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Summary

In this teaching session, the instructor will guide medical professionals through a series of lessons and discussions on peroperative medicine. Drawing on feedback from previous sessions, the seminar will feature a variety of updated slides and resources, as well as multiple-choice questions and detailed diagrams to help attendees better understand the subject matter. The session will focus on the preoperative assessment process from the perspective of an anesthetist, and the factors that determine whether a patient is fit for surgery. This event will also cover a myriad of topics such as perioperative ASA grading, the specifics of how certain medications need to be adjusted before an operation, and the crucial importance of understanding anticoagulants in the surgery process. This learning experience will also highlight the implications of Warfarin adjustment for surgery, a topic which frequently emerges in medical examinations. This on-demand session is suitable for medical professionals seeking to deepen their comprehension of peroperative medicine.

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Description

Join the Northern Ireland Foundation Doctors' Anaesthetics and ICU Society for the 3rd event in our Prepare for Finals Series: Anaesthetics and Peri-operative Medicine, taught by FY2 Dr Ellen Pauley. We will be covering the key learning outcomes for your upcoming final exams in MCQ format, with opportunity for questions at the end.

Register via MedAll to attend. Certificates of attendance will be provided on completion of feedback. Follow us on Instagram + Twitter, and look out for Part 4...

Learning objectives

  1. Understand the pre operative assessment necessary for most procedures and the role of the anaesthetist in deciding the patient's fitness for operation.
  2. Learn about the American Society of Anesthesiology (ASA) grading system and its importance in assessing patient's risks before surgery.
  3. Understand the importance of treatment modifications in the perioperative period, especially for patients with chronic diseases like Addison's.
  4. Understand the need for particular caution with patients who are taking anticoagulants and the strategies to manage the risk of bleeding during surgery.
  5. Gain knowledge on how to interpret the INR (International Normalized Ratio) values associated with anticoagulant therapy and the necessary steps to manage warfarin therapy in anticipation of surgery.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK. Hello guys. Um So that's a few minutes past. So I think that we will just get started now. Um So let me know if anyone can't hear me or anything. Um I've added to the start slide there and put a message in, feel free to message into the chat at any point. Um There'll be some time for questions, et cetera at the end, this event is recorded. So if you want to go over any of the questions after time, you will be able to um and I've included some links to other resources throughout so that you can go back and have a look at some more questions. So tonight's talk is on peroperative medicine. Uh Some of you may have attended one of the foundation for finals talks last month on this same topic which I ran. Um I've adopted the slides based on the feedback that I received from that talk. So I've added some more MC Qs um and some more diagrams so you can let me know what you think. So, firstly, I've just got a bit of a plug for our society. So um we are a new society and growing. So we're trying to do lots of different teaching events this year. Um So we're on Instagram and Twitter if you want to hear about any future events and great and we'll get started. So to start off, I just wanted to flag up this resource. So this is a nice guideline on perioperative care and quite often the nice guidelines can be a really heavy read. Um But this is actually a really good resource like if you've just read through this, um it kind of covers everything that you will need for the like your level of your finals. And it has links to the other relevant guidelines. Like for example, on the preoperative care, what it mentions um anticoagulation, it will have links to the Warfarin guidance, et cetera. Um And it's not too detailed. So I think this is worth a read. It's where I've got lots of the information on this talk. So we'll start off with pre op assessment. Um So what things are involved in for the anesthetist? Um and their perspective of whether or not someone is fit for an operation or not. So these are just some of the things that they'll go through. So considering their past medical history, any previous surgery, um and mainly that is in terms of, did they have a general anesthetic before? How well did they tolerate it? Um Any dental problems like if they have caps or crowns in their teeth? Um The anesthetist has to be aware of that for the point of their intubation, whether or not they're gonna cause any damage allergies. So that includes, uh, drug allergies, food allergies. Um, I'm on my anesthetics taster week at the moment. And one thing that came up was someone allergic to eggs. And then that meant that they can't have propofol if they actually have, um, anaphylaxis to eggs because there's eggs in propofol, which is obviously a really commonly used agent. Uh, we've got what medications they were on previously. So as we'll come to some of these may need to be held or adjusted, um, smoking status, alcohol use and pregnancy. Um, and again, we'll come on to some of the risks that pregnancy poses in addition to anesthetics. So this slide is all about a sa grading. So it's the American Society of Anesthesiology grading. Um And it's basically what the person's like, preoperation, comorbidity status is in terms of their anesthetic risk, how much they need the operation. So, as you can see, a SA one is just someone completely normal, healthy, uh no comorbidities. And then it ranges up to um A SA six, which is someone is brain dead and undergoing organ donation, um, an E for emergencies. So you can see. So number two, there is mild systemic disease. Um, so something that doesn't cause day to day symptoms, uh something which maybe you may not even require medications for, um A SA three more severe systemic disease, disease. So, things like, uh, cancers, um, would be relevant here. A SA four. So something that's a constant threat to life. So, something like that might be an unstable angina or a poorly controlled CO PD, um, or a very poorly controlled diabetes, like, um, someone that's regularly in DK A, so something that's actively causing symptoms at that time. Um, and five so expected to die without the operation. Um Yeah, so these are something that might come up as a quick M CQ. Um So just to be aware of these. So we'll start with our first um, question, I'll start a pool in the chat now. So we'll start pulling here. So, Alex is a 60 year