It’s 4:30pm on a Friday afternoon. You still haven’t finished your notes from clinic, there are scripts waiting to be signed, and you’re hoping to get through it all before handover. But your pager goes off:

“Please review Mrs Smith in bed 16, complaining of 8/10 pain.”

Mrs Smith has been in and out of the hospital for weeks; a complex polytrauma patient with severe left foot pain in the context of newly diagnosed CRPS. She’s known to multiple teams, has a well-documented pain plan from the pain service, and you’ve already reviewed her twice today for pain.

Before you even walk into the room, there’s a familiar thought:  What am I actually going to do that hasn’t already been done?

These reviews are incredibly challenging – not because we don’t know the medications, but because we’re often unclear on what success even looks like. We vaguely understand that managing these patients isn’t just about adjusting analgesia. It’s about how we approach the conversation: how we listen, what we validate, and how we set expectations in a situation where there often isn’t a simple fix. So what do you do next?

Step 1. Do not ignore the page and wait for the nurses to page again (hopefully when the cover resident takes over).
It’s tempting to delay this review and hope it gets handed over. Clinical inexperience and workload both push us in that direction. But delaying these reviews rarely helps. 

Recently on the paediatrics ward, I started a cover shift to a parent-initiated MET call for pain in a patient on a PCA who had lost IV access. While re-siting the cannula was already the priority for the evening medical team, the parent had no clear sense of when (or if) this might happen and was left watching their child in pain. What should have been a straightforward procedural review quickly escalated into a more complex situation requiring longer discussions, additional documentation, and increased nursing support.

When a patient familiar with chronic pain asks for help, it usually means the current plan isn’t working. Leaving it escalates the situation and signals to the patient that no one is listening. 

Step 2. Enter with an open mind. 

We are not strangers to cognitive bias in medicine. It is easy to get bogged down by the things we think we know. It is far too easy to rule out important differentials before we have all the clinical evidence and, as uncomfortable as it is to admit, it is easy to dismiss a patient before we have even entered the room. At times, I find it helpful to approach the interaction as a blank slate. 

In practice, this can be as simple as letting the patient speak uninterrupted for a couple of minutes. Evidence suggests that up to 78% of patients do not speak for longer than 2 minutes when allowed to speak without interruptions, and often, what they say in this time can reframe the entire objective of the review (Kreijkamp-Kaspers & Glasziou, 2012, pg909).

I’ve found open ended questions can help reset the conversation:

• “What’s different about today?”
• “What were you hoping I could help with?”

Additionally, taking a moment to ask “what if it’s something else?” has changed my management more than once. I once revisited a non-English speaking patient’s abdominal pain, previously attributed to chronic constipation, with a formal interpreter service and uncovered a urinary tract infection on a day she would have otherwise been discharged.

Step 3. Don’t be afraid to treat your patient, and escalate early if you think you can’t.

Severe pain can make history taking and examination tricky. In some situations, it may be more helpful to offer a stat or PRN dose of rapid-onset analgesia before attempting a detailed assessment. This can create enough space for a more meaningful review, rather than trying to assess a patient who is too distressed to engage.

At the same time, consider whether you may be walking into a pain crisis that requires early escalation with an urgent clinical review or MET call. Managing acute pain in patients already on significant multimodal regimens can be daunting, and it’s not something you need to manage alone.

Step 4. Acknowledge, reassure, and validate. 

Managing acute on chronic pain challenges our ability to troubleshoot complex clinical dilemmas, which often do not have satisfying solutions. It’s uncomfortable to acknowledge a symptom without being able to offer a quick fix, but this is often a hidden barrier to a meaningful and productive conversation. Simple acknowledgements such as “It sounds like today has been particularly difficult” can go a long way in letting someone know you are seeing them, that you believe them. Validation doesn’t have to mean agreeing with everything said, but rather reassuring a patient that their lived experience is an important part of the equation too.

Step 5. Set expectations!

The best pain reviews I’ve seen have been honest and a bit humble. These conversations can go either way. I’ve seen them escalate into full-blown arguments (and even a code grey once!), and I’ve also seen a single conversation completely change how the rest of the admission goes. A lot of that comes down to expectations.

One thing I’ve taken from discussions with various pain specialists is to avoid overpromising. Most of the time, we’re not going to make someone pain-free, and not all patients know what the end point of inpatient treatment may look like without a transparent discussion. The NICE guidelines for shared decision-making recommend early discussion of the patient’s goals for treatment and clarification of any misconceptions they might hold (NICE, 2021). 

Simple things like:

• “We might not be able to get rid of the pain completely, but we’ll try to make it more manageable.”

It also helps to be upfront about the longer-term plan:

• “We can try these medications to settle things over the next few days, but we’ll need to start weaning them before you go home.”

In my experience, having this conversation early saves you or an unsuspecting colleague from having a much harder one later.

Step 6. Come up with a plan, knowing that it may fail. 

I find it helpful to frame each management plan as a trial run: all possible options are weighed collaboratively, but only one distinct route is chosen by the end of the review. For example, many patients tend to insist on premature escalation of opioids. While this is not necessarily always appropriate in the first instance, especially for patients being overseen by a pain service, it can be reassuring to let them know that there will be a plan for staged assessment of effect and that medication changes are still on the table for discussion depending on how things progress. 

One situation where this negotiation process comes up often is when I’m reviewing patients that have declined simple analgesia, and usually this is followed by a “paracetamol never works for me.” While I’ve come across the odd patient or two who are receptive to explanations around the analgesic ladder and multimodal analgesia, most patients just prefer simplicity. One phrase I tend to reuse often is:

• “Worst case scenario, the paracetamol won’t do anything. Best case, it takes the edge off while we figure out what else we can do, while giving me more information to work with.”

In my experience, setting it up this way makes the next review easier, for both you and the patient. It turns the interaction into a shared process that they understand, rather than a single moment where you’re expected to get everything right.

In summary,

In 2020, the IASP revised their definition of pain as being “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”, taking into account the subjective and personal nature of pain that is influenced by not only biological factors, but also psychosocial factors (IASP, 2020). Patients in pain present in vastly different ways. 

The above suggestions won’t suit every patient’s communication style, but it is not possible to communicate without first starting a conversation. And it is not possible to hold a conversation without listening to what the person in front of you needs.  

Some days it will feel like your patient hates you and the entire hospital no matter what you try. Many patients will find these discussions frustrating, while some need you to acknowledge that their experience is real and difficult. Some patients like to know about every piece of the puzzle, while others are just waiting for someone who can subtract all the medical jargon from the details that matter. Regardless, all patients deserve to be spoken to in a language they can understand.

References

IASP Announces Revised Definition of Pain – International Association for the Study of Pain. (2020, July 16). International Association for the Study of Pain. Retrieved April 1, 2026, from https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/

Kreijkamp-Kaspers, S., & Glasziou, P. (2012, November). A is for aphorism. The power of silence. Australian Family Physician, Volume 41(11), 909. https://www.racgp.org.au/afp/2012/november/a-is-for-aphorism

NICE. (2021, June 17). National Institute for Healthcare and Excellence. Shared decision making. https://www.nice.org.uk/guidance/ng197/chapter/Recommendations#putting-shared-decision-making-into-practice

Purpose of the pre-anaesthetic assessment:

• Identify patients who have increased peri-operative risk;
• Diagnose, assess, and optimise patient comorbidities to minimise peri-operative risk;
• Plan and prepare for the patient’s perioperative journey;
• Encourage patient-centred discussion regarding risk and benefit of surgery and to reach a decision on whether to proceed or delay/cancel.

The structure and depth of the preoperative anaesthesia assessment will vary depending on the severity and stability of the patient, the urgency (elective versus emergency) and risk profile (low risk vs high risk) of the surgery. However, a general structure is always required to encapsulate the key domains imperative for perioperative planning. There is no fixed method, and juniors are encouraged to observe different styles used by perioperative clinicians and adopt one’s own. Here we present the key areas that should be explored during a pre-operative assessment:

1. Detailed History
   1. Anaesthetic history
   2. Past medical history, with specific focus on cardiovascular and respiratory systems
   3. Medication history
   4. Social history & functional status
2. Targeted examination
   1. Airway assessment
   2. Vital signs
   3. CVS exam
   4. Respiratory exam
3. Relevant investigations
4. Surgical considerations
5. Risk stratification

Detailed History

1. Anaesthetic history

• Any issues with prior anaesthetics. Any difficulties encountered with regional/neuroaxial anaesthesia.
• Family history of GA issues -> malignant hyperthermia (MH), sux apnoea (SA) due to pseudocholinesterase deficiency.
• Previous difficult airway.
• Anaphylaxis & other adverse drug reactions.
• Any unplanned HDU/ICU admission following anaesthetic?

