Additional Information
Department of Anaesthesia University of Cape Town Additional Information
Disclaimer: The information is supplied in good faith and is believed to be accurate at the time of editing, but errors may be present. The contributors, editors, Dept. of Anaesthesia and University of Cape Town do not accept liability for any consequences arising from the information supplied. It is incumbent on the reader to verify the accuracy and suitability of any information prior to clinical use.
Essential drugs & doses
Volatiles MAC (%) Induction agents mg kg-1
Halothane 0,75 Propofol Adults 1,5 - 2,5 (1 - 1,5 in elderly)
Enflurane 1,7 Children 2,5 - 3,0
Isoflurane 1,2 Thiopentone 3 - 5
Sevoflurane 2 Etomidate 0,2 - 0,3
Desflurane 6 Ketamine Induction IV 1 - 2
N2O 105 IM 5 - 10
Analgesia IV 0,2 - 0,4
Muscle relaxants mg kg-1 (adult bolus) Opiates -1 Suxamethonium 1 - 2 (100) Morphine 0,1 mg kg -1 Pancuronium (Pavulon®) 0,1 (6) Fentanyl (Sublimaze®) 1- 3 µg kg -1 Vecuronium (Norcuron®) 0,1 (6) Sufentanil (Sufenta®) 0,1 - 0,2 µg kg -1 -1 Rocuronium (Esmeron®) 0,6 - 1,0 (50) Remifentanil (Ultiva®) 0,05 - 0,5 µg kg min 50 mg ml-1 Atracurium (Tracrium®) 0,5 (30) -1 Cisatracurium (Nimbex®) 0,15 (10) Alfentanil (Rapifen®) 10 µg kg up to 30 µg kg-1 (To ↓ intubation response) Mivacurium (Mivacron®) 0,15 (10) -1 Repeat doses are 20 % of the original dose Tilidine (Valoron®) drops 1 mg kg (1 drop = 2,5 mg) Reversal of muscle relaxants Antagonist to opiates -1 -1 -1 Neostigmine with either 40 µg kg (2,5 mg) Naloxone (Narcan®) 2 - 10 µg kg dose -1 Glycopyrrolate (Robinul®) 8 µg kg (0,4 - 0,6 mg) 0,4 mg amps Titrate to effect and follow with -1 -1 -1 if necessary or 20 µg kg (1 - 1,2 mg) Dilute to 10 - 20 ml 10 µg kg hr Atropine
Oral premedicants mg kg-1 IV sedatives mg kg-1
Midazolam (Dormicum®) Kids 0,5 max. 7,5 mg Midazolam 0,1 - 0,3
Adults 7,5 - 15 mg Diazepam 0,1 - 0,2
Diazepam (Valium®) 5 - 10 mg (Total dose) Antagonist to benzodiazepines
Trimeprazine (Vallergan®) 2 - 3 (Children > 1 yr) Flumazenil (Anexate®) 0,2 mg q 1 min max. 1 mg Repeat q 20 min x 3 Droperidol (Inapsin®) 0,1 - 0,2 max. 5 mg All 2 hours pre-op., except Midazolam - 30 min pre-op.