old man undergoing a total laryngectomy surgery for a squamous cell cancer of his glottis. He is in news of two and takes only atorvastatin regularly. What is his A SA grade? So wait for a few more responses to come through. And if you need a reminder while we're going through this, uh A SA two is mild systemic disease. A SA three is severe systemic disease. A SA four is severe systemic disease that constantly is a threat to life. And A SA five is more abound. Ok. So I've accidentally clicked on there. So the answer here is A SA three. So we had some mixed results um in the pool there. So, yeah, most people got BA or B. Um, so in terms of severity. So, squamous cell carcinoma of the glottis. Um, so a tumor basically in your throat. If he's having a total laryngectomy, we can assume that there's some degree of airway compromise that's expected there with that tumor, uh, which I think would classify it as being severe. Um, because he's not symptomatic at the moment, we can see that he's in use of zero. So basically in, for this question that's telling you there's no oxygen requirement. So the airway isn't significantly compromised right now. So he isn't meeting four. So we'll move on. Um If anybody again has any questions about that, just pop it in the chat. OK. So another MCQ here. So I will create the pool. Ok. So MEREDITH is undergoing elective hand surgery to treat damage caused by rheumatoid arthritis. She has a past medical history of Addison's and takes the progesterone only pill. What advice do you give MEREDITH for her perioperative period? So we've got a um on NSAID advice. Um, do not take them in the week prior to surgery. B stopping her progesterone only pill for four weeks prior to surgery. C stopping it for one week prior to surgery and using an alternative form of contraception and D doubling her normal steroid dose in the POSTOP period. Ok. So we've had a bit of time there. So most people got it right. So D so doubling the normal steroid dose for 2 to 3 days after surgery. So this question is really highlighting that you need to know about common drug changes, like what drugs need to be held, what drugs need to be increased, decreased in that perioperative period. So again, that nice document that I flagged up has all of this laid out really nicely. Um But we'll go over these ones. So in terms of contraception, this is a common one that comes up. It's only estrogen containing contraception or H RT that needs to be stopped four weeks before surgery. Um And the reason for that is to reduce the risk of VT E. So, DVTs and P ES um around that period. So it's the estrogen really um in terms of the progesterone only pill, um neither of those are correct. Uh So we can stop it. Um just at the time. Uh long term corticosteroids if someone is taking more than 5 mg a day of oral prednisoLONE. So this doesn't apply if you're just taking inhaled steroids, et cetera because of the additional stress that surgery is adding to the body. Um Normally, uh if you don't have Addison's, your body would increase its steroid production. Um So there's an adrenal suppression um in those patients who are taking long term steroids. So the management for this involves giving IV hydrocortisone at induction and immediately postoperative. And then, as we've said here, doubling the normal steroid dose for a few days. So until they're eating and drinking, um and it depends, of course, on the operation, how long this would go on for. Um But that's something to be aware of. OK. So we'll just flag up uh more specifically anticoagulants in the perioperative period. So I've put a note here. The main point on bleeding. The best way to reduce the bleeding risk is to not operate on somebody that's anemic. So this will be something that'll flag up. Maybe you'll be given a set of bloods. Um and a question about anticoagulants. So remember to just replace the blood if they're anemic. So, hemoglobin greater than 80 is really the target for surgery. You'll find often some like orthopedic surgeons, et cetera will want a hemoglobin of 100 and that's for things like hips that are like big blood loss surgeries. So remember to be aware of that Warfarin. So we want a normal Inr prior to surgery. So of course, a normal inr is one and because it's a ratio, um if the person it's an emergency procedure and you haven't had time to adjust their warfarin dose or hold it, we can reverse it with IV. Vitamin K And if you're holding someone to Warfarin um to get their I nr to be one. So less than the target, say 2 to 3 or 3 to 4 depending on why they're on it. They must be on bridging Clexane. So um a low molecular weight heparin just to, to make sure that they're still anticoagulated for whatever the reason they're on their warfarin and then do wax. Sopanox Span, et cetera. They need to be stopped between 24 and 72 hours before surgery. So it's usually just 24 hours. But again, if it's a big procedure like hips et cetera, they'll want it stopped before. So that one is less likely to come up because it's a bit more operation dependent. I thought we'll go through the warfarin stuff in detail. You'll maybe be covering this in other sessions as well. Um But this really, really commonly comes up. Um So I think it's really important to know this. So again, this is from the nice. So if the person has major bleeding or if they're going for an emergency operation, like they're this um a sae grade person IV, Vitamin K And then if it's major bleeding dried prothrombin complex concentrate, so, octaplex or fresh frozen plasma if that is not available. So that's really to reverse warfarin completely. Um And then these are things to do with holding it based on the I nr. So basically, you don't do anything unless the I NR is greater than five. And that's a common mistake that comes up. Even if the target, say the target's 2.5 the Warfarin, the I nr can be 4.9 and you don't need to do anything. So I would go over all of this. So if it's no bleeding, hold a couple of doses. If there's minor bleeding, you can give IV Vitamin K Um if it's greater than eight with no bleeding, it's oral Vitamin K and hold Warfarin. And if it's greater than eight with any bleeding, it's IV. Vitamin K So basically the always the answer is always Vitamin K but if it's bleeding, then give it by IV. And that's really to speed up the reversal of Warfarin. So moving on to another question here, I've put the link at the bottom here. Um And I can put it in the chat box as well. I've borrowed two questions or three questions in this talk from the British Journal of Anesthetics Education website. They have so many um MC Qs on this area. Um So if you want more, you want more practicing questions. They have different documents for different things like um medications, diabetes, et cetera, all in the per op period. It might be almost too much for finals. But if you're looking for extra questions, um this would be a really great resource. So I'll make