The best predictor of intraoperative anaesthetic complications is previous complications and patterns.

Reviewing the previous anaesthesia chart can be a wealth of information. Aside from reviewing major complications and airway grade, note induction medications and doses, vasopressor, analgesics, and antiemetic use. For example, a patient with stable looking blood pressure recordings but needing large doses of metaraminol and ephedrine would be a red flag for any future inductions. Was this a mild case of anaphylaxis, or a sign of decreased cardiac function and undiagnosed heart failure?

Patients with previous anaesthetic issues such as difficult airway, anaphylaxis, MH or SA often carry letters or have electronic record prompts to alert clinicians. Any family members who have undergone genetic or allergy testing after an anaesthetic should prompt the clinician to chase further correspondences of the nature, indications and results of the investigations.

Any unplanned admission to an intensive care setting post-operatively should be reviewed, particularly if the admission was anaesthesia-related:

• Airway trauma / oedema preventing safe extubation.
• Refractory bronchospasm / aspiration event / unexplained oxygenation & ventilation defects requiring ongoing invasive positive pressure ventilation (IPPV).
• Delayed emergence requiring prolonged airway/respiratory support.
• Intraoperative haemodynamic compromise / cardiac event.
• Intraoperative neurologic event.

Etc.

2. Past medical history (PMHx)

With the advancement of perioperative medicine and minimally invasive interventions, clinicians are faced with growing numbers of multimorbid patients who are considered for surgery. This requires a succinct structure to identify and review pertinent PMHx that is relevant for the perioperative setting. Of the body systems, cardiovascular and respiratory conditions are the biggest contributors to perioperative morbidity and mortality.

With any condition that is identified, the following acronym developed by Dr. Lahiru Amaratunge can be used to elucidate important details of the condition:

SSCCT

Severity: how severe is the condition

Stability: is there any acute change recently

Cause: why has this condition occurred

Complications: has this condition led to other disease

Treatment: what is the management, is it working, what is the follow-up

Based on this, one can quickly determine the level of attention you need to pay for a particular condition.

For example, an asthmatic with 2 previous ICU admissions requiring IPPV, with an FEV1/FVC of 0.5, who has presented with new wheeze and cough, on the background of newly diagnosed pulmonary hypertension despite regular preventers and biologics, presents far greater perioperative risks than another mild but otherwise fit asthmatic who barely uses salbutamol PRN with no previous hospital admissions.

Cardiovascular disease:

-Enquire about: chest pain, syncope, orthopnoea, paroxysmal nocturnal dyspnoea, leg swelling, syncope

-Cardiac comorbidities:

• Acute coronary syndrome (ACS)/ ischaemic heart disease

• Cardiac arrhythmias

• Congestive heart failure (CCF)

• Valvular disease, in particular aortic stenosis (AS) / mitral stenosis (MS)

• Pulmonary hypertension (pulmHTN)

• Congenital heart disease

-Current management, such as coronary stenting and/or bypass, AICD/pacemaker

-Patient exercise tolerance, using validated scoring systems. E.g. Duke activity status index (DASI), metabolic equivalent tasks (MET)

-Recent cardiac investigations: ECG/Holter/TTE/stress TTE/CT cardiac/angiogram

Respiratory disease:

-Enquire about: exertional tolerance, requirement for home oxygen, hospitalisations in the past 12 months due to respiratory illness, current or former smoker?

-Recent respiratory function tests

-Illnesses of note: COPD, asthma, pulmonary hypertension, OSA

-Consider the STOP-BANG questionnaire to detect undiagnosed OSA (see below)

Other:

-Diabetes: T1 vs T2? Insulin dependent? Recent HbA1c? Recent hypo/hyperglycaemic episodes?

-Thyroid, renal, liver disease

–GORD, conditions affecting lower oesophageal sphincter function and/or delayed gastric emptying (poorly controlled reflux poses increased intra operative aspiration risk and may affect induction technique)

-Fasting status, GLP-1 agonist use?

-Conditions which may affect the cervical spine e.g. rheumatoid arthritis, ankylosing spondylitis

-In women of reproductive age, ask about possibility of pregnancy

3. Patient medications

-Medications of note include

• Anticoagulants, antiplatelets

• Cardiac, including ACEi/ARB, beta blockers

• Diabetes medications (in particular insulin, SGLT-2 inhibitors and GLP-1 agonists) [Check ANZCA’s latest guidelines https://www.anzca.edu.au/safety-and-advocacy/standards-of-practice/clinical-practice-recommendations-regarding-patients-taking-glp-1],

• DMARDs, steroids and other immunosuppressive medications

• Opioids and other long-acting opioid replacement therapies

-Consider the need for peri operative anticoagulation bridging for patients on warfarin

-Patient allergies – clarify type of reaction e.g. anaphylaxis vs medication side effect )

4. Social History & functional status

–Smoking and alcohol intake

-Other illicit drug use

-Activities of daily living, whether patient is requiring assistance with basic or complex tasks, fatigue and overall frailty

Examination

The physical exam should include a thorough airway, cardiovascular and respiratory assessment, but may include other systems depending on the patient.

Airway assessment

-Modified Mallampati score

-Thyromental distance (note if less than 6cm from thyroid notch to chin when head is extended)

-Inter-incisor distance (should be able to fit approximately 3 fingers when mouth is fully opened)

-Dentition

-Patient body habitus

-Facial hair

-Freedom of neck movements

-Jaw protrusion

The best predictor of a difficult airway is a history of a difficult airway. Recent anaesthetic charts should therefore be reviewed for previous airway grades, ease of BMV, and size of well-seated supraglottic airways.

The above are useful to identify patients with potentially difficult airways, but none in isolation provide the sensitivity nor specificity to confirm one. Nevertheless, the greater the presence of difficult airway risk factors, the more preparation is required in our airway planning. Importantly, if a genuine difficult airway is anticipated, such as those with fixed flexion deformity, extremely limited mouth opening, or retrognathia with limited jaw protrusion, an awake fibreoptic technique should be discussed with the patient and the anaesthetic team looking after the patient.

Cardiovascular

–Key vitals: BP, HR

-Chest auscultation, noting any cardiac murmurs or added heart sounds, bilateral added lung sounds

–Fluid status, noting any pedal oedema

Respiratory

-SpO2, RR, work of breathing, presence of adventitious breath sounds

Investigations

Further investigations depend on the individual patient’s comorbidities, type of surgery and time available for optimisation before their operation

Young patients undergoing low risk elective surgery may not require any investigations prior to surgery.

Bloods:

1. FBE (anaemia or thrombocytopenia, or if having major surgery)
2. EUC (eGFR, electrolytes, creatinine)
3. LFT (if known or suspected liver disease e.g. Hepatitis)
4. HbA1c (elective surgery will often be postponed for patients with poorly controlled HbA1c e.g. > 9)
5. TSH (known or suspected thyroid illness)
6. Coagulation profile (if patient takes anticoagulant medications (particularly warfarin) or haematological disease/ high bleeding risk)
7. Group and hold +- crossmatch (if blood loss anticipated)

Bedside:

1. ECG (particularly for older patients, those with cardiovascular disease or those having high risk surgery)
2. Pregnancy test: for women of reproductive age

Imaging:

1. TTE (may be considered on basis of ECG, unexplained dyspnoea, or if known or suspected CCF or valvular disease, see below)
2. CXR (not routine but may be done if suspected cardiovascular/pulmonary disease)

Other:

1. Respiratory Function Tests: to quantify airways disease (COPD/ asthma/ ILD) or if underlying respiratory illness suspected
2. Cardiac stress test: may be considered for patients with cardiovascular disease (see below)
3. Dental clearance: if concerns on airway assessment (false teeth, poor dentition etc)

Surgical Considerations

Many surgeries present their own unique challenges that anaesthetists must prepare for in our perioperative planning. As junior trainees build up their volume of practice and gain experience in the specific considerations of particular surgeries, it is often helpful to discuss with our surgical colleagues to better understand their special requirements. As always, a general structure helps to encapsulate broad surgical factors that should be included in our planning:

Space: Patient and Surgery

• How is the patient positioned? Supine, lithotomy, lateral, prone, Tredelenburg?
  • Each position is associated with cardiovascular, respiratory changes and specific pressure injury risks.
• How is the patient oriented? Head away from anaesthetic machine? Is our airway close to operative site?
  • These will present logistical challenges that need to be navigated on the day.
• Do I have access to my IV?
  • This is absolutely imperative in cases where access will be restricted, such as when arms are fully tucked or during robotic cases. Make sure you are confident with your IV, and have at least two if total intravenous anaesthesia is used.
• Where and how big is the operative site?
  • Certain regional techniques are extremely useful as a sole method of providing anaesthesia or as an adjunct to perioperative analgesia, especially in high-risk multimorbid patients or in patients where opioid minimisation is ideal. Knowing where the incisions are will help determine the best block technique.