Resuscitation Bolus Local anaesthetics Max. safe dose mg kg-1
Ephedrine 5 - 10 mg (Titrate to effect) Lignocaine (Xylocaine®) 3 (or 7 with adrenaline)
Phenylephrine 50 μg (Titrate to effect) Bupivacaine (Marcaine®) 2- 2,5 (Paediatrics) Adrenaline Arrest 1 mg q 4 min Local anaesthetic induced cardiac arrest - ® -1 CVS collapse 50 - 100 μg (Ttrate) Intralipid 20 % 1,5 ml kg and follow with -1 -1 0,25 ml kg min infusion Atropine Arrest 1 mg q 4 min max. 3 mg
Bradycardia 0,2 - 0,5 mg (Titrate) Additional information
Anti-emetics Paeds (Adult) Antibiotics Paeds (Adult) -1 -1 Dexa- / Beta- methasone 0,15 mg kg (8 mg) Cefazolin (Kefzol®) 50 mg kg max 1 g(1 - 2 g) -1 Droperidol (Inapsin®) 15 μg kg (0,5 - 1 mg) Co-amoxiciclav (Augmentin®) (1,2 g) -1 -1 Ondansetron (Zofran®) 0,1 mg kg (4 / 8 mg) Ampicillin 50 mg kg (1 g) -1 -1 Granisetron (Kytril®) (1 mg) Gentamycin 5 mg kg (5 mg kg ) -1 Metoclopramide (Maxolon®) (10 mg) Metronidazole (Flagyl®) 7,5 mg kg (500 mg) -1 Prochlorperazine (Stemetil®) (12,5 mg IMI)Clindamycin 20 mg kg (600 mg) For penicillin-allergic patients All IV except for Prochlorperazine - IM
Antidysrhythmics Diuretics -1 -1 Lignocaine 1 - 2 mg kg Furosemide (Lasix®) 0,1 - 0,6 mg kg -1 Amiodarone (Cordarone®) 300 mg loading over 1 hr then Mannitol 20 % & 25 % 0,25 g kg -1 900 mg day infusion Adenosine 6 mg rapidly – If no effect, repeat after 1 - 2 min 12 mg rapidly Non-opiate Analgesics
Verapamil (Isoptin®) 2,5 - 10 mg slowly (Titrate) NSAIDs Paeds (Adult - mg) -1 Ibuprofen (Brufen®) 5- 10 mg kg (200 - 400) Miscellaneous -1 Diclofenac (Voltaren®) 1- 2 mg kg PR (50) slowly over 1 min and follow -1 Oxytocin 2,5 iu Indomethacin (Indocid®) 0,5 - 1 mg kg PR(25 - 50) with infusion if needed -1 ® -1 10 - 20 iu l (Titrate to effect) Ketorolac (Toradol ) 0,5 mg kg IV (30 IV) ® -1 Ergometrine 100 μg slowly over 5 min or 200 Parecoxib (Rayzon ) 1 mg kg IV (40 IV) - 500 μg IM Paracetamol Sodium citrate 30 ml PO (30 min pre-op) Oral / IV 20 / 15 mg kg-1 (1 g) -1 Ranitidine (Zantac®) 300 mg PO (2 hr pre-op) Rectal 40 mg kg
Bronchospasm Hypertension
↑ Volatiles All are bronchodilators Labetalol (Trandate®) 5- 10 μg bolus -1 -1 Salbutamol 0,2 - 1,2 mg hr Esmolol (Breviblock®) 0,2 - 0,5 mg kg bolus (5 mg in 50 ml = 100 μg ml-1 -1 -1 MgSO4 30 - 60 mg kg Rate = 2 - 12 ml hr ) -1 Hydrallazine (Nepresol®) 0,5 - 1 mg min -1 Ketamine 0,1 - 1 mg kg (25 mg in 200 ml N Saline) -1 -1 Propofol 10 - 20 mg bolus Glyceryl trinitrate 0,5 - 2 µg kg min (50 mg in 50 ml = 1 mg ml-1 Hydrocortisone 100 mg -1 Rate = 2 - 8 ml hr )
Essential equipment
ETT sizes Length cm LMAs Vol Size mm Oral Nasal Size ml
Paediatrics Premature 2,0 - 2,5 5 - 7 6 - 9 Infants < 5 kg 1 4
Term - 6 / 12 3,0 - 3,5 8,5 - 10 10,5 - 12 Infants 5 - 10 kg 1 ½ 7
6/ 12 - 1 year 3,5 - 4,0 10 - 11 12 - 14 Children 10 - 20 kg 2 10
1- 2 years 4,0 - 4,5 11 - 12 14 - 15 Children 20 - 30 kg 2 ½ 14
2- 4 years 4,5 - 5,0 12 - 14 15 - 17 Children / Adults > 30 kg 3 20
4 - 6 years 5,0 - 5,5 14 - 15 17 - 19 Adult females > 50 kg 4 30
6 - 8 years 5,5 - 6,0 15 - 16 19 - 20 Adults > 75 kg 5 40
8- 12 years 6,0 - 7,0 16 - 18 20 - 22 Adult males > 100 kg 6 50
