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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 AbidinInternational Islamic University of Malaysia

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Outlines

1. Principle of Anaesthesia care2. Intra operative monitoring of the patient3. Recovery from anaesthesia4. Regional anaesthesia5. Monitored anaesthesia care/ monitored

sedation6. Pre-Anaesthetic consultation7. Pre Operative fasting

Principle of Anaesthesia Care

ANAESTHETIST

Who administer anaesthetic

Medical Officer / trainee

Qualified specialist anaesthetist

Under adequate supervision of

Specialist

Shall be responsible for the overall anaesthetic care of patient

Must be contantly present from induction/monitoring until safe

transfer to PACU/ ICU

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

• Assist anaesthetist• Must be available all the times of conduct of anaesthesia• Should not have any other duty

SKILLED ASSISTANT

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• 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

Principle of Anaesthesia Care

• Minimum 3 person• Anaesthetist responsible to take care

of airway, head and neckTransfer/ positioning

of patient

Oxygenation•Colour of mucous membrane•Colour of operative site•Spo2 with variable pulse tone & low alarm limit

•Circulation•BP•Pulse rate

Ventilation•Excursion of chest wall•Movement of reservoir beg•Ascultation of breathing•Tidal volume monitoring•Capnograph•Quantitative assessment of ventilation•Detection of adverse clinical event (PE/ air embolism)•Indication of correct placement of ETT/ LMA

Temperature•Neonatal / paediatric patient

•Neurovascular•Peripheral nerve stimulator

•Anaesthetist effect on brain•MAC•BIS

Clinical observation of

VS

Monitoring equipments

INTRAOPERATIVE MONITORING

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Regional Anaesthesia

• Major RA should received equivalent standard and care as general anaesthesia

• Examples:– Spinal anaesthesia– Epidural anaesthesia– Plexus block

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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

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Monitored anaesthesia care/ monitored sedation

• Anxiolysis• Produce degree of amnesia• Maintain cooperation of patient

Objective of sedation

• 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

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

66 cases of aspiration of stomach content into Lungs In 45 cases aspirated materials recorded

1946 Landmark paper by

Mandelson

5 solid and all died

40 liquids

Positive CXR changes – no death

Similar vomitus liquids injected into rabits lungs – simlar CXR changes

Neutralized vomitus liquids no CXR changes

• No oral feeding during labour• IVD should be given• Wider use of regional Anaesthesia• Careful administration of GA with full appreciation of the

danger of aspiration during induction and recovery Conclusions

MORTALITY 3-70%MORBIDITY –

bronchospam, hypoxia, pneumonitis, lungs

abscess

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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

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Recommendation

2 hours

•Clear Fluid

4 hours

•Breast milk

6 hours

•Milk

•Solids

8 hours

•Fatty food

•Large amount of food intake

Water, glucose drink, cordial drink, Ribena,

black tea

less hungryLess thirsty

Less irritableLess likelyhood of dehydration and

hypotensionLess stress

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Recommendations base of cases

Am List

•No solid food from 12MN

•Breast milk up to 4 hours before surgery in infant

•Oral pre med 1-2hrs before surgery up to 150ml of water

Pm List

•Light breakfast at 7 am

•CF until 2-3 hrs before schedule time

Emergency List

• If operation is Semi-Emergency, to follow the above

•Regional anaesthetic should be considered

•To be careful in “adequately” fasted duration . (Delayed gastric emptying in trauma and labour patient.

•Extreme care in gastric outlet obstruction/ bowel obstruction however long the fasting duration

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

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Role of Cricoid pressure

• to prevent regurgitation• to assist with visualisation of the glottis• Prevention of gas insufflation

• Nausea / vomiting• Esophageal rupture

• Difficult tracheal and mask intubation (pressure > 40N may compromise patency)

COMPLICATIONS

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Thank you….Rebak Island, LangkawiAnor Hidayah