Time: Duration and special timepoints

• How long is the surgery?
  • Duration of surgery often correlates with the complexity, degree of physiological insult, and risk of perioperative complications, such as MACE, hypothermia, major fluid shift, delayed emergence, post-operative nausea & vomiting etc.
• Are there critical moments that require special attention? Some examples include:
  • Laparoscopic surgery: pneumoperitoneum
  • Limb surgery: tourniquet tightening & release
  • Major vascular: vessel clamping & release
  • Neurosurgery: head pin, aneurysm clamping

Bleeding

Major cardiac, hepatic, vascular, obstetric and orthopaedic surgeries often carry significant bleeding risk, and appropriate perioperative management should be in place:

• Preoperative:
  • Up-to-date group and hold, with option for 2x crossmatched blood ready
  • Management of anaemia through combination of iron supplementation, optimisation of comorbidities, and blood loss minimisation (withholding of antiplatelet/anticoagulants)
• Intraoperative:
  • 2x large bore IV, hot fluid line, rapid infuser device, cell saver, blood available, ROTEM/TEG available

Special cases

• Nerve monitoring e.g. thyroidectomy, plastics reconstruction, nerve repair
  • Intraoperative avoidance of neuromuscular blockers to ensure nerve can be monitored

Risk stratification:

There are several tools which are very useful in assessing patient anaesthetic/ surgical risk. These can be used to make decisions about pre-operative optimisation and predict care requirements in the post operative period.

American Society of Anaesthesiologists Physical Status Classification System (ASA):

Useful to assess and communicate a patient’s medical comorbidities.

ASA 1 – A normal healthy patient – e.g. healthy non smoking patient

ASA 2 – A patient with mild systemic disease – e.g. current smoker, obesity, pregnancy

ASA 3 – A patient with severe systemic disease – e.g. poorly controlled diabetes, hypertension

ASA 4 – A patient with severe systemic disease that is a constant threat to life – e.g. MI or stroke < 3 months ago

ASA 5 – Moribund patient, not expected to survive the next 24 hours, with or without surgery – e.g. ruptured aortic aneurysm

ASA 6 – Declared brain dead, entering theatre for organ retrieval purposes

Major adverse cardiovascular events (MACE) represent one of the most significant complications contributing to perioperative morbidity and mortality. The presence of major cardiovascular conditions, such as ACS, CCF and arrhythmias, as well as any new, acute-on-chronic, or untreated conditions, all disproportionally increase the risk of MACE. Clinicians must consider the benefit-risk profile of delaying surgery for optimisation of these conditions.

The 2024 AAHA/ACC Guideline for Perioperative Cardiovascular Management for Non-cardiac Surgery provides a detailed flowchart to assist clinicians in deciding the most appropriate actions for patients presenting with significant cardiac comorbidities for non-cardiac surgery. To summarise:

Table 1. Adaptation of Figure 1 of 2024 AAHA/ACC Guideline for Perioperative Cardiovascular Management for Non-cardiac Surgery

Is it emergency surgery	If YES -> Proceed with surgery If NO -> Move to step 2
Does patient have either ACS (within 60 days) Unstable arrhythmias Decompensated CCF	If YES -> consider postponing surgery for management of acute cardiac condition If ACS is managed with drug-eluding stent (DES) PCI requiring cessation of 1 or more antiplatelet therapy Delay for 12 months Delay for 3 months for time sensitive surgery Also consider if any new or undiagnosed/untreated cardiac conditions If NO -> Move to step 3
Does the patient have Elevated risk for MACE based on validated risk calculators and/or Have any risk modifiers? Validated risk scores include: Revised Cardiac Risk Index (RCRI) American College of Surgeons NSQIP Surgical Risk Calculator (ACS-SRC) Risk modifiers are: Severe valvular heart disease Severe pulmHTN Elevated risk congenital heart disease Prior coronary stent/coronary bypass Recent stroke AICD or pacemaker Frailty	If Low risk score AND no modifiers -> Proceed with surgery Represents low risk procedure / low clinical risk If elevated risk score but no modifiers: Consider ECG for asymptomatic patients with no established CVD Commence or optimise guideline-directed medical therapy (GDMT) Once complete, move to step 4 If any risk modifier present: TTE for evaluation of left ventricular function, valvular pathology, or new symptoms Commence and optimise guideline-directed medical therapy And For valvular pathology, consideration of corrective intervention (valve repair/replacement) Once complete, move to step 4
Does the patient have reduced or unknown functional capacity, MET <4 or DASI <32	If NO -> Proceed to surgery If YES -> move to step 5
Will further testing change management	If NO* -> Proceed to surgery OR consider non-operative options If YES -> move to step 6
Does patient have elevated risk based on cardiac biomarkers: NT-proBNP / BNP Troponin	If NO -> Proceed to surgery If YES: Consider TTE or stress testing, and follow-up with Low risk findings -> Proceed Elevated risk -> GDMT and consideration of non-operative options Proceed w/ post-op cardiac biomarker surveillance

The 2024 AHA/ACC guideline provides a structured framework that can be adapted for any medical condition that may pose increased perioperative risk to patients. A useful mnemonic by Dr. Lahiru Amaratunge distils the steps of the 2024 AHA/ACC guideline that can be universally applied:

“Every Anaesthetist Loves Morning Coffee”

1. Emergency surgery -> proceed, with as much optimisation as possible;
2. Active condition -> if new condition or acute decompensation/deterioration, consider postponing;
3. Low risk -> if low risk procedure / low clinical risk -> proceed
4. MET >4 -> proceed
5. Cardiac investigations (or investigations relevant for the condition) -> further risk stratification and optimisation

Conclusion:

The preoperative anaesthesia assessment aims to minimise a patient’s intra and post operative risk. It encompasses a focused history, examination and select investigations. The assessment is influenced by the patient’s comorbidities, the risk of the operation, and the urgency of the operation.

Useful links:

Peri operative medication management – UpToDate

https://www.uptodate.com/contents/perioperative-medication-management

STOP-BANG Questionnaire

https://www.mdcalc.com/calc/3992/stop-bang-score-obstructive-sleep-apnea

Mallampati Score – LITFL

https://litfl.com/mallampati-score/

NSQIP Risk Calculator Tool

https://riskcalculator.facs.org/RiskCalculator/index.jsp

DASI – MDCalc

https://www.mdcalc.com/calc/3910/duke-activity-status-index-dasi#evidence

References:

Ng ACC, Kritharides L. Preoperative assessment: a cardiologist’s perspective. Aust Prescr 2014;37:188-91.https://doi.org/10.18773/austprescr.2014.079

Pang, C. L., Gooneratne, M., & Partridge, J. S. L. (2021). Preoperative assessment of the older patient. BJA education, 21(8), 314-320.

Lamperti, M., Romero, C. S., Guarracino, F., Cammarota, G., Vetrugno, L., Tufegdzic, B., … & Afshari, A. (2025). Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology| EJA, 42(1), 1-35.

Hendrix, J. M., & Garmon, E. H. (2025). American Society of Anesthesiologists Physical Status Classification System. In StatPearls. StatPearls Publishing.

Writing Committee Members, Thompson, A., Fleischmann, K. E., Smilowitz, N. R., de Las Fuentes, L., Mukherjee, D., Aggarwal, N. R., Ahmad, F. S., Allen, R. B., Altin, S. E., Auerbach, A., Berger, J. S., Chow, B., Dakik, H. A., Eisenstein, E. L., Gerhard-Herman, M., Ghadimi, K., Kachulis, B., Leclerc, J., Lee, C. S., … Williams, K. A., Sr (2024). 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 84(19), 1869–1969. https://doi.org/10.1016/j.jacc.2024.06.013

Welcome to anaesthesia!