Adults Females 7,0 - 7,5 18 - 22 24 - 26
Males 7,5 - 8,0 20 - 24 25 - 28 Formula: (Age / 4) + 4 (Age / 2) + 12 (Age / 2) + 15
2 Additional information
Ventilation and breathing circuits
Ventilator settings Fresh gas flows Spontaneous Controlled -1 Tidal volume 6 - 8 ml kg Magill system 1 x MV 2,5 x MV -1 Respiratory rate Adult 10 - 15 b min Bains system 2 - 3 x MV 1 - 1,5 x MV Neonate 30 b min-1 T-piece system 3 x MV 1,5 x MV Children < 6 yr or < 20 kg PEEP 3 - 10 hPa Minute volume Adult 70 ml kg-1 min-1
I : E ratio (R R dependant) 1 : 1,5 to 1 : 20
Inspiratory time 0,5 - 1,5 sec Premature - adult
Intra-operative fluids
Crystalloids + colloids Blood products -1 -1 Paediatric 4 : 2 : 1 rule 4 ml kg for 1st 10 kg - Packed cells 4 ml kg (↑ Hb 1 g dl-1) -1 -1 for maintenance 2 ml kg for next 10 kg - Whole blood 8 ml kg (↑ Hb 1 g dl-1) -1 e.g.: 27 kg child = 67 ml hr -1 -1 1 ml kg for each kg > 20 kg - FFP 10 - 30 ml kg and 16 kg child = 52 ml hr-1 -1 body weight Platelets 1 ml kg (↑ platelets by 5 000) Rehydration of deficit 1,0 ml kg-1 x hours NPO Maintenance 1,0 ml kg-1 hr-1 -1 -1 Replacement of 0 - 8 ml kg hr operative losses (depending on surgery) Replacement of blood losses 10 % loss Crystalloids (3 : 1)
10 - 20 % loss Colloids (1 : 1) Blood or clear colloids depends on starting Hb and transfusion trigger for patient
Useful web pages
Department of Anaesthesia at UCT .. www.anaesthesia.uct.ac.za/anaesuct.htm
South African Society of Anaesthetists ...... www.sasaweb.com Resuscitation Council of South Africa ...... www.resuscitationcouncil.co.za World Anaesthesia Society (Updates in Anaesthesia) ...... www.worldanaesthesia.org The Association of Anaesthetists of Great Britain & Ireland ... www.aagbi.org Royal College of Anaesthesia ...... www.rcoa.ac.uk Anaesthesia Education Website (Australian) ...... www.anaesthesiamcq.com Australia and New Zealand College of Anaesthetists ...... www.anzca.edu.au The American Society of Anesthesiologists ...... www.asahq.org GASnet Anesthesiology Homepage (virtual textbook) ...... anestit.unipa.it/HomePage.html New York School of Regional Anaesthesia ...... www.nysora.com European Society of Regional Anaesthesia ...... www.esraeurope.org
3 Additional information
Guide to pre-operative investigations
Test → Ward U / Cr & Blood FBC CXR ECG Urine PFTs Other Patient category ↓ Hb Elecs sugar Healthy pt. for minor surgery + Age > 60 yr or major surgery + + + Surgical blood loss > 600 ml + Diabetes, well-controlled, + + + < 40 yr and minor surgery Diabetes, well-controlled, + + + + + > 40 yr or major surgery Major abdominal surgery + Major vascular surgery + + + + + + Cardiovascular disease + + + + Limiting respiratory disease + + + + Renal impairment + + + + Liver disease with LFTs, INR, + + + + + + right heart failure Albumin Thoracotomy + + + Morbid obesity BMI > 35 + + + + + + Steroid (pred > 10 mg day-1) + + Females of child-bearing age + Pregnancy
Additional notes:
All cases must be fully clerked. Further tests may be necessary on clinical grounds. CXRs < 1 year old need not be repeated unless there is a change in symptoms ECG < 6 months old need not be repeated if symptoms stable.