a call for this one as well. OK. And we'll start that poll there. So we've got regarding Warfarin and these are really kind of true or false statements. So which one is true is the one you vote for protein C is dependent on Vitamin K So its production is limited in patients on warfarin therapy. It is 70% eliminated by renal filtration. It is highly protein bound. Uh A patient on a stable dose of Warfarin would have an increased I nr if they're given amiodarone Glucozide or metroNIDAZOLE. And unlike Warfarin, Heparin does not increase the risk of stillborns and abortions, it will give you a bit of time to answer this. OK. We've had most of our uh responses there. So this was a tricky one. The answer is actually a um so protein C, so basically, the way warfarin works is that it inhibits the action of Vitamin K And the way Vitamin K acts on the clotting cascade is that it's involved in producing protein C and S which are involved in the coagulation cascade. So that is quite nitty gritty um high level knowledge. But again, it could come up maybe more likely to come up in something like your psa exam. Um Again, so some of the other answers were there. So b um it's actually a hepatic metabolism, not a renal metabolism C. Um It is highly protein bound causing it to be susceptible to numerous drug interactions. The reason that warfarin is so, so susceptible to drug interactions is to do with its hepatic metabolism. Um Again, because it is metabolized by that P 450 system that so many other drugs um are affected by D. Uh So, a person on a stable dose of Warfarin would find an increased in R. So this statement is true for the amiodarone and the metroNIDAZOLE. They both increase the effects of Warfarin. However, Gliclazide does not interact with Warfarin. And then a so unlike Warfarin, Hefarin does not cause increased risk of stillbirths and abortions. So that is false. So basically, any anticoagulants increase the risk of stillbirth and abortions. Uh so that is incorrect. Great. Um So we'll move on to diabetes um and their perioperative complications. So this again, this is a super common one to come up and will there be slides made available in, in the chat? Yes, there will. So this is all recorded, I can send out the slides and upload them to this event. Um And so the feedback form gets emailed to you after this session. Um And when you complete that, you'll automatically get your certificate of attendance. Um, unfortunately, we're not able to post a link in the chat, uh, just from the way metal is set up. So I hope that's ok. Great. Ok. So, but basically the reason why diabetes is such a thing around surgery is because of all the fasting and everything that goes around around that period. Uh So obviously, if someone with diabetes on their usual medications to keep their blood sugars low is fasting, it could push them into a hypoglycemic state. However, the stress of surgery while they're actually in the operation can cause an increase in the blood glucose levels. So it's a tricky thing to navigate. These are three really key ones to learn. So just learn these. Um and they are again, especially the Metformin, one is very likely to come up. So, Metformin is associated with a lactic acidosis. That risk is particularly high in patients with a renal impairment. SGL DLT two inhibitors like Doin and BCO Flosin, they can cause DKA um in dehydrated or acutely unwell patients. Um and that can even be in patients that are euglycemic. So normal blood sugars and then glycoside or sulfonylureas, they have a hypoglycemic risk and that risk is true even outwit the operative period. Uh So they are completely emit until the patient is eating and drinking. Ok. Uh So another question on this is I'll set up another pool here. Ok. So we've got Lexie is a type one diabetic and she's undergoing an elective surgery in the morning. Her usual dose is 20 units of Lantus nightly and she takes 0 to 8 units of novorapid depending on her blood glucose before her meals. What advice do you give ahead of her procedure? And in response to the message in the chat there, um is clotting factor one A inhibitor used yet. I haven't come across it. It could well be, I have never seen it used. Um But again, I'm, I'm just f two. So I've only been working for a year and a half that could very well be in use. I've never seen it um on the wards or NE D or anything like that. Ok. So we're pretty, pretty split in answers between C and D for this one. The correct answer is C so fasting for six hours prior to surgery, ait no rapid and take 16 units of Lantus. The reason why that is um and again, I'm going back to those nice guidelines. Again, that this explains that all really clearly. So inpatients that are on insulin going for surgery continue at a lower lower dose of their long acting insulin. So the B NF currently recommends 80% of their long acting insulin. So that's why in this case, we've got 16 units of the Lantus. Um In our correct answer, we have to stop the short acting insulin whilst fasting or not eating until they're eating and drinking again. So that's the novorapid. Uh So we're stopping it uh while the patient's fasting. Um then we've got have a variable rate insulin infusion going alongside a glucose, sodium chloride and potassium infusion. So that is called a sliding scale um to carefully control their insulin glucose and potassium balance during the interoperative period. So just going through these other ones, the reasons why they're incorrect. So a taking their insulin as usual aiming BM 6 to 10. So we do aim for BM 6 to 10 in the perioperative period. However, we like we've said, we adjust the long acting and omit the short acting B continue eating and drinking up to two hours prior. So again, um we continue drinking clear fluids up to two hours prior, but we fast six hours prior. Um and 50% is incorrect. See is the correct answer as we've gone through and d so we do commence a variable rate insulin infusion. However, we, we do not give any short acting and we adjust the long acting insulin. Ok. So here I've got another one of these questions that I've linked below um from the British Journal of Anesthesia. Um, so I've stolen another one of their questions. So this again is on diabetes management in the perioperative period. So I will start another pool for this. Ok. Um, and sorry. Factor 11 A to the question in the chat again, I haven't seen it when patients have come in to Ed with a bleed. I've seen them being given, uh IV, Vitamin K and Octaplex or the, which is the brand name of PCC E Prothrombin Complex concentrate. It may be that that is a new drug or isn't licensed here yet or is too expensive. So the NHS isn't widely using it. Um, I just, I just haven't seen it myself but it could well be in use. Ok. So, um, we've had a few responses there. So I think these British journal of anesthetics ones are a bit trickier. Um But as we covered in the previous question, this one is the only