Your anaesthesia rotation will be one of the most interesting, demanding and hands on rotations during your medical school experience. This document will provide a few insights, expectations, tips and administrative information for your term.

Expectations

I want to maximise your learning in the time you are with us. A few ways to get the most out of this rotation include:

1. If you are not sure of anything, please ask me!
2. When you are performing a task (eg intubation), speak your thoughts out loud. This will allow me to either state your thinking is appropriate or give you advice on how I would approach a situation.

Eg. As you are intubating you might say something like: ‘I am inserting the laryngoscope on the right side to move the tongue away. I can now see the epiglottis, I am placing the tip of the blade into the valeculla, I can’t get a good view of the cords, I think I should use BURP and ask for a bougie…’

3. I want you to challenge yourselves and take as much responsibility as possible under my supervision. If you want to manage an airway, ask for it. If you want to do a spinal, ask… In general, I will allow you to do many procedures supervised as long as you have done the background reading and work. Eg. know the setup, method, risks, complications, and watch any video you can find on Vimeo or Youtube etc….

4. I will teach you as much as you would like, but please write down/record useful information. Please download an app such as Evernote to record all the useful info/methods/techniques/tips so it’s on hand (and so your consultant doesn’t have to repeat themselves)

Much of medicine is about access to knowledge! You cannot expect to remember the millions of parcels of knowledge required for effective medical practice – so utilize your smartphones to store, sort and access valuable information.

Apps that are worthwhile to download include

• Drug doses
• Medscape
• Medcalc
• Evernote (already mentioned)

Tasks to do before your rotation

1)
Sign up to ABCs of Anaesthesia facebook group,

and follow us on Instagram – ABCs of Anaesthesia

2)
Sign up for a free 7-day trial of my Anaesthesia Foundations Course for all the basics of preoperative assessment and anaesthesia basics.

If you need an extension of the free trial, please contact me at abcsofanaesthesia@gmail.com.

3)
Check out the ABCs of Anaesthesia Youtube Channel

Watch the ABCs of Anaesthesia Boot Camp Playlist for a great beginners orientation

Cannulation will be your most frequently used practical skill, please watch these videos on theory and practice before your rotation

For more in depth information check out these playlists – medical students and procedural skills

Phone numbers, street addresses and codes

Footscray hospital

160 Gordon Street Footscray 3011

Closest train stations are West Footscray and Middle Footscray.

Sunshine Hospital and Joan Kirner Hospital

176 Furlong Rd, St Albans 3021

Closest train station is Ginifer

Williamstown Hospital

77B Railway Crescent, Williamstown, 2016

Closest train station is Williamstown Beach

Sunbury Day Hospital

7 Macedon Street, Sunbury, 3429

Closest train station is Sunbury station.

Theatre

Theatre morning lists generally start at 8am and pm lists start at 1pm.

How to arrange your rotation and lists

You can essentially allocate yourselves to any lists at Sunshine, Joan Kirner Footscray or Williamstown hospitals with any of our anaesthesia consultants supervising. When I am working at Sunbury hospital, I am happy to supervise you there.

The variety of experiences available include assisting with anaesthesia in the operating theatre or ‘off the floor’ such as in radiology/endoscopy rooms/cath lab, pain rounds, chronic pain clinic, pre admission clinic and cardiopulmonary exercise testing.

You are free to choose to be in essentially any theatre, with any consultant who is happy to have you. That said there are certain theatres that will be most appropriate to getting the most out of this rotation.

Footscray Hospital generally does longer operations in sicker patients. So will not be the best place to get lots of repetitions of airway practice. That said it is a great place to see some large vascular, liver, ortho and thoracic cases with interesting pathophysiology.

Sunshine Hospital generally has more patients per list so great for procedures and practice with airway management. You can also observe obstetrics, gynae and paeds here. The ECT lists are great for airway practice as you will be ventilating up to 13 patients in the list!

Williamstown Hospital also has more patients per list so great for procedures and practice with airway management.

Most consultants will be happy to have you observe and assist, but occasionally it may not be appropriate. Don’t worry, just ask myself or the Anaesthesia consultant in charge and we can easily reallocate you.

Some Typical Tasks to Perform Every Day

• Assess patient
• Check bloods and electronic medical record
• Fill in anaesthetic form
• Make a plan
• Draw up medications
• Check machine

Assessing the patient and making a plan will be the daily ritual that much of your learning will branch from. The more assessments you do, the more you will learn about the relevance and implications of disease in anaesthesia. Making an anaesthetic plan (see Anaesthesia basics pdf) will allow you to make decisions to test your understanding of how to conduct anaesthesia.

Keep a logbook

Your ability to self audit is an integral part of continuous improvement and accountability. I suggest you keep an excel spreadsheet (which I’ve attached with the prereading) to log cases and important details. At the end of your rotation, not only will you see how many cases, intubations, LMAs, iv cannulas etc you’ve placed, but you will also be able to see how your success rate improved.

Skills to develop

Anaesthetists are among the most hands on of specialists. We learn to perform a large number of manual tasks often in high demand situations. Use this list as a checklist to cover as many tasks as possible during your rotation. Ask your anaesthetist/registrar/nurse to supervise and teach you the following techniques.

Airway

• Bag mask with guedel, 2 hands and jaw thrust
• Insert LMA
• Intubate
• Use CMAC video laryngoscope
• Use BURP
• Use a bougie or stylet
• Use Optiflow thrive
• Set up ventilator
• Use mask ventilation for an entire case
  • By doing this you’ll develop the experience of mask ventilation in a few days instead of months
  • You will learn the micro-adjustments necessary
  • You will develop the muscle memory required for successful mask ventilation
• Observe awake fibreoptic intubation
• Deep extubation
• Do Electroconvulsive shock therapy (ECT) list for repeat, multiple bag mask ventilation practice

Cardiovascular

• Insert iv cannulas
  • Once competent attempt large iv cannula
  • Insert/observe rapid infusion cannula (RIC) insertion
• Insert arterial cannula
• Set up fluid line
• Set up fluid line with pump set
• Set up art line
• Observe/set up level 1
• Use ultrasound to insert iv cannula or arterial line

Medications

• Draw up induction medications (propofol, muscle relaxant, opioid)
• Draw up other meds (antibiotics, antiemetics…)
• Program syringe driver
• Set up metaraminol infusion
• set up remifentanil infusion

Anaesthesia

• Sedate a patient with various agents (combinations of propofol/midaz/opioids etc)
• Observe spinal anaesthesia
• Observe epidural anaesthesia
• Learn to attach monitoring
  • ECG, sats probe, BP cuff, BIS, neuromuscular monitor, temp probe

Inductions

• Do a low risk anaesthetic induction
• Thiopentone induction
• Ketamine induction
• Inhalational induction
• Cardiac stable induction (keeping HR and BP within a tight range)

I hope you enjoy and make the most out of your anaesthesia rotation!

Dr Lahiru

NB: If you are interesting in doing a medical elective in anaesthesia, please contact wcs-electives@unimelb.edu.au. Limited places are available every year, so apply early!

I remember the nervous excitement of my first anaesthesia rotation as a medical student. I was assigned a highly sort after 6 weeks at Monash Medical Centre (one of the largest public hospital systems in Australia) and I had little idea what to expect. I just knew that I had learnt very little anaesthesia in my medical student curriculum, and that I needed to perform well to impress my supervisors and hopefully lead to an anaesthesia training position in the future.

I didn’t realise how crucial this first rotation was for several reasons. Unlike medical, surgical and emergency rotations, this was an optional selective. Not every student is given the opportunity, and I found out years later that the first impression I made here probably set the tone of how this anaesthesia department perceived me into my future anaesthesia rotations.

Insider Tip #1: Make a great first impression

The difficulties in making a great first impression

• Lack of exposure in med school
• Anaesthesia is different
• Multiple consultants
• Newer and more procedures
• Lack of time

Lack of exposure

I realised that I have little recall of any anaesthesia lectures or assessments at all in my medical school days except for learning about the neuromuscular junction. I needed to find a resource ASAP to at least have an idea about was expected of me.

Resources I found useful as a medical student

How to survive anaesthesia was the first book I was recommended. The large books were far too detailed (Millers Anesthesiology). The Oxford Handbook of Anaesthesia was too brief and point form wasn’t easy to for comprehension.