U / Cr & Elecs need not be repeated if normal in previous 3 months & no new diuretics / therapy.
Respiratory disease: Asthmatic: Young and well-controlled Nil Older or symptomatic Spirometry (pre- and post- bronchodilator)
Severe COAD: Spirometry (pre- and post- bronchodilator), blood gases Anaesthetic consultation
Previous lung surgery: Anaesthetic consultation
Cardiovascular disease: Hypertension: Hb, U & E, ECG, urinalysis Diastolic BP > 115 mm“Hg” Refer to physicians at least 2 wks before elective surgery Urgent surgery with DBP > 115 mm“Hg” Anaesthetic consultation
Ischaemic heart disease: Unstable or frequent angina Physician and anaesthetic consultation MI in past 6 months Anaesthetic consultation
Cardiomyopathy: Anaesthetic consultation
Pacemakers: Review of pacemaker by technologists within past year
Previous cardiac surgery: Anaesthetic consultation
Airway problems: Anaesthetic consultation
4 Additional information
CONTROL OF PAIN FOR SIMPLE SURGICAL PROCEDURES IN CHILDREN:
GUIDELINES FOR DISTRICT HOSPITALS IN THE WESTERN CAPE These guidelines are directed at the management of pain for dental extractions and adeno- tonsillectomy. They are intended to ensure an adequate standard of analgesia for these procedures at all facilities in the Western Cape. These guidelines only contain drugs that are already coded for use in Level 1 hospitals.
Principles 1. Pre-empt the development of pain - Rather than allowing pain to become established, provide adequate analgesia before, during and after the procedure. Plan the time of drug administration so that the effect is predicted to match that of the painful stimulus.
- Assess pain. Simple measures such as parental presence, a calm environment and the use of distraction techniques (suitable toys, etc.) can aid in distinguishing anxiety from pain.
2. Consider intra-operative analgesia in addition to options 1 - 3 -1 - Local infiltration by dentist if less than 4 extractions (max. 0,3 mg kg of 1 % lignocaine + adrenaline) -1 - Fentanyl 0,5 - 1 μg kg IVI following induction of anaesthesia for extractions and tonsillectomies
3. Drugs available on code for Level 1 hospitals - Paracetamol syrup - Paracetamol suppositories 125 mg and 250 mg - Ibuprofen syrup - Diclofenac suppositories 12,5 mg and 25 mg ® - Tilidine (Valoron ) drops
ANALGESIC OPTIONS [Either option 1 or 2 peri-operatively and then follow with a postoperative prescription]
Option 1 Pre-operative oral (if not using option 2) Paracetamol syrup 20 mg kg-1 and ibuprofen syrup 5 mg kg-1 or Option 2 Intra-operative (ideally following induction of anaesthesia) Paracetamol suppositories 40 mg kg-1 (once only loading dose). If more than 1 g needed then rather use 1 g oral pre-operatively and diclofenac suppositories 1 mg kg-1 (round off to the nearest suppository dose) and Postoperative prescription Paracetamol syrup 20 mg kg-1 6-hourly Ibuprofen syrup 5 mg kg-1 6-hourly
ALTERNATIVES (if postoperative oral paracetamol and ibuprofen fails to control pain within 45 minutes of administration) Preferred option 1 Tilidine (Valoron®) drops 1 mg kg-1 6-hourly (body weight in kg ÷ 2,5 = drops per dose). Preferably administer under the patient’s tongue
Preferred option 2 Oral ketamine 2 mg kg-1 by mouth 4-hourly (maximum 2 doses)
Compiled by the Provincial Anaesthetic Coordinating Committee In consultation with Professor Jenny Thomas and Dr Graeme Wilson, October 2008
5 Additional information
SAFE USE OF NEUROMUSCULAR BLOCKING AGENTS
GUIDELINES FOR DISTRICT HOSPITALS IN THE WESTERN CAPE
A. The aim of this protocol is: 1. To replace the use of alcuronium with the safer, modern agents together with the use of peripheral nerve stimulators to monitor neuromuscular blockade and its reversal. 2. To provide adequate muscle relaxation for intubation and to facilitate surgery. 3. To indicate when safe reversal can be undertaken, thereby preventing residual postoperative neuromuscular blockade.