true statement. So it is safe to continue you to use a patient's long acting insulin alongside their variable rate. So going through these um so question a it is safe to discontinue a variable rate infusion. Um during an elective procedure, he had me at all subcut insulin. So that is not safe. Um So they have to continue that variable rate. So remember the variable rate infusion is not just insulin. So as we said before, it's also got a dextrose and potassium infusion. Ok. Um So that is not safe um during that period for controlling their sugars and B when stopping the variable rate, the direct order is stop it, give subcut insulin and measure blood glucose. So no, so the correct procedure for that would be the blood glucose is being measured continuously. We make sure the subcut of insulin is given first before stopping um the variable rate. So it's to make sure the person has a background level of insulin. Um that's gonna be acting for a longer period. The variable rate of insulin is very short acting. So that's only acting while the infusion is up. So we need to make sure they're covered for the period after it stops. See. So a 45 year old with type one diabetes is undergoing an emergency laparotomy. Uh variable rate is running and the sugar score is 4.1. No. So we aim for 6 to 10. Uh so not too low and not too high. Um Of course, you know, 4.1 isn't necessarily a hypo, but in someone that has been fasting and is interoperative. We aim for a tighter control D is correct. And E so we covered that in the previous question. Uh The preferred fluid is dextrose with potassium included as well. We've had a question in the chart there. So can you explain the differences between fixed rate, variable rate and sliding scale? Yeah. Uh So fixed rate insulin, the only time that's really used is in a DK A or HHS situation. Um because you'll see somebody being given, I think it's 0.1 units of insulin per kilogram per minute. Um So that fixed rate is just when the amount of insulin being given per minute or per hour is fixed depending on that person's weight. So that's not being adjusted for their blood glucose level. The variable means we're varying it based on their blood glucose level. So that when you see a variable rate infusion, the variable rate and the sliding scale are just the same thing um in terms of infusions. So it basically means when the nurses are setting this up, there's a chart that has what rate of insulin they have to run it for, for each um value of their blood glucose. So for example, um again, it'll be, I don't know it off the top of my head to be honest, but it'll be say, let's say the blood glucose is between 6 to 8 millimoles, then it'll say two units per hour of novorapid for it to run. But then the next time they check the patient's insulin or they check the person's glucose level and their BMS are 8.3 then they'll go 08 to 10. I'll increase the insulin rate to four units an hour. So, the, we're just varying based on what their blood glucose level is at that time. Does that make sense? Abby, um, sliding scales. You can also see people using that term on the wards when it's not an IV, like not a very low rate. So we'll say someone's on a sliding scale like the person from the previous question where they take 0 to 8 units of novorapid depending on what their blood sugars are at the time. That can be a sliding scale. So we can say to patients, look if your BM is 20 take the eight units, if your BM is 10, take two units so that some people call that a sliding scale. Ok. So moving on now to general anesthesia. So these three are considered the triad of general anesthesia. So we've got heos so basically putting somebody to sleep or sedating them muscle relaxation. Um So neuromuscular blocking drugs to facilitate getting a tube down their airway, that isn't going to be met by resistance from the muscles of your airway and allowing you to be breathed for it with the machine and analgesia. So taking away the pain of the operation. So we'll go through these so hypnosis. So these are just some of the drugs used to make patients unconscious. So again, for your finals, you do not need to know the details of these. You just need to know these drugs are used for hypnosis basically. So in terms of IV agents, the most common one you'll see is propofol, that is the white infusion. Again, like I said something I learned today is that people who have egg anaphylaxis cannot have propofol. Um ketamine is also it can be used as a um analgesic as well. Um Some of these have other properties too. And then, so the the main difference is the IV agents versus inhaled agents. So more and more you'll see this TV concept or total intravenous anesthesia. So that involves only using IVS for induction. Um So putting someone to sleep on maintenance. So keeping them asleep. So this is usually used because it can give a nicer recovery as they wake up compared to these agents on the right. So these are the volatile anesthetic agents. So these inhaled agents are halogen gasses. So, ceva fluorane is the most common one. So they are stored as liquids that heat into a vapor um and it's mixed with oxygen. So when people are attached to the anesthetic machine and they have that mask on, this is what the agent they used. So it's most commonly, not only just used to put someone to sleep, usually they're not continuously breathing it in anymore. Um And the reason is that these, the IV agents are just a bit cleaner. Um, and they don't make patients feel as sick when they wake up so they're popular. And also in terms of the environment, so there's a lot of push on not using these halogens anymore, um, because of the environmental impact. And again, I know we had a talk, um, a couple of weeks ago, um, by Jane, that was on the kind of airway side of your finals and stuff. So I won't cover this in any detail, but this is just a flag up. This is probably something that you should be aware of just um at a basic level here of like where the tube goes. Um So I don't know if you can see my pointer, but basically, the tube is going like obviously in the mouth past the pharynx, when the anestrus is looking down, you're looking to see the vocal cords and going in through the cords. So you basically, you don't want to intubate their esophagus is obviously the main thing. So that's why they're always saying like are the cords visible or not. Um So if you're kind of going down and then aiming forward great and then moving on to the muscle relaxation. So there are really two options here. So the muscle relaxation is basically blocking at that synapse, acetylcholine from meeting the receptor. So acetylcholine cannot stimulate a response from the muscles and there are two main like sets of drugs that do this. So, depolarising agents. Suxamethonium, you don't rarely see this being used and non depolarizing. So, Rocuronium is the most common one that you'll see and the reason they are good is that