Since then I’ve realised that Clinical Anesthesiology by Morgan and Mikhail is a great all round resource after learning the basics.

And a little plug for my ABCs of Anaesthesia Foundations course: it is a very practical compilation of everything you need to know, and actions/decisions you need to be able to make in your first anaesthesia rotation.

No matter what resources you have access to, having advice from a helpful mentor a year or two ahead was invaluable to uncover the nuances of that specific hospital and demystify the answers to all those little questions and uncertainties that I had.

Anaesthesia is just different. Every surgical or medical job felt more like an administrative position. I would be running around writing to-do lists, making sure work was completed, and then trying to make sense of complex patient plans, or get to theatre to watch a surgeon operate. Anaesthesia felt like I was in a real apprenticeship. My (supervised) daily tasks were:

• Check the theatre setup
• Assessment of each patient (I would take a detailed history lasting about 15 minutes, and my consultant would ask a few brief questions and be done in a minutes)
• Draw up the medications (not always a medical student role)
• Insert an IV cannula
• Transfer the patient
• Attach monitoring
• Manage the airway
• Complete the intraoperative anaesthesia chart
• Rinse repeat

Insider tip #2: Make a checklist of your daily tasks

Except for IV cannulation, EVERY TASK was novel. I felt great! The work was extremely engaging, I felt productive, and I felt like my learning curve was steep and rapid! I kept a logbook (with detailed notes of my learning points), and this was seen as very impressive by my supervisor. I have been recommending this ever since!

Insider tip #3: Keep a logbook

You might work with 10 different consultants/supervisors in 1 week! This is unheard of in any other specialty, but as anaesthesia is often the largest single medical department in hospital, this is common. While it’s great to have so many specialists to teach you, each of them may instruct you in a different and sometimes contradictory way. I found learning one reasonable approach difficult and frustrating. Again, being aware of this, accepting this and using strategies to mitigate this issue is critical!

I would just be appreciative of any learning at all. It felt like a privilege to have one to one tuition from a busy specialist. This rarely happens in any other field! If something was very different to another consultant’s approach or opinion, I would politely mention this other approach and ask why. This would often lead to an interesting discussion which I believe helped create rapport with my supervisor.

Insider tip #4: Ask consultant to justify their approach.

Anaesthesia has many procedures that you may even be able to help with as a medical student or junior doctor! IV cannulation, airway management – bag mask ventilation, LMA insertions, intubation, video laryngoscopy, setting up fluid lines, rapid infusion devices, high flow oxygen, regional anaesthesia, spinal anaesthesia, arterial lines, and central venous lines. The secret to getting these experiences is to know they are options for the case, be extremely prepared, and politely ask for the opportunity.

I’ll write a system for this in more detail in a future article.

Insider tip #5: Preparation leads to opportunity

Anaesthesia has multiple time critical incidents that makes learning a challenge. Every theatre list is busy, airway management = risk of desaturation, hypotension needs rapid meds. There’s just less time to think, ponder options, guide the trainee through a technique, wait for the trainee to act when things could rapidly go disastrously wrong!

So how do we manage to learn all the skills and techniques?

Time and creating opportunities.

Over 5 years of training, with diligent effort, and 2 big exams, most anaesthetists will have the experiences and incidents to be an effective and competent anaesthetist.

But how do you increase ‘time’ when doing a 1 to 6 week rotation? I think it can be achieved by taking a systematic approach.

• Arrive early to the theatre. You’ll need time to orientate, do all the tasks, and assess your patient.
• During the case, check the patient notes for the next case, and even go to see the next patient/have them called to theatre early to give you more time to assess.
• If you are going to do an IV or another procedure, set up your equipment in preparation. Again, request the patient to theatre earlier.
• Plan and know your steps with procedures and verbalise this as you perform the task (more on this in a future blog)

For example

• • Know to escalate bag mask ventilation attempts with 2 hands, manoeuvres like a jaw thrust, adjuncts like a Guedel airway,
  • Verbalise this plan -so your supervisor knows all your next steps and doesn’t intervene too early. You want to get as far as you can with your management before they intervene! The more confidence the boss has in you, the more time they will give you and the more opportunities you’ll have to learn

Insider tip #6: Plan, perform and project (verbalise) your procedures

• When intraoperative problems (hypoxaemia, hypotension) occur, engage in the 4 phase approach to resolution. Again plan, perform and project.

As a supervisor now, I realise that the process of learning is mutual exchange of thoughts. The rate of learning is much slower if the exchange of thoughts happens slowly. The simplest way to each this is verbalisation of ideas and plans as I am performing them, whether it’s airway management or managing a crisis. If the reasons for my actions are glaringly obvious, learning can occur without incorrect assumptions. Conversely, the verbalisation of my trainees’ thoughts means I can either agree or give feedback to why I would have used a different approach.

A few extra ways to make a good impression.

• Anticipate
• Read an article, ask a question with an opinion
• What next

If you can anticipate what your team needs, even at a junior level you can be extremely helpful and less of a hindrance (I’m sure we all felt this going through medical training, when we were high in enthusiasm and low in execution).

For example:

• Your supervisor is placing an urgent IV cannula, bring the sharps bin close to them…
• The patient has a complication, offer to make the referral to ICU
• Everyone’s busy running a difficult case, offer to complete the anaesthesia record to free up time

It is absolutely the role of trainees to ask questions and learn. This is encouraged! But I also know that much of what my teachers tell me, I may forget, and consultants get asked the same questions on repeat. To keep things interesting, why not read a recent or controversial article, form an opinion and quiz your consultant.

You’ve now had to work for your knowledge, formed more stable memory, and potentially sparked your consultant’s interest in something they may have not considered in a while! Check out more of my articles and also directly from journals like the BJA, BJA education, Anesthesia and Analgesia, The ANZCA Blue Book and any anaesthesia journal really.

If you find that you’re not doing much, try to think “what next?”.

• Ask if you can help with anything
• See the next patient
• Complete the anaesthesia chart
• Read an article
• Practice setting up equipment -Optiflow, fluid lines, fibreoptic scopes
• Explore the difficult intubation trolley, MH trolley, Anaphylaxis box, massive transfusion protocol…

I really hope that was useful and provided you with my insights from my experience teaching, medical student supervisor, critical care resident supervisor and as a specialist anaesthetist.

For my information for junior anaesthetists, check out my ABCs Foundations Course, it has everything you need to know in your first 12 months of anaesthesia practice.

Please ask any questions or comment below and share with anyone about to embark on a rotation in anaesthesia!

Good luck in your career!

Dr Lahiru

Objectives

• Define pain
• Explore how it is classified
• Refresh the physiology of nociception and pain
• Review the pharmacological treatment of pain
• Explore the notion of multimodal analgesia
• Use RAT approach to manage pain

Prereading

Great presentation called Essential Pain Management by Wayne Morris and Roger Goucke

http://www.developinganaesthesia.org/essential-pain-management.html

QUESTIONS
(hint: see above website and your foundation term pain lecture notes)
1. What is pain? (IASP defn and simple defn)

2. Why should we treat pain? (Patient, family, society)

3. How does chronic pain differ from acute pain?

4. What 2 the other ways of classifying pain?

Answers to 3 and 4 are the 3 main questions that help us to broadly classify pain
5. What is nociceptive pain?

4. What is neuropathic pain?

5) Draw a diagram showing the pain pathway

6) What are the non-drug methods of treating pain, giving examples?

7. How do you recognize pain?

8. When assessing pain, what 3 aspects of pain are graded?

9. What are the 10 questions used to assess pain? (hint: severity, radiation….)

10a. What is the WHO Analgesic ladder and b. Define multimodal analgesia?

11. Complete this table

12. List the common sides effects and lethal side effects of opioids? How can these risks be mitigated and treated (give medication names and doses)

13. When does a patient require a PCA?

14. When does a patient require an Acute Pain Service Referral?

15. What specialized techniques can be employed by anaesthetists to treat severe pain?

16. What is the sedation score?

• 0
• 1
• 2
• 3
• S This may no longer be used at Western Health

17. For one patient from the pain round complete recognize/assess/treat management plan.

Recognize (how do you know they are in pain?)

