it's quite important you do not use adrenaline on digits on the fingers because that will can cause um necrosis of the the finger and the tissue indications for this is analgesia are preprocedural. So they'll be com we have be commonly given local aesthetics for like central line insertions, art line insertions if you're doing sutures in somebody who has split open their, their leg. For example, complication is the local anesthetic systemic to, to, to toxicity. And the management of this is the 20% lipid emulsion. So if you're in, for example, I know for the Southern Trust there is um there is kits in say the likes of Ed which have, which is um the last kit. So if somebody is concerned that a patient has local anesthetic, systemic tox toxicity, they can go and get this kit and start B tra. Uh So this is just a wee slide. Uh there's a lot going on, but I'll sort of take you through it. So on the top left hand side, you have your, your different types of local anesthetic and how much of your dosing you can give. Um So, you know, for example, lidocaine, it's 3 mg per kilo with a max of 200 mg. Um The next one down is basically the, the A a GBI safety guideline. So this is the guideline that you will use to kind of go through if there is concerns of severe local anesthetic toxicity. And then finally, on the right hand side, it's sort of given you um excuse me. Yeah, or it. Um so th that diagram on the right hand side is sort of taking you up through the levels of um the different signs and symptoms that patients will proceed to get basically whenever they have um local anesthetic toxicity. So quite, it's quite useful to kind of look at what sort of present in first and that can kind of trigger you to kind of act quite quickly. So common things you'll see very common is the tingling of the tongue and lips. So that should make you quite suspicious. And I'm basically aware of basically the. So it's the system toxicity is that to prevent it. When you're administering local anesthetic, you want it before you administer, you will need to draw back on the syringe to make sure you're not in the vein. And before you inject the local anesthetic, uh touching a little bit now on chronic pain. So chronic pain, um there's, it's quite, it's becoming very popular nowadays. So it is. Um and there's quite a lot of things that can be used to deal with it. So there's different types of therapy, um such as CPT commitment therapy, you've got acupuncture, there's antidepressants and sort of psychological interventions. Um or, or go to see like clinical psychologists, for example. Um the nice guidelines do say that medication is not a treatment option for chronic pain. So they're more based on trying to get the person to sort of develop sort of psychological coping mechanisms. Um whenever a person is presenting with sort of neuropathic pain, so you're burning, sort of peeing sharp. Um you only wanna be giving them one medication at a time. So traMADol is only for rescue. So if they're crippled with it, you'll only give the traMADol, but it's a one off. Um You can sort of, you can give the, the capsaicin cream, you can get them going to physio uh physiotherapy and also psychological therapy. Uh You can also give them the likes of uh antidepressants as well. So you can give them DULoxetine, you can give them amitriptyline, carBAMazepine as well as well as pregabalin and gabapentin. You'll quite see this very commonly. Um I've seen quite a lot of patients coming in on like the lex of amitriptyline and this is really for neuropathic pain. Mhm. Um So for example, if you have trigeminal neuralgia and you're giving them carBAMazepine. Um If this doesn't work, you want to be, then considering a specialist. So you don't want to be adding more and more on to this person. Uh Another question which I've already gave you the answer to, I apologize. So basically, it was a 48 year old old lady with a history of diabetes. She has chronic severe pain in both lower limbs. Um She describes it as shooting and burning and the most appropriate treatment to give this person is DULoxetine. So what she's prescribing is neuropathic pain. So that's the shooting and the burning. And also whenever you have a history of type one diabetes, you want to be thinking of the sort of, um, neurological damage that this can cause, um, as part of like the microvascular complications. And then finally, um, I know I didn't touch on everything tonight. Um, based on your wee sort of learning intentions, but I just sort of would talk really briefly on some emergency scenarios involved in anesthetics ICU you might not necessarily be off this in your, um, but for anybody who's quite interested in that specialty, um, he might be a bit interested to learn some of these things. So, or at least be aware of it, excuse me. So, um, you have epiglottitis. So it's becoming quite common, um, especially in the flu season. So there's a lot of people I've seen I was in an ICU placement and there's quite a lot of people coming in with a Alois these individuals in A&E anesthetics and ent are both called to these people. And basically what they'll do is they'll get an awake fiber. Um So basically this person is awake and you're basically doing an awake intubation. But you're using a fiber, these patients will usually get a nasal tracheal tube instead of uh um endotracheal. So it'll be the ET tube, it would be like an et tube going down through their nose. Um And this is really based on the fact they're awake because if you um anesthetize these patients, there are ways very fragile, they could lose it. And again, if you're trying to do an ET two, it's quite difficult to because you need to get the person lying flat. And again, if you lie them flat, they could, um they could become obstructed. Um Other situations would be out of hospital, cardiac arrests in which they've got ROSC um and brain