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Recommendation for Safety Standards and
   Monitoring during Anaesthesia and
        Recovery Revised 2008
  & Guideline for Pre Operative Fasting
                  2008


              Dr. Nor Hidayah Zainool Abidin
        International Islamic University of Malaysia
                        Anor Hidayah
Outlines
1. Principle of Anaesthesia care
2. Intra operative monitoring of the patient
3. Recovery from anaesthesia
4. Regional anaesthesia
5. Monitored anaesthesia care/ monitored
   sedation
6. Pre-Anaesthetic consultation
7. Pre Operative fasting
                     Anor Hidayah
Principle of Anaesthesia Care

    ANAESTHETIST                   Medical Officer / trainee
                                                                               Under adequate
                                                                                supervision of
      Who administer                                                              Specialist
                                   Qualified specialist
       anaesthetic
                                   anaesthetist


Must be contantly present from
induction/monitoring until safe         Shall be responsible for the overall
    transfer to PACU/ ICU                   anaesthetic care of patient

In acceptional circumstances, deligate temporarily to an appropriately qualified person
                               competent of the task


        SKILLED                     • Assist anaesthetist
                                    • Must be available all the times of conduct of anaesthesia

       ASSISTANT                    • Should not have any other duty

                                         Anor Hidayah
Principle of Anaesthesia Care
• Every patient must have pre-anaesthetic
  assessment
• Adequate and legible records of anaesthesia &
  must be part of patients medical record
• Anaesthetist responsibility to make sure all
  equipments corrects and functioning

      Transfer/      • Minimum 3 person
    positioning of   • Anaesthetist responsible to take
       patient         care of airway, head and neck
                        Anor Hidayah
Clinical                                                               INTRAOPERATIVE
                                    Monitoring
 observation
                                    equipments                              MONITORING
    of VS




Oxygenation                         Ventilation                          Temperature
• Colour of mucous membrane         • Excursion of chest wall            • Neonatal / paediatric patient
• Colour of operative site          • Movement of reservoir beg
• Spo2 with variable pulse tone &   • Ascultation of breathing
  low alarm limit                   • Tidal volume monitoring
                                                                         • Neurovascular
                                    • Capnograph                          • Peripheral nerve stimulator
• Circulation                        • Quantitative assessment of
 • BP                                  ventilation                       • Anaesthetist effect
                                     • Detection of adverse clinical
 • Pulse rate
                                       event (PE/ air embolism)            on brain
                                     • Indication of correct placement    • MAC
                                       of ETT/ LMA                        • BIS


                                               Anor Hidayah
Regional Anaesthesia
• Major RA should received equivalent standard
  and care as general anaesthesia
• Examples:
  – Spinal anaesthesia
  – Epidural anaesthesia
  – Plexus block




                       Anor Hidayah
Recovery from Anaesthesia
• Designated area (PACU) – medical staff should be
  immediately available for emergency
• Standard equipments in PACU
  – Oxygen supply
  – Appropriate delivering equipments means for
    ventilation (ETT, Laryngoscope, LMA)
  – Equipments, drugs for resuscitation
  – Easy access to monitoring equipments
  – Suction apparatus
  – Pt warming devices(forsced air warmer, radiant
    heater), temp monitoring devices

                        Anor Hidayah
Monitored anaesthesia care/ monitored
              sedation
Objective of • Produce degree of amnesia
              • Anxiolysis

  sedation • Maintain cooperation of patient
• Requirements
  – Patient should be assessed
  – The medical practitioner should know
     • basic knowledge of action of drugs
     • detect and manage complications
  – Recorded time and dosage given and vital signs
  – IV access
  – Location with cardiopulmonary resuscitation
                        Anor Hidayah
Pre Anaesthetic Consultation

• To assess and ensure patient is optimised
  before surgery
   Preferable to be given by anaesthetist who
  is to administer the anaesthetics
• Medical history, medicines and
  allergy, laboratory & radiological
• Other investigation
• Anaesthetic consent  Discussion of the
  nature of procedure, details of anaesthesia.
                     Anor Hidayah
History
                                                            5 solid and all
     1946           66 cases of aspiration of                    died
  Landmark          stomach content into Lungs
   paper by          In 45 cases  aspirated
  Mandelson         materials recorded                        40 liquids

   Similar vomitus liquids injected into rabits           Positive CXR changes – no
   lungs – simlar CXR changes                                       death