Assess (Duration, cause, mechanism, severity – rest/movement/FAS)

Treat (non drug AND drug-what would you write on drug chart)

Objectives

By the end of this module you will

• Understand the approach to the unwell/unstable patient vs the stable patient
• Understand that a diagnosis is not necessary to treat a patient effectively
• Be able to follow D R S A B C D E to systematically and effectively assess and treat any patient
• Compile a system for assessing and diagnosing the reversible causes (4H4Ts)

Background

When I commenced internship I found that managing a sick patient was very difficult and confusing. Throughout medical school I had been told I had to do a history examination and investigations, then treat a number of targeted differential diagnoses.

While this works for the stable patient in an outpatient setting it does not account for the unwell patient who needs immediate treatment.

If you look at all the acute care programs today whether ALS, ATLS, EMST – they are all about treating the problem at hand with a systematic DRSABCDE approach.

This works!

Traditional approach to patient management

• Hx/Ex/Ix à Dx à Rx
• Med school indoctrinates us that the way to assess any patient is
  History
  Examination and
  Investigation
• This leads us to a differential diagnoses
• We then treat with any number of supportive, medical, surgical and other managements.
• If your patient is unwell, do you need to follow the Hx/Ex/Ix à Dx à Rx approach?
  Do you need a diagnosis before you treat?
  Do you treat any less effectively without a definitive diagnosis?

NO!

Don’t let a lack of diagnosis get in the way of initial treatment

• What is vastly more important is assessing and treating the airway, breathing, circulation, disability and exposure or the ABCDEs

The nurse calls you to manage a patient…

1. 1. What problem have you been called about?
      • Hypoxaemia, hypotension, stridor or simply concern that patient looks unwell
   2. Does the patient look sick or stable?
      If patient looks stable, then do your normal Hx/Ex/Ix à Dx à Rx
      If patient looks sick or you’re not sure then follow your ABCDE
   3. DRSABCDE
      Follow this step by step approach to assessing and optimizing ABCDE
      (NB. This is my approach to any MET -medical emergency team- call. I have included just the high yield signs to look for and the most effective management steps that most experienced doctors would do)
      • Ask nurse to apply monitoring and specify:
        A&B -O₂ sats, resp rate
        Circ – BP cuff to cycle every 5mins and ECG monitoring leads+/-defib PADs
        BSL (easy to do and often forgotten so ask nurse to do with obs) Temp
      • Request patient notes, drug chart and print out of recent bloods
        
        Danger
        
      • Put on gloves +/- goggles as you arrive
      • Be aware of dangers in the environment. This could be water on the floor, wires you might trip on, defibrillator, blood, needles…
        
        Response
      • Introduce yourself, ask patients name, and how do they feel.
      • This will give much information on the patients general state, GCS, airway and you will build rapport simply because they know that a doctor has arrived.
        
        Send for Help?
        
      • Call for help early rather than later
      • The easiest way is to call a MET call or Code Blue.
      • Directly ask a staff member to do this and confirm it has been done
      • You will never be criticized for calling for help! And likewise don’t criticize others either!AirwayAssess
        • Ask ‘how are you feeling?’

        If patient is talking effortlessly – airway is safe.

        • Check for stridor, tracheal tug, paradoxical breathing and obvious foreign bodies or visible obstructions.

        Rx

        • Head up at 30% is a good position for every situation
        • Maneuvers: Sniffing the air position. Jaw thrust. Neck extension
        • Airways: Guedel. Nasopharyngeal airway
        • If these do not help its vitally important to call for an airway specialist (anaesthetist/ICU/emergency doctor)

        Breathing

        Assess

        • Inspect for: accessory muscle use, paradoxical breathing, asymmetry
        • Palpate for: tracheal deviation
        • Auscultate: equality, symmetry, wheezes and crackles
        • O₂ Sats and resp rate

        Rx

        • Apply 15L/min O₂ via Laedel bag (if patient very unwell requiring 100% FiO2) or Hudson mask (if patient looks more stable)
        • Assist ventilation

        Circulation
        For arrest situations the ALS protocols are very comprehensive.
        (The following is a format to quickly assess and treat more common issues – which is almost exclusively hypotension in ward patients)

        Assess

        • • Finger on pulse à ?CPR
          • BP and HR give quick indicators of stability
          • ECG/ monitoring with Pads will identify a lethal rhythm.
          • Other less precise signs can be identified
            • Inspect: pallor, mucous membranes, JVP
            • Palpate: cool peripheries, cap return
            • Auscultate heart sounds
            • Check Hb, urine output, fluid balance

        Rx

        This is best guided by the Advanced Life Support guidelines available at www.resus.org.au (also downloadable for iPhone/iPad)

        • Legs up (instantly increase venous return to improve cardiac output)
        • iv access and take a full set of bloods (FBE, UEC, LFT, COAG, GH and BSL
        • Give bolus fluid with an iv pump set (250-500mls is a safe initial bolus in almost every hypotensive patient)
        • ECG

      Disability

      • Check GCS or AVPU
      • Check pupils for reactivity, size, symmetry
      • Check limbs for power

      Exposure

      • Check patient from head to toe (secondary survey)
      • Check temperature
      • Cover and warm as appropriate
   4. Review DRSABCDE again!
   5. Hx/Ex/Ix
   6. Consider the reversible causes – 4Hs and 4Ts
      Hypovolaemia, Hypoxaemia, Hypothermia, Hypo/Hyper electrolytes
      Tension pneumothorax, Tamponade, Thrombosis (cardiac or pulmonary), Toxins

Objectives

• To develop a thorough system for diagnosing and managing common problems
• To develop a list of differential diagnosis for each presentation.
• Identify the most likely causes
• Identify the critical causes not to be misses

Introduction

Internship will be one of the most difficult transitions you’ll have to do as a medical doctor. Clinical practice is very different to being a student in university or on the wards.

The major challenges that I believe most interns face are

• Lack of knowledge in very specialized units
• Many high priority tasks
• Limited time
• Many patients to look after

One way that you can tackle this is to become competent and efficient at those tasks that will be commonly asked of you. This includes

• Practical skills such as IV cannulation, urinary catheter insertion, and obtaining arterial blood gas
• And the ability to solve common problems.

By competently and safely solving the common problems, you will not only have more time to learn the knowledge and specialized skills of your particular unit but also give your patients better care.

The common problems that we solve daily in anaesthetics in very unwell patients with significantly altered physiology, have remarkable overlap with the problems you will be asked to solve for ward patients.

What are the common problems?

• Hypoxaemia
• Tachypnea
• Bradypnoea (slow resp rate)
• Hypertension
• Hypotension
• Tachycardia
• Bradycardia
• Oliguria
• Decreased conscious state

Complete the following exercise to diagnose and manage the common problems

Hypoxaemia

You get a call from the nurse stating your 60yo male patient has decreased oxygen saturations to 92% 1 day after his total knee replacement.

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Request the patient sit up to improve lung mechanics and functional residual capacity
• Repeat a set of vitals

On the way to the patient you consider these broadly classified causes

• Decreased FiO2
• Hypoventilation
• V/Q mismatch – shunt vs dead space
• Diffusion abnormality

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• Hypoventilation secondary to opioids
• Sputum plugging in a smoker
• Atelectasis post surgery

What critical diagnoses are not to be missed?

• Pulmonary embolism
• Drug error/overdose
• Pneumonia
• Pulmonary oedema

Tachypnoea

You get a call from the nurse because your 80yo male patient admitted to gen med for foot cellulitis has a resp rate of 36 (PHx: CCF and renal failure)

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Request the patient sit up to improve lung mechanics and functional residual capacity
• Repeat a set of vitals

On the way to the patient you consider these broadly classified causes

• Pain
• Resp disease
• CVS
• Metabolic acidosis
• Respiratory alkalosis
• Drug/overdose

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Slow resp rate (bradypnoea)

You get a call from the nurse stating a 40yo female patient has decreased resp rate of 8 post thymectomy for myasthenia gravis.

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Request the patient sit up to improve lung mechanics and functional residual capacity
• Repeat a set of vitals

On the way to the patient you consider these broadly classified causes

• CNS
• Drug
• Neurotransmission
• Lung mechanics/chest wall
• Neuromuscular junction
• Muscle pathology

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Hypotension

You get a call from the nurse stating your 50yo male patient has a BP of 90/40 day 1 post anterior resection

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Request the patients legs elevated and with head slightly up
• Repeat a set of vitals
• If inadequate access – IV trolley at bedside and fluid line set up

On the way to the patient you consider these broadly classified causes

• Preload
• Rate and rhythm
• Contractility
• Afterload
• Obstructive

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Hypertension

You get a call from the nurse stating your 70yo patient is hypertensive post a long mastoidectomy.