they can be reversed instantly with giving a drug called Sugammadex. Um And the main benefit of that is if someone's then waking up from the operation, I imagine waking up from an operation and you're still like you're now awake and aware, but you're paralyzed. So obviously, that's would be terrifying. So the main benefit of this is it can be um reversed really quickly. Um And for some operations, surgeons will want the patients to not be paralyzed so that they can make sure they're not harming any nerves. Um So that can be effective too. So you'll see something called train of four stimulation um in terms of the uh neuromuscular blockade. So that's really uh they put a monitor on someone's thumb and first finger and it causes this kind of response. So it stimulates the nerve and train of four as they test it four times and it'll generate a response number like a percentage. Um And basically the response should get weaker and weaker with each stimulation. Whereas if somebody wasn't um trying to be paralyzed, it would have the equal response each time. So if you're ever getting a question about monitoring, it's the train of four stimulation that's used to test whether this has worked or not. OK. And analgesia. So again, I'm sure you've all covered this um in plenty of other modules. But usually these are opiates um in terms of the perioperative setting. So patients uh will likely be already on things like paracetamol ibuprofen. Um and some of the nsaids of course, have bleeding implications to be aware of. Um But usually it's opiates because they give a stronger anesthetic. Um And something to remember is I've put a star here combined with antiemetic therapy. So most common thing related to these is POSTOP nausea and vomiting. So, um not only are they going to get that because of the general anesthetic but other risk factors are being female. Um having a history of motion sickness or previous um POSTOP nausea and vomiting, nonsmokers oddly are less like if you do smoke, you're less likely to feel sick. POSTOP um use of opiates of massively increases your risk being younger and using these volatile agents. So these three antiemetics are the commonly used ones. So Ondansetron um again, so avoid in patients at risk of prolonged QT. So if they give you their QT interval, it's probably because you can't have this in the question, dexamethasone use with caution in people that are diabetic or immunocompromised. So, dexamethasone is corticosteroids. So it causes your blood sugar to go up. So that would be one to look out for Um in terms of the exam technique, if the person you're being asked about is diabetic and cyclizine. Uh So caution in elderly patients, patients with heart failure. Um But there's no absolute contraindications to any of them. These are just little things they might try and trip you up with in the exam. OK. So we move on to another question. That's quite a lot of um talking there and I will just create a pool and yes, this session is recorded um And the slides will be available um on metal after the event. OK. So we started at the pool here. So Derek is a 42 year old man undergoing an elective hernia repair under G A 40 minutes into the procedure on his continuous cardiac monitor. It's noted peak T waves and a pro pr interval. The theater nurse reports a temperature of 38.7 degrees. What mode of inheritance is the genetic mutation associated with this passed on? OK. So we've had most of our answers here. Um Most are correct. So this is autosomal dominant. So what this question is referring to is a malignant hyperthermia presentation which is a rare um side effect of general anesthetic. Um And it's something that is inherited by autosomal dominant inheritance. So this is why as part of the pre op assessment, you'll always get asked, you know, if you ever had an anesthetic before, any problems with that anyone in your family have any problems with anesthetics. And this is really what the anesthetist is looking for in this. So, peak T waves and a prolonged pr interval. This is referring to hyperkalemic changes on an ecg. Um So that's why malignant hyperthermia can be so lethal as it causes hyperkalemic arrest. Um So yeah, autos abdominal was correct. And another follow up on this question. So we'll just do this one more quickly. Ok. So what do we give for this person? Ok. Be dry. That is correct. Well done. Ok. So I've already covered some of these but just to flag up again. Um because it's one of those common things that come up. So the risks of general anesthesia. So they're really common things POSTOP, nausea and vomiting. That's because of the drugs we're giving and sore throat. That's because of the tube down your throat. Aspiration risk. That is basically the risk of say that's why we're fasting patients. Pre op is the main thing, um reduce the stomach contents, which means there's less risk at that point of intubating of stomach contents coming up your esophagus and going down that tube causing an aspiration pneumonia. Um So that is obviously a risk, particularly these patients are usually lying flat for a long period. Um, rummaging around their abdomen. This is something to flag up why this this risk is particularly increased in pregnant patients. Um And I'm sure you can appreciate the reason for that is they've got something huge in their abdomen that's increasing the pressure up into their airway. So, dental injury, again, that's at the point of intubation, damaging any loose teeth caps or crowns coming off anaphylaxis. So you can be allergic to the drugs we're giving cardiovascular events. So lots of the anesthetic agents cause you to become hypotensive and you can become hypotensive with the spinal anesthetic. Um So that is a major risk, accidental awareness. So, like we said before, there is always a very tiny risk that you might actually be aware during the operation. But because you're paralyzed, you won't be able to express that obviously, that risk is tiny and there are many checks done to make that even smaller. That is a risk malignant hyperthermia as we said, and death. So we'll just cover quickly here, rapid sequence induction. So again, you don't need to know this in any detail. But I think the concept did come up in my finals in terms of, you know, emergency um need for intubation. What's the procedure? Rapid sequence induction? So basically, this is how in an emergency situation somebody is intubated. So like if you've ever had a cardiac arrest and the anesthetists come, this is what's happening. Um And some of the key concept of this are this is from the difficult airway society website, by the way, if anyone wants to look it up, so pre oxygenate, so get 100% oxygen on the patient for a few minutes before you do this. And that just means it buys you a bit of time that you know, that their blood is well perfused at the point that you're trying to get their airway in and they're not on oxygen cricoid force. That's