B. How to achieve these aims: 1. Administer the correct doses of neuromuscular blocking agents and reversal agents 2. Use a peripheral nerve stimulator (PNS) To confirm suxamethonium reversal before a non-depolarising muscle relaxant (NDMR) is administered. To monitor NDMR block during surgery. To confirm adequate NDMR reversal before reversal agents (neostigmine plus anticholinergic drug) is administered. To confirm NDMR reversal after reversal agent is given.
C. Intubating doses of neuromuscular blocking agents 1. Suxamethonium (depolarising muscle relaxant) 1 - 2 mg kg-1 intravenously for rapid sequence induction. A 70 kg adult would typically receive 100 mg.
Onset time 30 - 60 seconds and duration 5 - 9 minutes. Suxamethonium may be used in acute spinal injuries and burns during the first 24 hours post injury but is contraindicated for 1 to 2 years after healing of the burn affected skin has occurred and until neurological recovery or onset of spasticity in spinal injuries. Reversal is by a naturally occurring plasma enzyme, pseudocholinesterase. Neostigmine is therefore not administered for reversal. In the rare case where there is an enzyme deficiency, ventilation should be maintained until recovery occurs (up to 5 - 6 hours). 2. Vecuronium (NDMR): -1 Intubating dosage 0,1 mg kg . A 70 kg adult would receive 6 - 7 mg.
Onset time 2 - 3 minutes and duration 30 - 40 minutes. Follow up dose 0,02 mg kg-1. A 70 kg adult would receive 1 mg. 3. Rocuronium (NDMR): 0,6 mg kg-1. A 70 kg adult would receive 40 mg.
Onset time is 2 - 3 minutes and duration 37 minutes. -1 Follow up dose 0,1 - 0,15 mg kg . A 70 kg adult would receive 10 mg.
D. Dosage of reversal agents for non-depolarising relaxants. -1 1. Neostigmine 0,035 - 0,05 mg kg (max. 2,5 mg dose) 2. Glycopyrrolate 0,01 mg kg-1 or atropine 0,015 mg kg-1 i.e. Approximately 2,5 mg neostigmine and 0,6 mg glycopyrrolate for average adult. If unsure of adequate reversal following initial dose, do not give repeat doses. It is safer to keep the patient ventilated until complete reversal has occurred.
Typically this may take 30 - 40 minutes. During this period remember to continue with inhalation anesthetic agents or provide hypnosis / sedation with midazolam or propofol.
E. How to use peripheral nerve stimulator (PNS): 1. After rapid sequence induction with suxamethonium Execute rapid sequence induction, intubate and ventilate patient.
Wait approximately 5 - 10 minutes, look for clinical signs of suxamethonium reversal for example spontaneous breathing.
If no clinical signs are visible after 5 - 10 minutes select and execute TOF option. Give non-depolarising muscle relaxant only if four twitches are visible
6 Additional information
2. During non-rapid sequence induction Ideally, prior to induction place black lead electrode over ulnar nerve at the wrist and red lead electrode proximally (see diagram at bottom of document) towards the elbow. Set current at 60 mA. Give induction agent, maintain airway. Ventilate the patient’s lungs for approximately 3 minutes while administering the inhalation agent of your choice. Select TOF and press button to activate it; observe amplitude of four twitches as a control. Give intubating dose of non-depolarizing muscle relaxant. Continue to ventilate with a facemask until only one twitch is visible before tracheal intubation is attempted. Intubate the trachea and continue to ventilate patient.