injury. So these patients will tend to be intubated and ventilated and they'll be brought to ICU for what's called neuro prognostication. So basically, they'll be kept in ICU for about 72 hours, there'll be tight parameters that ICU will be going by. They keep, you know, for example, their carbon dioxide within a certain level, their map above 65 you know, um if their urine out, what starts to increase, do you add in um sort of a desmopressin sort of medication into that because you'd be, um, worried for like diabetes insipidus. For example, there's quite tight parameters and the guidelines that ICU will go by for the 72 hours to kind of keep this person, um, what's called neurop prognostication. And after this, especially for like sort of brain injuries, what they'll be starting to do if there's no signs of, sort of the person coming around, they'll do brainstem testing. Um Other scenarios, anesthetics have been called down in ICU it an esophagal of VCE blades in this room for the airway management. Um mostly because obviously there's loads of blood coming up and it's very important just to protect the airways so that they're not aspirating. Uh another very common thing especially in the winter time is respiratory failure. So obviously there's patients um a lot of CO PD nowadays, um there's a lot of people more um high risk with immunosuppression with getting infections and having respiratory failure. So this is both um type one which is hypoxic respiratory failure or you've got type two, which is hypercapnic, hypoxic respiratory failure. A management that they can be given um with anesthetics is they can be given in IV or her. These can also be done on a and the respiratory ward. But basically, if there is concerns that the person might actually deteriorate further and need intubation. ICU might end up taking these patients. Um So for the likes of N IV you will be given these people for this would be for like the likes of your hypercapnic hypoxic respiratory failures um with signs of sort of becoming acidotic, your hers will be those mostly for hypoxic respiratory failures. Um and then obviously intubated and ventilated as if they completely um fall off a cliff with the respiratory system. Another situation would be sepsis resultant in multi organ failure. Um anesthetics will an ICU will be called to people with, with this. And these will be basically for, you know, your CRT or dialysis basically will they need pressor. So in, in, in certain, in the central line also sorry for CRT, they also need a dialysis line. So you could might see people who might on one side of their neck have a central line for pressors or one side of their neck for um dialysis. They could have both at times. Um and then also what they need intubated and ventilated. If they're really unwell uh individuals, you'll be called as well to those who have um suspicious of an overdose and you'll be uh treatment for anesthetics. This will be the airway protection of these individuals. If depending on what substance they have taken, they might need to be dialyzed as well. And then you want to sort of look if there's any reversal agents to whatever they have taken and a good resource for this would be to space. Um And then also there is commonly seizures you know, like epilepsy or preeclampsia, um that's not terminated. So your status is uh anesthetics could take them and intubate and ventilate them and sedate them until they are what has evidence of that. Um So I think that is me sort of concluding. So guys, I really do appreciate everybody who has joined me this evening. I know it's a Friday evening and everybody's sort of just getting, getting ready for Christmas and looking forward to it. So for plenty as we're all coming on, I hope that it was very useful for you all. Um those for your finals. Those are just some helpful resources. I find very beneficial for my finals. So the gee medic has an ay guide and I think you can buy it as it might. I'm not too sure the price of it, but I remember from my finals, it didn't cost a lot, but it was great in that you had loads of oy stations to practice through. And um it, it was very beneficial. Uh There is an app which is called medical flashcards app, um or flash notes. Sorry. And that's the logo in the top righthand corner. So again, this is very helpful for, you know, if you there, there's great summaries of conditions on it that you're not read through greens and reads of taxes for to the point, but very helpful. And it was also very helpful if these are eons as well. Obviously past medicine I know maybe some of these have all your finals completed in fourth year. And so past past medicine is maybe not as applicable but good. Also for keeping sort of the knowledge up with regards medications and clinical situations. Again, off these stop as well. Great book to have. Um, summarize all your histories and any conditions, there's pictures on it as well for like skin conditions, great and then also the of guidelines for emergency situations. So you have the eye app or the website quite useful to have and kind of keep up to date with the, um, guidelines for the likes of anaphylaxis, um, tachycardia, tachycardias, bradycardias, so on and so forth. So guys, um, again, thank you very much for coming. Uh, I've just put in the wee link there into the chat. If anybody wants to leave some feedback of the presentation, I'd be very appreciated of that. And if there's any questions I'm just gonna, here I go back to, you can pop them into the chat, you can message me directly or I've left my email here. She really match it at the end, but sort of slides. That's my email address. If any of you have any questions or anything at all, um, more than happy to be contacted. Um, yeah, thank you very much and I hope you enjoy the rest of your Friday evenings. Thank you. Don't worry. Have a good Christmas. See you later.