basically putting pressure over the cricoid cartilage. And the reason for that is, um, if this is an emergency situation, we haven't been able to fast the patient. So we haven't been able to say you don't eat for six hours before to reduce their stomach contents. So we're putting pressure to collapse the esophagus um and reduce that aspiration risk. And then these other things are just to do with the actual intubation. Um And yeah, no more than three attempts. Ok. We'll come back a bit to the malignant hyperthermia. Um So just a bit more about it. It's a hypermetabolic response to general anesthetic. So, like I flagged up here, it's really those volatile gasses. It's very rare but potentially fatal. Any genetic implications should be picked up in the pre op assessment. And the way it presents in op is hyperthermia, tachycardic, um acidotic hyperkalemia, muscle rigidity and increased CO2 production. So some of these like the muscle rigidity you might not be able to pick up um unless you're looking for it and the acidosis, you're not going to pick that up unless you're running a gas. Um But if the person's temperature is going up, they're becoming tachycardic, they're co2 on the capnograph is going up. The, the anesthetist would be asking for a gas to confirm this. And like we said, Dantrolene is the treatment. Um So it acts on skeletal muscle to interrupt this meal metabolism. Ok. And again, just to flag up the key things you need to know about fasting. So usually, obviously, there will be some operations that there's an exception to this. But the usual plan before a planned anesthetic is period of fasting to make sure they've got an empty stomach to reduce the risk of the stomach contents refluxing. So fasting typically involves six hours of no food um in the period before two hours of nil by mouth. So basically in that period of six hours before to two hours before you're usually allowed clear fluids like water. And that is because of the aspiration risk. Ok. So we'll move on to a bit about local anesthesia. So general anesthetic has several side effects and risks that we've discussed. Um where possible. It is obviously desirable to keep the patient awake. Um It's significantly less risky if they're breathing for themselves, um and not being put to sleep and don't have this aspiration risk. Um Other pros of the local anesthetic options are better pain relief, POSTOP. Um For example, in the spinal and epidural, it means they can give a long acting pain relief directly into the CSF or directly into the intrathecal space. Um Depending on which one it is. And that can obviously improve recovery. And that's one of the reasons why spinals are still preferred instead of gas for cesareans. So we'll just go through these so peripheral nerve blocks. Um So that's really when local anesthetic is injected around specific nerves. So example, like a brachial nerve block, inject the lidocaine in and around that area. So it can numb up a whole limb limb. Um that's done under ultrasound. So they can check where the uh nerves are. And then so central and your axial anesthetics are spinals or spinal blocks. So again, commonly things like cesareans and hip fractures, uh we'd use this. So for a spinal, the injection of the local anesthetic is going into the subarachnoid space. Um So the needle usually at L3 L4 or L4 L5. So below that level that the spinal cord end, so it's not going to have a risk of causing nerve damage. And a common thing that comes up is to check that it works is using a cold spray or an ice cube. Um And that is to check because as you'll know from your neuro, um it's the spinothalamic pathway that transmits pain and temperature. So they're checking with temperature to see if the patient, if the temperature um of the ice cube feels normal to the patient and not cold, they'll know that they're not going to be feeling pain from there as well. Then epidural. So most commonly seen in pregnant women, et cetera. But it can also be common if someone's had like a big laparotomy or a big abdominal surgery. Um, it can be common to see an epidural because it's really effective like POSTOP anesthetic. And that as occlusion, the name epidural. So outside the dural layer, so not the same as a spinal. And again, the spinal is just a one off injection and the effect will last for a couple of hours. Whereas an epidural you leave a catheter in. So a continuous infusion, then if the local anesthetic is left in and it's usually levobupivacaine for this. So some side effects um of these can be headaches. So you'll have heard like postural puncture, headache, um hypotension, motor weakness in the legs, uh rarely nerve damage, infection. Obviously, you're there's infection risk with introducing a needle into any space where there isn't normally meant to be a needle there and hematoma. So that's why we're really, really careful about holding anticoagulants um before doing epidurals and spinals because a hematoma could cause a spinal cord compression. Um OK. So we'll move on to an M CQ on this one. So I'll just create another pool. Ok. So before we go through this one, there's a message in the chart. Can you please explain simum apnea? Um So that, that's kind of like almost like an allergy or not an allergy, but like an intolerance to suxethonium So that's basically when someone doesn't actually have the enzymes to break it down, um, it's going to cause the like intercostal muscles, like the muscles, like a diaphragm muscles of breathing to be paralyzed. So the person can't breathe. Um, and that's not like a side effect. That's more something that occurs if the patient does not actually have the enzymes to break that down. So that would be like a genetic thing. Um So again, something that you'd be asking about allergies, et cetera, or if you've had a bad response to an anesthetic in the past. And that's one of the reasons why um people like things like rock erodium that they can reverse quickly whereas you can with the Su Suad. So are you, are you happy with that? Does that make sense? Ok. OK. So correct answer for this is B. So we're quite split between B and D there. So you're in Labor Ward discussing analgesia options with Christina and Christina opts for an epidural anesthetic. What side effects or risks should you inform her of? So, in terms of labor, so we covered the other risks in terms of labor. The risks is a prolonged second stage of labor rather than a first stage. Um And really the reason for that is it takes longer because the like it might have some side effect of motor weakness. So not being able to push as hard b increased chance of requiring forceps delivery. Yep. And that's really for the same reason. So prolonged second stage, if it's going on too long and baby's not happy, then it'll have to be converted to forceps. So, c it's actually a hypotension risk with an epidural or a spinal and, and the sensory weakness in the legs. So that is actually the desired