Visual and tactile evaluation of TOF
T4 decreased: 70 - 75% of receptors occupied T3 lost: 85% of receptors occupied
T4 lost: T2 lost: 80% of receptors 85 - 90% of receptors occupied occupied
3. For monitoring muscle relaxation during surgery Follow up dosages are not necessary to administer routinely and should be given only on clinical indication, such as a tight abdomen. Intermittent TOF testing during operation should elicit no more than one or two twitches for body cavity surgery and no twitches for eye surgery. Should TOF twitches increase to more than two administer only 25 % of original dose as a top-up dose. See dosage indications above.
4. At the end of the surgical procedure before patient is aware Response to TOF stimulation should be at least 3 visible twitches before neostigmine and glycopyrrolate are administered. Four TOF twitches equal to the control twitches during induction will confirm almost complete reversal. Note: 1. The response to peripheral nerve stimulation is merely a guide as to the degree of neuromuscular blockage, when to administer more relaxant and when to attempt reversal of neuromuscular blockage. Tactile feeling of the twitches elicited is probably more accurate in assessing return to four equal twitches. 2. Despite the presence of apparent full reversal on peripheral nerve stimulation the decision as to when a patient is able to effectively clear and maintain their airway is ultimately a clinical decision to be taken by the medical practitioner responsible for administering the anesthetic. 3. Contact your regional specialist for practical assistance and further clarification
Electrode placement over ulnar nerve:
Compiled by the Provincial Anaesthetic Co-ordinating Committee, May 2008
7 Additional information
OBSTETRIC SPINAL ANAESTHESIA:
GUIDELINES FOR DISTRICT HOSPITALS IN THE WESTERN CAPE
PREPARATION
1. Drugs
- Heavy bupivacaine (bupivacaine 0,5 % with dextrose 8 %) -1 - Fentanyl (50 μg ml )
- 2 % lignocaine for SC infiltration -1 - Ephedrine: 50 mg (1 ampoule) diluted to 10 ml (= 5 mg ml ) ® -1 - Etilefrine (Effortil ): 10 mg (1 ampoule) diluted to 10 ml (=1 mg ml ) -1 - Phenylephrine: 10 mg (1 ampoule) in 200 ml bag of normal saline (= 50 μg ml ) (Check that it is available in the fridge. Only prepare if needed for low blood pressure resistant to ephedrine or etilefrine) - Drugs for GA (thiopentone or propofol, suxamethonium) - Atropine and adrenaline should be immediately available
2. Equipment - Know how the theatre table works (head down and lateral tilt) - Anaesthetic machine with breathing circuit attached and checked for leaks
- All necessary equipment for general anaesthesia (ET- tubes / laryngoscopes / introducer / bougie)
- Suction: Adequate vacuum (- 40 mm“Hg”) and pipe long enough - Sterile pack + sterile gloves + mask + cap
- Chlorhexidine in alcohol / iodine solution ←Whitacre - Pencil point spinal needle (25 G) - 2 Syringes: 2 ml + 5 ml - Needles: blue x 1 (local SC) ←Sprotte
green / pink / black x 1 (draw up drugs) - 3. Patient - Full pre-operative examination (CVS, lungs, airway) ←Quincke - Patient fit for GA (check for co-morbid diseases and patient’s intravascular volume status) 2 - Consider referring patients with BMI above 40 (BMI = weight in kg / length in m ) - Good IV access (at least 18 G IV catheter, but 16 G is better) - Premedication: Sodium citrate 0,3 M 30 ml PO immediately pre-operatively Cefazolin 2 g IV prior to incision Metoclopramide 10 mg IV (pre-induction if GA or for symptoms under spinal) - Co-load: 1 000 ml Ringer’s lactate through rapid running IV line while performing spinal (reduce to 500 ml in pre-eclamptic patients)
TECHNIQUE
- Have everything prepared to start general anaesthetic immediately
- MONITORS: ECG, NIBP, SaO2 - STERILE TECHNIQUE: Wear cap + mask - Scrub hands and put on sterile gloves
