hi everyone this is lahiru from abc's of anesthesia and in this little video
i'm going to go through one of the most common questions that i get asked now this question is
what do you do in preparation for your theater list as an easter list so what we're going to do
we're going to go through my system which is essentially the six ps these six ps are personnel
and place as well as patient procedure pathology and overall preparation so let's get to it
now the first thing is as a junior doctor and a junior anesthetist you really want to get hang
of ropes so i would always come in early like literally for most of my career i come in 15
minutes early to make sure that i could go through all these six p's now the first two
are quite easy you want to know that you've got the right personnel and you and you're familiar
with the environment which you generally will be busy you'll get an orientation so i don't worry
too much about personnel in place unless i'm going to a new hospital altogether the next few
things the next four ps are very important and apply every day and these are patient procedure
and pathology as well as overall preparation so with patient it's really easy even before the
patient arrives i want to make sure that i'm there early and i can review the medical records and
often this is looking at the emr or the electronic medical record or looking at the paper record
and just filling out an anaesthetic chart that way i've got an idea of exactly what's going to happen
and at least an overall idea of how this patient might be before i actually talk to the patient
so that's the first thing and that's that's pretty straightforward just requires a bit of diligence
and you can look at my website anesthesia to collective.com for a few different patient
assessment performers the next thing is pathology so again the night before even in the morning of
your list make sure you know what's going on so sometimes it's going to be something
really straightforward such as a lap collar you don't really need to do too much research into
this but let's say you're going to be doing a liver resection for some carcinoid tumor or some
other you know weird pathology you want to be sure that you've got all of that cover that you've read
the notes you've read the latest review articles for example one of the greatest resources i found
was the british journal of anesthesia education series and they go through some amazing very
focused articles on all the specific pathologies that anesthetists really need to worry about and
this includes everything from you know thyroid to theochromocytomas maybe medical conditions like
rheumatoid arthritis or other different types of procedures like liver operations aaa repairs
or any other you know advanced or subspecialty anesthetic cases now let's talk about procedure
again once you get used to the day in day out of most surgeries you'll be very familiar with what
a lap collie needs or what an inguinal hernia repair needs from an anesthetic point of view
but as soon as i see the surgeon or the surgical registrar i always have a conversation with them
and what this means is i ask them all the common things how long is this going to take
is there any expected blood loss what antibiotics do you need do you need dvt
prophylaxis and do you need anything else special for example where do you want to
position the arms this has a lot to do with where i'm going to put the drip for the case
now you'll get very comfortable with asking these questions and i think it's a really great thing to
have a conversation with the surgeon you know that way you get to have a chat with them before
something crazy happens and you just get into conversational modes that you can get a lot of
useful information really quickly so the things i want to know about the procedure the duration and
the expected blood loss where is the surgeon expecting to position the patient especially
are the arms out or are they in as well as do you need antibiotic prophylaxis dvt prophylaxis
and then there's always some particular special instruments or gadgets that the surgeon might need
for example ent surgery or airway surgery you may want to ask what airway specifically do you need
do you need a throat pack do you need a special neuromuscular monitoring tube such as a nymptube
for thyroid surgery or maybe you're expecting a lot of blood loss and do you think a cell
saver might be appropriate there's a lot of other nuances to this and that's for definitely advanced
level training but at the very start i have a conversation with the surgeon about their needs
finally there's overall preparation and in my abc's of anesthesia bootcamp playlist that you
can find in the playlist on this channel you'll see a whole bunch of stuff to do with checklists
and so my checklist in the morning is always the 4ms checklist and this is machine monitoring
mabel's that's m-a-b-e-l-s mabel's and that's airway equipment and finally medications so those
are some of the things we're going to go through so let's start with the first m and this is
machine so these fancy machines are really great for example usually in the morning my nests are
fantastic they already go through the integrated checklist and the full machine test that is
automated back in the old days you'd have to do this manually but these days on the new machines
you can literally press this button full test and then it goes through a full checklist i might do
that in another video what i do is i literally go to show log and make sure that all of these
things have been passed for example ventilating gas passed on this date
with a leak that's okay so it's less than 100 mils generally up to 250 ml is okay if it's
greater than 250 mils you really want to talk to your supervisor the circuit lease has been passed
again the date is today's date and it's less than 100 that's fantastic and now the low pressure
leaks are often done uh once a week or so but again this is has all been passed and it's fine
what i do then is i even though i know that the machine check has been done i make sure that a
few other things are also really good for example i go around to the back of the machine to make
sure that i have a self inflating liddell bag or a bag mask valve and this means that if this machine
was to stuff up in any way it's a very complicated device it's you know with a
couple hundred thousand dollars at least you can still do most of the essential functions which is
positive pressure ventilation with a led back so if something went really wrong with this machine
the ledell bag would be absolutely fine for this so that's the first thing so i make sure that the
machine has been checked and i have a ladell bag let's go on to mabel's so mabel's m a b e
l s stands for masks so i check that i've got a mask and it's and i've got also a range of sizes
it's usually in one of the drawers and see here i've got a range of sizes of masks that can fit
pretty much any face a is for airways i'm just making sure that i have godel's airways again
we'll go through this in a later airway talk that i'll upload soon and also nasopharyngeal airways