effect, of course, of an anesthetic. So we wouldn't even say that's a side effect, sensory weakness is what we're wanting to achieve because we don't want the person to be able to feel pain down below. Um So we wouldn't say that that's a side effect more that would be a desired effect moving on. OK. So I've just put this just as a diagram just to kind of illustrate visually the difference between an epidural and a spinal. So as you can see epidural is going outside that dural layer um and a spinal is going deep to the subarachnoid layer. So, II assume, I hope that you guys can see that through the best quality image. And here's another one just to demonstrate an epidural. Um So you can see where that catheter gets left in, in this person. It's gone in at L3 L4 level. Um And you can see that the tube just runs alongside the spinal cord. So it's not going into that. So that purple layer would be the subarachnoid space. So the epidural layer should not go in there. OK. And these are just some of the local anesthetic actual agents. So, lidocaine is one that you see really commonly on the ward. Sometimes people even give this if you're putting in a big cannula or doing an arterial line or an ABG or something in somebody that's quite anxious. Um So good for surface anesthetic. And then Levo and bupivacaine are ones that take uh they both have a bit of analgesic properties as well. So it's usually Levo that you'll see for a spinal because it works a bit more quickly and then bupivacaine takes longer to work, which is why somebody can't just change their mind right before they're giving birth and say I want an epidural now because it won't have enough time to work, but because it takes longer to work, it has a longer time in the body. So better POSTOP pain relief. One thing you'll also see commonly is addition of adrenaline to local anesthetics. Um So local anesthetics cause your blood vessels to dilate. Um just from like what we were talking about about causing the hypotension is the way that works. But because the blood vessels dilate, it increases the blood flow to that area and causes it to be cleared away more quickly. So, adding adrenaline, which is a vasoconstrictor, um basically cancels that out. So prolongs the anesthetic effect. So that's why you see that basically, OK. And then POSTOP management. So I'm sure you will have covered this in surgical talks, but I'm just flagging up here, the really common postop things. So you're gonna get loads of questions in your finals. I'm sure saying this person is one week POSTOP for this or this person's 48 hours postop for this. These are the common things you're looking out for. So anemia, obviously because of bleeding and the operation atelectasis. So portion of the lung collapsing due to under ventilation, um the way to prevent this is really good pain management. If somebody pain isn't controlled, they don't actually have it in them to take a deep clear breath. So, well, that's why it's really important to ensure POSTOP pain is well managed. Um, atelectasis can increase the risk, mask of getting an infection in the lungs. Um And things like chest physio is why is the treatment for this rather than anything else? And then infections, of course of the wound, chest urinary tract, whatever. So the wound not healing properly, breaking up and eyes. So, peristalsis in the bile is reduced usually after an abdominal surgery, hemorrhage. Um So bleeding into a drain, bleeding into a wound, DVT pee, uh obviously, it's causing a period of immobility in and around surgery is why the risk of this goes up, um shock. So, blood loss sepsis, um having an M I or stroke again, that could be related to this whole clotting cascade AK I and that's really secondary to shock hemorrhage like kind of prerenal AK I it would usually be urinary retention um on delirium. So, of course, the delirium more common in the elderly frail patients. Ok. And just a bit on the VT prophylaxis. So most commonly you'll see an oxy and that's for people that aren't, of course, on a doac preadmission. So if you come into hospital and you're on Apixaban, you just keep your Apixaban going, you don't get anything else added. But usually it's a low molecular weight happen like enoxaparin or Dalteparin IPC S are the intermittent pneumatic compression. So they're just cuffs around the legs that inflate and deflate, just squeeze the veins. I'm sure you will see those and then Ted Stockings. So just the really tight compression stockings. Um So quite often if patient is in critical care, um like ICU or an Ortho ward, usually they like them to have T ES and an oxy. So two types of anticoagulation. Um And that's just because the risk of VT is higher in those patients because they're, they're more immobile and pain management. So again, I don't want to labor all of this too much because I'm sure you all have gone through this in other talks 100 times. But in your MC Qs don't be caught out by thinking the questions are more complicated and that they're about which opioid to use. Usually those are trick questions wanting you to go back to this ladder. So if someone's in pain and they haven't tried paracetamol, give them paracetamol. Like you always start at that bottom level, even if someone's in severe pain. I know that in practice, usually if someone's in severe pain, you're thinking right. Paracetamol is not going to cut it. Let's just go straight to an opioid. But for the purpose of your exams, you always work up this pain ladder. So, non opioids first, like paracetamol, ibuprofen, um, adjuvant or things like creams that might help and then adding on weak opioids and building up that chain. Um But being aware of the side effects of opioids that come up very commonly in exams, constipation, skin itching, nausea, altered mental state, like feeling sedated or confused and respiratory depression. So that is obviously the key risk um in patients that are maybe a bit more opioid naive. Um and with larger doses and we use naloxone to reverse the effects of opioids in a lifethreatening overdose. So monitoring key key things, signs of this would be the respiratory depressions who say respiratory rate is eight. They've got pinpoint pupils. Um they're not talking to you, this ARED, they haven't moved their brows in four days. Like those are all things they're screening for in that POSTOP period of someone who's been on strong opioids. Ok? And then just neuropathic pain. So these are um key ones to be aware of just to be aware of these drugs. So according to that nice guidance, nice recommend using any one of these four as a first line. Um And if it doesn't help, remember, don't just stop one and switch another, you have to slowly withdraw it. Um and then gradually increase it. So any of these can be first line if they come up with a question. Um Usually the question would be describing a clear neuropathic pain like a sciatica or something like that. Um And they'll put it