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Repeat a set of vitals
• Repeat BP on both arms

On the way to the patient you consider these broadly classified causes

• Preexisting
• Pharmacological
• Pain (somatic, visceral)
• Physiological (CVS, resp, CNS, endo)

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Tachycardia

You get a call from the nurse stating your 60yo male patient has decreased oxygen saturations to 92% 1 day after his total knee replacement.

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Repeat a set of vitals
• ECG

On the way to the patient you consider these broadly classified causes

• Primary tachycardia (SVT, AF, Atrial Flutter, VT!)
• Secondary
  • Physiological (resp, CVS, CNS, metabolic/endo)
  • Pharmacological
  • Pain (somatic, visceral, anxiety)

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Bradycardia

You get a call from the nurse stating your 70yo male patient is bradycardic at 36bpm after being admitted with a NSTEMI

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Repeat a set of vitals
• ECG

On the way to the patient you consider these broadly classified causes

• Primary bradycardia (HB)
• Secondary
  • Vagal tone (baroreceptor, Cushings reflex)
  • Pharmacological

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Oliguria

You get a call from the nurse stating your 60yo male patient is making 20ml/hr or urine day 1 post right hemicolectomy.

Before you attend, over the phone you

• Request bladder scan
• If inadequate access – IV trolley at bedside and fluid line set up

On the way to the patient you consider these broadly classified causes

• Prerenal
• Renal
• Post renal

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Decreased conscious state

You get a call from the nurse stating your 50yo male patient is minimally rouseable post scleral buckle surgery for vitreo retinal haemorrhage

Before you attend, over the phone you

• Ask if a code blue or MET call needs to be called
• Request high flow oxygen via Hudson mask
• Repeat a set of vitals
• If inadequate access – IV trolley at bedside and fluid line set up

On the way to the patient you consider these broadly classified causes

• Physiological
• Pharmacological
• Neurological
• Other

At the bedside you optimize the airway, breathing and circulation and consider what aspects of the history, examination and investigations will assist diagnosis?

What are the most likely causes in this patient?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

What critical diagnoses are not to be missed?

• ____________________________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

Objectives

By the end of this module you will

• Know the ALS flowchart from memory
• Know the first vital priorities when arriving at an arrest
• Know the crucial detail necessary to save lives in ALS

Reference

http://www.Resus.org

Flowcharts and ALS guidelines documents

Background

Successful resuscitation requires many different attributes

• Knowledge
• Technical
• The ability to work in a team
• And manage your resources.

This exercise will attempt to improve your knowledge to the level of a senior medical professional in the area of advanced cardiac life support. I believe that having exceptional knowledge in this area will assist you to greatly improve your technical skills and ability to manage a team and resources.

Task

Complete this exercise by reading the ALS documents provided and answer the questions as you read. This document will be an amazing resource during your training, as it will contain all the critical knowledge necessary to ensure effective resuscitation.

THE BIG PICTURE QUESTIONS

1. Draw the ALS flowchart
2. Draw a rough sketch of the flowchart 5 more times
3. Imagine yourself on a general medical ward in your hospital. A nurse shouts for help from the adjacent room. To ensure you don’t forget a step you realize the need to follow the DRSABC system. What does each stand for and what action can you perform for each (look at BLS flow chart)

Danger

Check for danger

Apply personal protective equipment (gloves mask, eye protection)

Response

Check for a verbal and pain response by loudly asking the patient their name and giving a firm squeeze of the trapezius muscle

Send for help

Depending where you are,this may be done by pressing an alarm, calling the medical emergency team or calling an ambulance.

Airway

Look, Listen and feel for any signs of airway obstruction

Alleviate an obstruction with a combination of positioning the patient, carefully removing obvious obstructions, using manoeuvres (jaw thrust, chin lift, head tilt) and airway adjuncts (guedel, nasopharyngeal airway)

Breathing

Look, listen and feel for the signs of breathing. You can often observe respiratory effort, hear breath sounds or feel air movement near the nose or mouth.

If the breathing is absent or abnormal… what is the very next action?

COMMENCE CPR

4. Now that you’ve commenced CPR, you have many tasks to do and only limited time to achieve them. What are the FOUR most important priorities during an arrest?

1. 1. Chest compression
   2. Attach defibrillator pads and perform a rhythm check
   3. Airway management (ventilate and oxygenate using self inflating bag and mask)
   4. Obtain iv access and have adrenaline, amiodarone and fluid ready

NB: Knowing these you will be able to manage your time and resources to address the most important issues. Understand that you will not be able to do 1 or more of these until equipment and expertise arrives. CPR does not require any special equipment so can be commenced immediately.

5. What is the most difficult thing about commencing CPR?

Making the decision to act!

6. After which shock is adrenaline administered? What dose? When is it re- administered?

2^nd shock. 1mg adrenaline. Readminister the dose every 4 minutes.

7. How many cycles of CPR 30 compressions:2 breaths occur for every 2 min period?

5 cycles

8. After which shock is amiodarone given? What dose? When is it re-administered?

3^rd shock. 300mg. An additional dose of 150 mg could be considered. This may be followed by an infusion (ie: 15 mg/kg over 24 hours).

9. What are the shockable rhythms?

Ventricular fibrillation (VF) and ventricular tachycardia (pulseless VT)

10. What are the non-shockable rhythms

Asystole: remember to check your leads – most modern machines will show a dotted line if there’s a disconnection. Also check the gain and check other leads to see if there is a rhythm

PEA: any rhythm that’s not mentioned above can be pulseless electrical activity. Eg. If the patient is in Sinus rhythm, SVT, AF, 3 degree heart block or any other rhythm – make sure to check for a pulse.

No pulse = PEA.

11. What are the reversible causes you must consider?

Hypovolaemia, Hypoxaemia, Hypothermia, Hypo/Hyper electrolytes

Tension pneumothorax, Tamponade, Thrombosis (cardiac or pulmonary), Toxins

THE ESSENTIAL DETAILS

Introduction to ALS

1. Effective external cardiac compression provides a cardiac output of
20-30% of the pre arrest value?

2. What are the first 2 most important priorities in resuscitation from sudden cardiac arrest?

 Effective chest compressions and early defibrillation

3. To prevent cardiac arrest, patients that present with characteristics symptoms of arrhythmic syncope should be managed by specialist cardiology assessment (and include an ECG, Echo, stress test)

These characteristics includesyncope in the supine position, occurring during or after exercise, with no or only brief prodromal symptoms, repetitive episodes, or in individuals with a family history of sudden cardiac death

4. After reading the section on pre-arrest detection and management, what system of care should hospitals provide

• staff education about the signs of patient deterioration, 

• appropriate and regular vital signs monitoring of patients, 

• clear guidance (e.g. via calling criteria or early warning scores) to assist staff in the 
early detection of patient deterioration, 

• a clear, uniform system of calling for assistance, and 

• a clinical response to calls for assistance. 


5. As a future junior doctor, what factors in your opinion will impede you calling for help for the care of an unwell patient.