   Neutralized vomitus liquids  no CXR
   changes
                                                               MORTALITY 3-70%
                                                                 MORBIDITY –
                                                             bronchospam, hypoxia,
            •     No oral feeding during labour                pneumonitis, lungs
            •     IVD should be given                               abscess
Conclusions •     Wider use of regional Anaesthesia
            •     Careful administration of GA with full appreciation of
                  the danger of aspiration during induction and recovery
                                        Anor Hidayah
Patient at risk
• Residual gastrics fluid volume > 0.4ml/kg with pH < 2.5
  at the time of aspiration

• >0.8ml/kg needed to produce pneumonia resulting in
  mortality

• Amount of fluid instilled into the lung (not fluid
  contained in stomach)

• to prevent complication – Pre operative fasting 
  allow sufficient time for gastric emptying

                           Anor Hidayah
Recommendation
                                            Water, glucose drink,
          • Clear Fluid                     cordial drink, Ribena,
2 hours                                           black tea


          • Breast milk
4 hours                                           less hungry
                                                   Less thirsty
        • Milk                                   Less irritable
                                               Less likelyhood of
6 hours • Solids                                dehydration and
                                                  hypotension
        • Fatty food                               Less stress

8 hours • Large amount of food intake


                             Anor Hidayah
Recommendations base of cases
            • No solid food from 12MN
            • Breast milk up to 4 hours before surgery in infant
Am List     • Oral pre med 1-2hrs before surgery up to 150ml of water


            • Light breakfast at 7 am
            • CF until 2-3 hrs before schedule time
Pm List

            • If operation is Semi-Emergency, to follow the above
            • Regional anaesthetic should be considered
            • To be careful in “adequately” fasted duration . (Delayed gastric
Emergency     emptying in trauma and labour patient.
   List
            • Extreme care in gastric outlet obstruction/ bowel obstruction
              however long the fasting duration
                                    Anor Hidayah
Recommendations
• Majority of aspiration occur during
  laryngoscope and intubation
• Rapid sequence induction technique with
  functioning suckers
• In case of fail intubation, Pro seal LMA should
  be at hand



                      Anor Hidayah
Role of Cricoid pressure
• to prevent regurgitation
• to assist with visualisation of the glottis
• Prevention of gas insufflation


 COMPLICATIONS
                          • Nausea / vomiting
                         •Esophageal rupture
      • Difficult tracheal and mask intubation (pressure > 40N
                       may compromise patency)

                           Anor Hidayah
Rebak Island, Langka
Anor Hidayah

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Recommendation for safety standards and monitoring during anaesthesia