alongside opioids and say paracetamol and stuff haven't worked. So, amitriptyline is a tricyclic antidepressant. DULoxetine is an SNRI I gabapentin, um anticonvulsant and pregabalin also an anticonvulsant. So other kind of options for neuropathic pain are traMADol is really meant to be just short term capsicum cream. So chili pepper cream for localized areas of pain. So lots of people like that. Um physio and psych input for things like the chronic pain team um and chronic pain syndrome. Another key one for exams I should have put it on these slides is trigeminal neuralgia. So uh the pain in the region of the um trigeminal nerve. So fifth cranial nerve, that's a type of neuropathic pain. It's usually uh you know, men, the man reports, you know, electric shock pain when he's shaving or washing his face. And carBAMazepine is the first line for that. So it's different to all these other ones. It's always carBAMazepine. OK. And another M CQ. OK. And I know it's eight o'clock. Um We're nearly done here literally just have a few more slides. So thank you everyone for sticking with me. Ok. So we've had it, we're kind of split between A and B here. So the correct answer here is a um ok. And the reason why that is so he's undergoing an O GD to investigate symptoms of melena and fatigue. So the clue of this is George probably has some kind of slow bleeding ulcer or gastric tumor in that bleeding thing. Um, bleeding risk. Um And so anyone with this bleeding going on and stomach ulcers is another one. Nsaids are relatively contraindicated. So we don't want ibuprofen, naproxen, diclofenac. So other reasons they may be inappropriate to give are if the patient is asthmatic, severe renal impairment, heart disease and obviously the clincher is the stomach ulcer. So just be aware of that, that's big side effect of NSAID S is dyspepsia um and renal impairment. So, the reason why we've gone Cocodamol here is he paracetamol didn't cut it. We need to add something else in. So the next step on the ladder would obviously be adding ibuprofen, but we can't do that. So then we add a weak opioid. So we're adding in a codeine. So Cocodamol. So it's not c because we're adding in paracetamol, we're not just switching to codeine and then D PCA pump, we haven't trialed any weak opioids yet. So we're not at that stage yet. Ok. So I've just put in again a screenshot from the nice guidance here. So offer or an Ibuprofen for immediate POSTOP pain unless they've had a hip fracture. That's the current nice guidance um and do not offer IV in the immediate POSTOP period. So going into these guidance further, it says that it's relatively contraindicated. Um and going through some of the past um finals MC QS, uh they've flagged it up as being incorrect for these dyspepsia patients. So just be aware of that. Ok? And then just on the PCA pump. So PC is patient controlled analgesia. So it's an IV infusion of a strong opiate. So it's usually morphine or fentaNYL or sometimes oxyCODONE. So the patient um has a button and they control when they get the dose basically. Um So for example, if someone's got a PC during labor, if they get a contraction, they can just pump the PC. Um and it means they get a short acting bolus of that pain, but they can't continuously press the button. Um It's set out after a set time, so like 5 to 10 minutes. Um and it needs to be really carefully monitored to see how much is being used. Obviously, it'll be set that they like that lockout period to make sure they're not getting too much. But if they are using loads and have a bad high pain requirement, then they can look at what dose they've been needing and convert that into a patch or a long acting white odd cimal. Um Is this in relation to question the last M CQ? Um So if it is, it's because Cocodamol is paracetamol and codeine. So you're adding in a weak opioid instead of adding in an Ibuprofen? OK. So this is our last pool question. I'm just making the pool night. OK. I thought you can take Cocodamol with paracetamol. Yes. So it wouldn't be in addition to paracetamol. It's just instead of, So this last one again, this is a another borrowed question um from the British Journal of Education website. I'm putting a link to this in the chat. Now, if anyone wants to have a look at these. Um So this is just a link to the one that had this question in it. But on their website, they have loads. If you just search perioperative diabetes questions or something like that, they've got whole documents, they're really good. Um So this is in terms of intrathecal opioids. So things like having an epidural or a spinal to help with POSTOP pain. So, thinking about in the POSTOP period, how long can we expect the analgesia to onset? Um whether or not we can use like IV morphine, is it or is it a different type of drug? Can people also get their long term opioids? Um combining uh combining a painkiller with bupivacaine, which is one of the local anesthetics uh reduces the baricity. So, uh their absorption into the blood brain barrier and a neurotoxicity. So most people have answered. So the answer here is b so quite simply we use the same morphine as you give IV. So lots of people have put a, so onset of analgesia can be expected in the 1st 30 minutes. So actually, onset of analgesia should be pretty quickly in these because it's going directly into the CSF or epidural space. Um However, it's the onset of the numbing. So that kind of loss of sensation rather than loss of pain, um which is takes the 45 minute period for an epidural um c so you shouldn't be having your long term opioids on top of that because of risk of respiratory depression and d so actually, when you add like fentaNYL or diamorphine or something like that to the bupivacaine or levobupivacaine, it actually increases the um anesthetic effect. So it increases the uptake basically and it increases how long your anesthetic will last by adding in your analgesic. Ok. So we finally reached the end there, sorry for running a bit over time there guys. Um Everyone did really well in the pools. Um So it seems like everyone's really well prepared. Um So well done and thank you all for coming tonight. Um Like I said before, you'll all get a feedback link later tonight. If you fill out that feedback link, I would really appreciate it. Feel free to leave any comments or anything that you'd like improved. Um or anything you missed out on and when you fill that out, you will get your certificate of attendance emailed to you. Um And there's my email if you have any other questions or you can message the society, message us through Twitter, Instagram, um or email. So, thank you all. Um And best of luck to everybody, we're gonna have our final event on this, prepare for final series next Wednesday night. Um So that's going to be covering um medical emergencies. So kind of the second half of the presentation, which was last week. Um So, yes, good luck. Hope to see you all there. Thanks guys.