CPR for ALS providers

1. What is the purpose of cardiopulmonary resuscitation? To provide sufficient vital organ blood flow (eg. to brain, heart) to preserve life until the definitive procedures can be performed (eg. defibrillation, correction of underlying cause)
2. Observational studies have shown these 3 issues with health care professional CPR. Inadequate depth, excessive ventilation rates and excessive interruptions to chest compressions
3. What criteria must be satisfied before commencing CPR? If the victim is not responsive, the airway should be cleared and breathing assessed, and if the victim is not breathing normally
4. What is the ratio of compressions:ventilations? 30:2
5. Do you need to check for a pulse before commencing CPR? No
6. When is it appropriate to check for a pulse? and for how long? If you are an ALS provider trained to do so, and for less than 10 seconds
7. Where do you place your hands for CPR? Lower half of sternum
8. What is the depth of compression during CPR? At least 5cm or 1/3 AP diameter
9. At what rate do you perform CPR? Above which rate is there probably no benefit? 120 compressions/minute. Rates >120 showed no benefit
10. What is the duty cycle and what is the optimal duty cycle? Time in compression to time in relaxation. 50% is recommended, which is equal time in compression and release.
11. What can incomplete chest recoil cause during CPR? How can this prevented? It can cause decreased cardiac output. Ensure the heal of the hand is lifted slightly but completely off the chest
12. Is CPR more effective on a firm or soft surface? Firm
13. When is it reasonable to interrupt CPR? CPR should be continued without interruptions unless signs of responsiveness of normal breathing return or it is necessary to stop to perform specific tasks (eg. endotracheal intubation, rhythm analysis or defibrillation). It is recommended that attempts at intubation should ideally not interrupt cardiac compressions at all. For healthcare professionals, it is reasonable to check a pulse if an organized rhythm is visible on the monitor at the next rhythm check
14. When charging the defibrillator, does CPR pause?
15. What is the ratio of compressions to ventilations before the airway in intubated? How many ventilations per minute is this? ~5 per minute
16. When the patient is intubated, what ventilation rate is required? How many ventilations per compressions is this? 6-10 per minute
17. When do chest compression providers show fatigue? When do they become aware of it? 5 min
18. When should the ‘chest compressor’ be switched? Every 2 minutes or when fatigued
19. Is it safe to charge the defibrillator during chest compressions? Yes if safe protocols are followed
20. During which cycle of 30:2 does charging occur? (eg 1^st , 2^nd, 3^rd etc) 5th
21. After defibrillation what is the very next step?
    1. Rhythm check
    2. CPR
    3. Ventilation
    4. High five anaesthetist
    5. Amiodarone 300mg slow iv
22. Re: answer to 22) what is the theory behind this? Starting CPR immediately after defibrillation, irrespective of the electrical success (or otherwise) of the attempt at defibrillation, restores blood flow to the brain and heart and creates a milieu more conducive to return of spontaneous circulation. A period of good CPR (e.g. for 1-3 minutes) appears to be able to increase the likelihood of success of the next attempt at defibrillation8, 18
23. What monitor can be used to assess the adequacy of CPR? ETCO₂
24. The monitor in 23) is a safe an effective non-invasive indicator of cardiac output
25. During cardiac arrest, what information can arterial blood gases give you? The degree of hypoxaemia, metabolic acidosis, electrolyte imbalance, BSLs
26. If CPR is performed on a person not in cardiac arrest, what evidence is there of harm?
    • Post-mortem studies have identified a significant number of thoracic injuries after CPR. There are no data to suggest that the performance of CPR by bystanders leads to more complications than CPR performed by professional rescuers. One study documented no difference in the incidence of injuries on chest radiograph for arrest victims with and without bystander CPR. One study documented a higher rate of complications among inpatient arrest victims treated by less-experienced (non-ICU) rescuers. Two studies reported that serious complications among non-arrest patients receiving dispatch-assisted bystander CPR occurred infrequently. Of 247 non-arrest patients with complete follow up who received chest compressions from a bystander, 12% experienced discomfort; only 5 (2%) suffered a fracture; and no patients suffered visceral organ injury.
27. After return of spontaneous circulation, what respiratory rate should ventilate the patient at via endotracheal tube? 12

Protocols for adult ALS

1. When do you assess the rhythm?
   1. After 2 mins of CPR
   2. After 5 cycles of 30:2 compressions to ventilations
   3. As soon as the defibrillator pads are applied
   4. After 1mg of adrenaline is administered
2. What energy level is used for biphasic defibrillator shocks? 150 or 200J And monophasic shocks? 360J
3. After commencing CPR, outline the chronological steps up until you give amiodarone (after the 3^rd shock). As per ALS flowchart
4. Is there any evidence that the use of vasopressors such as adrenaline improve survival to hospital discharge? No
5. Is there any evidence that the use of antiarhythmics such as amiodarone improve survival to hospital discharge? No
6. Is there any evidence that the routine use of other any other medications improve survival to hospital discharge? No
7. Is there any evidence for the routine use of fluids? No
8. When might fluids be useful? Suspected hypovolaemia
9. When might thrombolytics be useful? Proven or suspected pulmonary embolism

Electrical therapy for adult ALS

1. How does defibrillation work?
   • A defibrillation shock when applied through the chest produces simultaneous depolarisation of a mass of myocardial cells and may enable resumption of organised electrical activity.
2. Should you delay defibrillation in order to provide a period of CPR? No, inconsistent evidence to support or refute
3. Where is the ideal location to pace defibrillation pads?
   • It is reasonable to place paddles or pads on the exposed chest in an anterior-lateral position. One paddle or pad is placed on the midaxilliary line over the 6th left intercostal space and the other on the right parasternal area over the 2nd intercostal space. Acceptable alternative positions are the anterior-posterior (for paddles and pads) and apex- posterior (for pads). In large-breasted individuals it is reasonable to place the left electrode pad (or paddle) lateral to or underneath the left breast, avoiding breast tissue. Consideration should be given to the rapid removal of excessive chest hair prior to the application of pads/paddles but emphasis must be on minimizing delays in shock delivery
4. If there is a pacemaker in situ, how far away must the pads be placed?
   • In patients with an ICD or a permanent pacemaker, the placement of pad/paddles should not delay defibrillation. When treating an adult with a permanent pacemaker or an implantable cardioverter defibrillator, the defibrillator pad/paddle should be placed on the chest wall ideally at least 8 cm from the generator position. The anterior-posterior and anterior-lateral pad/paddle placements on the chest are acceptable in patients with a permanent pacemaker or ICD.
5. Which provide better results, self- adhesive pads or defibrillation paddles? Pads.
6. What is the advantage of biphasic waveforms for defibrillation?
   • A single cohort study using the 2000 International Guidelines demonstrated better hospital discharge and neurologic survival with biphasic than with monophasic waveforms

https://riskcalculator.facs.org is an exceptional resource to provide reasonably accurate and patient specific risk information to help guide your perioperative decision making.

This calculator uses a series of 20 questions and the surgical procedure to provide 18 different outcomes within 30 days of the procedure. These include risk of death, serious complications and even the chance of whether the patient will need postoperative rehab.

Before this calculator existed I felt that I had a lack of insight into the risks outside of the intra-operative anaesthesia risk. As anaesthetists, we rarely follow up our patients and may not be aware of the patient’s risk a month after the operation. Even our surgical colleagues may not have great data on their patient’s risk profile on such a large scale.

This calculator was built using data from over ‘4.3 million operations in over 730 participating hospitals from 2013-2017‘

I find the calculator most useful when I have a particularly unwell patient. I am able to quickly plug in the requested data points and then assess the risk. Have a look at the risk profile below for this imaginary elderly male undergoing a laparoscopic cholecystectomy.

I find this incredibly useful information to guide my perioperative management and providing informed consent to the patient.

For example I may

• refer to HDU/ICU preop
• discuss risk factor modification and use it as a ‘teachable moment’
• use the data to highlight how high risk (or low risk) something might be to a patient or colleague who has a different opinion on the risk level
• plan post op nursing or rehab requirements
• choose to recommend a particular operation in a centre with ICU/cardiology support
• discuss the risks and benefits with more evidence than limited by my own experience

any questions please comment below!

I was recently supervising an exceptional trainee. He did everything right to make the most from our operative list together. He texted me the night before with things he wanted to learn, He arrived early to the list and had everything checked and set up. I was really impressed with his motivation and assertiveness and knew he would have a rapid learning curve. Now as it happened he also missed an intravenous cannula and wasn’t able to insert the spinal needle. What was really interesting was that this was quite upsetting for my trainee but my impression was that he was very competent and reliable doctor in training.

My assessment of his ability and his assessment of his ability were worlds apart!

I now think back to my own training, and how important it seemed that we are always ‘successful’. We are praised for success and often berated if we don’t succeed, even though many of our technical tasks as anaesthetists can be very humbling.

While we do improve over time, there will be some veins that we just fail to access, arterial lines that never seem to thread and spinals where we just aren’t able to find a route into that elusive intrathecal space.

But what I suggested to my trainee is that the path to success isn’t repeated success…

The path to success is a diligent process of repeated failure

I could now write a whole bunch of cliches or post some inspirational memes proving my point but you’ve probably already seen these, but one does stick to mind… you would never think an infant failed as they stumbled trying to walk. It is simply the process that gets us to a point of competence.

I hope that most of us (trainees and supervisors) realise the critical important of rewarding a diligent process and showing very little if any frustration or negativity if the initial outcome isn’t success.

I believe that this would foster a more productive culture for learning, development and welfare.