  • 1. Recommendation for Safety Standards and Monitoring during Anaesthesia and Recovery Revised 2008 & Guideline for Pre Operative Fasting 2008 Dr. Nor Hidayah Zainool Abidin International Islamic University of Malaysia Anor Hidayah
  • 2. Outlines 1. Principle of Anaesthesia care 2. Intra operative monitoring of the patient 3. Recovery from anaesthesia 4. Regional anaesthesia 5. Monitored anaesthesia care/ monitored sedation 6. Pre-Anaesthetic consultation 7. Pre Operative fasting Anor Hidayah
  • 3. Principle of Anaesthesia Care ANAESTHETIST Medical Officer / trainee Under adequate supervision of Who administer Specialist Qualified specialist anaesthetic anaesthetist Must be contantly present from induction/monitoring until safe Shall be responsible for the overall transfer to PACU/ ICU anaesthetic care of patient In acceptional circumstances, deligate temporarily to an appropriately qualified person  competent of the task SKILLED • Assist anaesthetist • Must be available all the times of conduct of anaesthesia ASSISTANT • Should not have any other duty Anor Hidayah
  • 4. Principle of Anaesthesia Care • Every patient must have pre-anaesthetic assessment • Adequate and legible records of anaesthesia & must be part of patients medical record • Anaesthetist responsibility to make sure all equipments corrects and functioning Transfer/ • Minimum 3 person positioning of • Anaesthetist responsible to take patient care of airway, head and neck Anor Hidayah
  • 5. Clinical INTRAOPERATIVE Monitoring observation equipments MONITORING of VS Oxygenation Ventilation Temperature • Colour of mucous membrane • Excursion of chest wall • Neonatal / paediatric patient • Colour of operative site • Movement of reservoir beg • Spo2 with variable pulse tone & • Ascultation of breathing low alarm limit • Tidal volume monitoring • Neurovascular • Capnograph • Peripheral nerve stimulator • Circulation • Quantitative assessment of • BP ventilation • Anaesthetist effect • Detection of adverse clinical • Pulse rate event (PE/ air embolism) on brain • Indication of correct placement • MAC of ETT/ LMA • BIS Anor Hidayah
  • 6. Regional Anaesthesia • Major RA should received equivalent standard and care as general anaesthesia • Examples: – Spinal anaesthesia – Epidural anaesthesia – Plexus block Anor Hidayah
  • 7. Recovery from Anaesthesia • Designated area (PACU) – medical staff should be immediately available for emergency • Standard equipments in PACU – Oxygen supply – Appropriate delivering equipments means for ventilation (ETT, Laryngoscope, LMA) – Equipments, drugs for resuscitation – Easy access to monitoring equipments – Suction apparatus – Pt warming devices(forsced air warmer, radiant heater), temp monitoring devices Anor Hidayah
  • 8. Monitored anaesthesia care/ monitored sedation Objective of • Produce degree of amnesia • Anxiolysis sedation • Maintain cooperation of patient • Requirements – Patient should be assessed – The medical practitioner should know • basic knowledge of action of drugs • detect and manage complications – Recorded time and dosage given and vital signs – IV access – Location with cardiopulmonary resuscitation Anor Hidayah
  • 9. Pre Anaesthetic Consultation • To assess and ensure patient is optimised before surgery  Preferable to be given by anaesthetist who is to administer the anaesthetics • Medical history, medicines and allergy, laboratory & radiological • Other investigation • Anaesthetic consent  Discussion of the nature of procedure, details of anaesthesia. Anor Hidayah
  • 10. History 5 solid and all 1946 66 cases of aspiration of died Landmark stomach content into Lungs paper by  In 45 cases  aspirated Mandelson materials recorded 40 liquids Similar vomitus liquids injected into rabits Positive CXR changes – no lungs – simlar CXR changes death Neutralized vomitus liquids  no CXR changes MORTALITY 3-70% MORBIDITY – bronchospam, hypoxia, • No oral feeding during labour pneumonitis, lungs • IVD should be given abscess Conclusions • Wider use of regional Anaesthesia • Careful administration of GA with full appreciation of the danger of aspiration during induction and recovery Anor Hidayah
  • 11. Patient at risk • Residual gastrics fluid volume > 0.4ml/kg with pH < 2.5 at the time of aspiration • >0.8ml/kg needed to produce pneumonia resulting in mortality • Amount of fluid instilled into the lung (not fluid contained in stomach) • to prevent complication – Pre operative fasting  allow sufficient time for gastric emptying Anor Hidayah
  • 12. Recommendation Water, glucose drink, • Clear Fluid cordial drink, Ribena, 2 hours black tea • Breast milk 4 hours less hungry Less thirsty • Milk Less irritable Less likelyhood of 6 hours • Solids dehydration and hypotension • Fatty food Less stress 8 hours • Large amount of food intake Anor Hidayah
  • 13. Recommendations base of cases • No solid food from 12MN • Breast milk up to 4 hours before surgery in infant Am List • Oral pre med 1-2hrs before surgery up to 150ml of water • Light breakfast at 7 am • CF until 2-3 hrs before schedule time Pm List • If operation is Semi-Emergency, to follow the above • Regional anaesthetic should be considered • To be careful in “adequately” fasted duration . (Delayed gastric Emergency emptying in trauma and labour patient. List • Extreme care in gastric outlet obstruction/ bowel obstruction however long the fasting duration Anor Hidayah
  • 14. Recommendations • Majority of aspiration occur during laryngoscope and intubation • Rapid sequence induction technique with functioning suckers • In case of fail intubation, Pro seal LMA should be at hand Anor Hidayah
  • 15. Role of Cricoid pressure • to prevent regurgitation • to assist with visualisation of the glottis • Prevention of gas insufflation COMPLICATIONS • Nausea / vomiting •Esophageal rupture • Difficult tracheal and mask intubation (pressure > 40N may compromise patency) Anor Hidayah

Notas do Editor

  1. Guidelines are made to for guide medical practitioner for high quality of anaesthesiapractise and safety of patient under our careAnaesthetist clinical judgement and observation remain the cornerstone of safe anaesthesia practiceAnd the vigilence of anaesthetist while administering anaesthetics cannot be overemphasized
  2. Sedative side effect – depression of protective reflexes, respiration, CVAWide variation in individual response to variety drugs especially in elderly and sick
  3. Bear in mind even adequately fasted patient can have residual gastric volume &gt;0.4ml/kg/hr that pH&lt; 2.5Fasted patient (reduce the risk of aspiration)Higher risk for aspirationDelayed gastric emptying  trauma patient, ingestion of fatty food, certain medicationsHiatus hernia, GERD, bowel obstruction, pregnant lady, morbidly obese, bulbar palsy
  4. In Chochrane Review75% of infant entered fasting state after 3 hrs of fasting17% in formula milkFlexible fasting policy
  5.  The initial article by Sellick was based on a small sample size at a time when high tidal volumes, head-down positioning, and barbiturate anesthesia were the rule.[