finally lmas in a range of sizes again kept in the drawer usually there's a three four and five lma
b is for boost you know this you can get these really fancy bougies that look
like this or you can just get the normal ones which look like this and this this bougie or a
stilette is fantastic when it comes to you know managing difficult airways so that's all sorted
e is for ett again i look in the drawer make sure i've got a range of ett's and sizes a 6 7
8 size tube is usually what i need l is for laryngoscope and this device is absolutely
essential obviously for intubating to getting that airway exposure to put the tube down into
the trachea i make sure i have two laryngoscope blades a size three and four mac blade and just
make sure without touching the blade that this is working you know that the light is working
which you might be able to see through there that it's working just fine again i checked
both of these because you definitely want this to work when you need it and having the light out or
the battery blown or the bulb blown is you know just a really difficult situation to deal with
finally suction so i make sure that my suction is on maximum and then i just check through here
that it's working you can hear that sound and if i was to put my hand on the end of that you would
show me that this suction was working because you'd feel some traction on the skin put that
safely away so that's mabel's m-a-b-e-l-s next i go to monitoring so monitoring this machine here
has so many different measurements that it takes especially with ventilator alarms and pressure
alarms apnea alarms but really the essential things i need in any situation are a sats probe
a blood pressure cuff a ecg an end n-tidal co2 so if i look over here in this particular machine
here i've got a sats probe here i've got the blood pressure tubing and a cuff will be present
and then i've got the ecg leads here and finally end tidal co2 is already attached to my mask
and that then leads up this wire through some side arm sampling all the way to this connection over
here and as soon as i've got that on the patient you'll receive a signal which shows that i've
got entitled co2 just along this trace here so that's my monitoring the absolute essentials i'd
need is saturation probe blood pressure cuff ecg dots from you know ecg monitoring of the heart
rhythm and then entitle co2 and i can go into those in another video finally i go over to
my trolley now medications these are absolutely vital obviously now the way i think about this is
there's obviously a lot of medications i need in anesthesia but the ones i need in an emergency
are my spa drugs sp aaa so first of all i need a fast acting relaxant and here it is
such some ethernet or even high dose rock uranium at 1.2 milligrams per kilogram
i need propofol which is here and then i need atropine adrenaline and aramine and ephedrine
so just to go through this here's atropine make sure i've got that again every draw is different
depending on which hospital you work at i've got aramine which is the trade name for metaraminol
which is just here and there's another type of aramine in that's concentrated in a vial and
adrenaline over here in different concentrations i always think of ephedrine as well because that
is like adrenaline but just not as potent and much easier to use in more most anesthetic
circumstances now those medications are obviously really important for a number of reasons now the
reason i chose my spa drugs or sucks propofol atropine adrenaline aramine versus all the other
drugs is because these drugs are so vital in the most emergent situations for example if a patient
has laryngospasm or is fighting the ventilator or something serious happens a rapid-acting muscle
relaxant can really help an anaesthetist solve those problems again these drugs are not to be
given by junior junior practitioners or ones who are not experienced and should always be done
with supervision so a must relax and absolutely vital uh to solve a lot of your problems p is
for profile and again propofol deep in the anaesthetic make sure that your patient
is asleep and can treat all things like a patient moving as well as hypertension and again you'll
see one of our medications videos which goes into that in a bit more detail now often with
anesthetics especially in kids hypoxemia can cause bradycardia and atropine's a solution for
that and there's a lot of different vagal type stimuluses that can happen during an operation
bezel-gyros reflexes bagel reflexes and these can cause very severe bradycardias even even asystole
so having atropine ready to go is absolutely vital adrenaline is probably the most common
sense emergency drug you need because any time a patient is close to respiratory rest or even a
rest you need to give that dose it's a treatment for a rest it's a treatment for peri rest
it's a treatment for vena dilation vasodilation as well as poor contractility and adrenaline is a
fantastic treatment for nap anaphylaxis increasing its central blood volume distribution through
vasoconstriction but also inhibiting mast cells that degranulate all that histamine everywhere
finally aramine and ephedrine these are the most common medications that you use on a day-to-day
basis after the induction of anesthesia because as we know giving propofol another drug for induction
causes veno dilation and vasodilation and the easiest thing to do there is give it a small dose
of aramine or metamol and that just tightens the veins and the arteries to improve your perfusion
likewise occasionally sometimes your patient just doesn't have great contractility maybe
you've given some medications some beta blockers or maybe the induction itself has caused the heart
just not just not to function as well now there's some occasions where you need to use ephedrine
now ephedrine has more you know inotropy and beta effects than alpha effects whereas our
aminometer amino does vino and vasoconstriction ephedrine does a bit of vena constriction and
vasoconstriction but also is a positive ionotrope and that's absolutely fantastic when you have a
patient who might not have a very good heart maybe they've got poor contractility or a poor injection
fraction or you've given a bit too much anesthetic and you just need to improve the heart function
so aramine and ephedrine really really commonly used and very important drugs in this situation
so obviously there's a lot of other medications that you need for an anesthetic but these are the
absolute vital ones that you need so hopefully that's helped we've gone through the six p's
firstly place and personnel only really relevant if you're in a new hospital and then the other
piece which is patient and making sure you've done that provisional assessment talked about
the procedure and we've talked about the pathology and making sure you've read up on that and talked
to the surgeon about those things and finally your overall preparation which is your four m's and
that's mabel's machine medications and monitoring so i hope you enjoyed this video if you have any
questions please ask them in the comments below and i'll see you guys next time thanks very much
you