Recommendation for Safety Standards and   Monitoring during Anaesthesia and        Recovery Revised 2008  & Guideline for ...
Outlines1. Principle of Anaesthesia care2. Intra operative monitoring of the patient3. Recovery from anaesthesia4. Regiona...
Principle of Anaesthesia Care    ANAESTHETIST                   Medical Officer / trainee                                 ...
Principle of Anaesthesia Care• Every patient must have pre-anaesthetic  assessment• Adequate and legible records of anaest...
Clinical                                                               INTRAOPERATIVE                                    M...
Regional Anaesthesia• Major RA should received equivalent standard  and care as general anaesthesia• Examples:  – Spinal a...
Recovery from Anaesthesia• Designated area (PACU) – medical staff should be  immediately available for emergency• Standard...
Monitored anaesthesia care/ monitored              sedationObjective of • Produce degree of amnesia              • Anxioly...
Pre Anaesthetic Consultation• To assess and ensure patient is optimised  before surgery   Preferable to be given by anaes...
History                                                            5 solid and all     1946           66 cases of aspirati...
Patient at risk• Residual gastrics fluid volume > 0.4ml/kg with pH < 2.5  at the time of aspiration• >0.8ml/kg needed to p...
Recommendation                                            Water, glucose drink,          • Clear Fluid                    ...
Recommendations base of cases            • No solid food from 12MN            • Breast milk up to 4 hours before surgery i...
Recommendations• Majority of aspiration occur during  laryngoscope and intubation• Rapid sequence induction technique with...
Role of Cricoid pressure• to prevent regurgitation• to assist with visualisation of the glottis• Prevention of gas insuffl...
Rebak Island, LangkaAnor Hidayah
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Recommendation for safety standards and monitoring during anaesthesia

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  • 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
  • Sedative side effect – depression of protective reflexes, respiration, CVAWide variation in individual response to variety drugs especially in elderly and sick
  • 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
  • In Chochrane Review75% of infant entered fasting state after 3 hrs of fasting17% in formula milkFlexible fasting policy
  •  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.[
  • Recommendation for safety standards and monitoring during anaesthesia

    1. 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. 2. Outlines1. 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 Anor Hidayah
    3. 3. Principle of Anaesthesia Care ANAESTHETIST Medical Officer / trainee Under adequate supervision of Who administer Specialist Qualified specialist anaesthetic anaesthetistMust be contantly present frominduction/monitoring until safe Shall be responsible for the overall transfer to PACU/ ICU anaesthetic care of patientIn 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. 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. 5. Clinical INTRAOPERATIVE Monitoring observation equipments MONITORING of VSOxygenation 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. 6. Regional Anaesthesia• Major RA should received equivalent standard and care as general anaesthesia• Examples: – Spinal anaesthesia – Epidural anaesthesia – Plexus block Anor Hidayah
    7. 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. 8. Monitored anaesthesia care/ monitored sedationObjective 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. 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. 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 abscessConclusions • Wider use of regional Anaesthesia • Careful administration of GA with full appreciation of the danger of aspiration during induction and recovery Anor Hidayah
    11. 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. 12. Recommendation Water, glucose drink, • Clear Fluid cordial drink, Ribena,2 hours black tea • Breast milk4 hours less hungry Less thirsty • Milk Less irritable Less likelyhood of6 hours • Solids dehydration and hypotension • Fatty food Less stress8 hours • Large amount of food intake Anor Hidayah
    13. 13. Recommendations base of cases • No solid food from 12MN • Breast milk up to 4 hours before surgery in infantAm 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 timePm List • If operation is Semi-Emergency, to follow the above • Regional anaesthetic should be considered • To be careful in “adequately” fasted duration . (Delayed gastricEmergency emptying in trauma and labour patient. List • Extreme care in gastric outlet obstruction/ bowel obstruction however long the fasting duration Anor Hidayah
    14. 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. 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
    16. 16. Rebak Island, LangkaAnor Hidayah

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