- Clean patient’s back with antiseptic (chlorhexidine-alcohol / povidone-iodine) x
- Locate interspinous level L3 / L4 where spinal needle will be inserted (A line that is drawn to connect both iliac crests, i.e. the intercrestal line, runs over the fourth lumbar spine)
- Inject local anaesthetic sub-cutaneously: 3 - 5 ml lignocaine 2 % (use blue / brown needle) - Use a 25 G PENCIL POINT (Whitacre) spinal needle for all patients (↓ Incidence of post-dural puncture headache) - After clear CSF is freely aspirated, the local anaesthetic can be injected (if blood is seen in the CSF, wait for the CSF to clear before injecting any drugs. If it does not clear, remove needle
and try in a lower interspinous level; L4 / L5)
8 Additional information
- DOSAGE of intrathecal medication: (Total volume depends on patient’s height, and is inversely related to patient’s weight) 1,8 ml heavy bupivacaine 0,5 % + 0,2 ml (10 μg) fentanyl = 2 ml total volume If the patient is overweight or very short, consider using total volume of only 1,8 ml (1,6 ml heavy bupivacaine + 0,2 ml fentanyl) - Place patient in supine position immediately (pillow under head and shoulders to flex neck, and table right side tilted up to establish left uterine displacement) - Measure blood pressure every 1 minute for at least 10 minutes or until delivery of baby; then every 5 minutes for at least 1 hour
- Need a T4 sensory block for a C / S (be prepared to treat a significant drop in blood pressure)
- After delivery inject oxytocin 2,5 iu SLOWLY IVI over 30 - 60 seconds, or by slow infusion
Management of hypotension - Make sure theatre table is tilted to give left uterine displacement (30º tilt may be necessary)
- Treat ↓ BP (systolic BP < 100 mm“Hg”) aggressively:
- Ephedrine 5 - 10 mg IVI boluses (1 - 2 ml of mixture) every 2 - 3 minutes, or
- Etilefrine 1 - 2 mg IVI boluses (1 - 2 ml of mixture) every 2 - 3 minutes - If blood pressure still low after a total of 50 mg ephedrine or 10 mg etilefrine, start using: - Phenylephrine 50 μg IVI boluses (1 ml of mixture) every 1 minute -1 - N.B. Phenylephrine must be diluted thoroughly in a bag of 200 ml normal saline (50 μg ml ) -1 - If ↓ BP is accompanied by bradycardia (HR < 60 min ) give atropine 0,5 mg and prepare -1 - Adrenaline: 1 mg (1 ampoule) diluted to 20 ml (= 50 μg ml ) BP unresponsive to above = EMERGENCY – CALL FOR HELP Adrenaline 50 μg IVI (1 ml of mixture) – Good response – Repeat as required
– Poor response – Repeat every 2 minutes until BP / HR stabilised – No response – Double dose and keep doubling every 2 minutes
High or total spinal - Early signs of high block: ‘Pill-rolling’ movement of hands, repeated lifting of hands off arm rests, inadequate hand grip followed by inability to cough and phonate - Total spinal: Apnoea and loss of consciousness (can happen very rapidly, with or without early signs)
- Treat ↓ BP aggressively (ephedrine / etelifrine / phenylephrine / adrenaline)
- Manual ventilation giving 100 % O2 by bag and mask
- If respiratory distress, apnoea or SaO2 < 90 % → intubate + ventilate (rapid sequence induction with cricoid pressure) and deliver baby - In the event of a cardiac arrest, DELIVER THE BABY IMMEDIATELY, while continuing to resuscitate the patient – Immediate delivery is part of the resuscitation!
RECOVERY
- Continue to monitor NIBP, SaO2 and respiratory rate every 5 minutes for at least 1 hour after the intrathecal drug was injected
- Patient may be sent to ward if sensory level below T10, blood pressure stable within 10 % of pre- operative value and no bleeding on pad check.
- Patient may ambulate when there is complete sensory recovery (± 6hrs) - Postoperative analgesia: Paracetamol 1 g 6-hrly PO + ibuprofen 400 mg 8-hrly PO + morphine 10 mg 4-hrly IM prn.
Postdural puncture headache
- Nature of headache: Typically postural, begins 6 - 12 hr after lumbar puncture, fronto-occipital, throbbing or dull aching, and may be associated with dizziness, nausea and vomiting. - Visual disturbances and photophobia suggests migraine. - Pyrexia and neck-stiffness suggest meningitis - Conservative treatment: Bed rest, simple analgesics, high fluid intake - Contact anaesthetic consultant at regional hospital to confirm diagnosis and consider possible treatment
Compiled by the Provincial Anaesthetic Coordinating Committee in consultation with Professor Rob Dyer, August 2007
9 Additional information
10 Additional information
11 Additional information
12 Additional information
13 Additional information
14 Additional information
15 Additional information
16 Additional information
17 Additional information
18 Additional information
19 Additional information
BASIC ANAESTHESIA MACHINE-CHECK
The following is a suggested method of checking a basic anaesthesia machine / workstation. These guidelines may be modified to accommodate different types of machine and some checks may not be necessary for modern electronic workstations with an automated “self-check”.
Switch ON if an electrical machine, turn off all flows and connect the breathing system
Check O2 monitor in room air – calibrate to 21 % & place at the common gas outlet (if possible) Verify correct assembly of breathing system – hoses, reservoir bag, Y-piece etc. Occlude or “park” the patient-end of the system, and fully open the APL valve -1 If present – Open air rotameter @ 6 l min – O2 monitor should read 21 - 25 % – and close -1 Open O2 rotameter @ 2 l min – O2 monitor should rise -1 Open N2O rotameter @ 8 l min – O2 monitor drops, but > 25 % - i.e. hypoxic guard OK
Disconnect wall O2 (or close 1° O2 cylinder) and :- Check that N2O flow ceases – i.e. O2 failure cut-off switch functional Wait for O2 failure alarm
Open O2 cylinder (or 2° O2 cylinder) and check pressure – P > 5 000 kPa
Check O2 flush – manometer < 5 hPa (cm“H20”) - i.e. valves OK & O2 monitor should rise
Close O2 cylinder and reconnect wall O2 (or open 1° O2 cylinder) and :- Perform "tug test" on O2, suction and all other wall probes Check all pipeline (or cylinder) gauge pressures
Replace O2 monitor in normal position Occlude the breathing system, close APL valve and perform :- Positive pressure leak test of CIRCLE and machine – vaporisers ON sequentially Check vaporiser interlocks Check function of valves of circle system Check soda lime – presence & colour - i.e. not exhausted
Check APL valve pressure release – manometer ± 60 hPa (cm“H20”)
Close all gas flows and vaporisers
Ventilator Check function of ventilator Check presence and function of self-inflating manual resuscitator, e.g. Ambu-, Laerdal- bag etc.
Suction Check function – > 50 kPa negative pressure Check for presence of suction nozzle, e.g. Yankauer, & catheters
Vaporisers Check if properly attached Filled
Ancillary equipment Check laryngoscopes (x 2) Check for presence of Magill forceps Introducer Masks Airways
Endotracheal tubes Alternative- / supra-glottic- airway, e.g. LMA
Check monitors Sphygmomanometer ECG / defibrillator Pulse oximeter Capnograph
Most important checks 1. Is there a constant flow of O2 available via the O2 flow meter and O2 flush button (1° O2 supply)? 2. Is there enough O2 in the reserve cylinder (2° O2 supply)? 3. Is the self-inflating resuscitator, e.g. Ambu bag, present and functioning (3° O2 supply – room air)? 4. Is there no leak in the breathing system with pressure testing and the vaporiser open?
5. Is the suction working with tubes and nozzle / catheters present?
Disclaimer – These guidelines are provided for the sole purpose of guiding students and junior doctors in performing the pre- operative check of an anaesthesia workstation. It is not a comprehensive checklist, nor a recommendation for the checking of anaesthesia machines or workstations in clinical practice. These guidelines have not been peer reviewed and have not been sanctioned by the South African Society of Anaesthesiologists.
20