hi everyone and welcome to abc's of anesthesia i'm lahiru and for this installment i'm going to go
through some of the structures and frameworks that have helped me for my first year of anesthesia
training through to the second part exam now this is the first time i'll be recording this
as a youtube video and a podcast to try and give you the opportunity to choose the medium that best
suits your needs and as always i'll post relevant information and links in the notes below so the
aim of having really good frameworks is to have a robust structure on which to attach the million
odd data points you will acquire through your training medical training is often opportunistic
and any individual bite of information will soon be forgotten without context that is why medical
training transitioned from a rote learning model to a case-based learning model to give context
and a story to the multitude of facts you'll acquire over the decades of your career so in this
installment let's go through some of the important frameworks that i wish i had paid more attention
to in my training that would have made the journey a lot more structured more meticulous and improved
my performance in exams and assessments i'll now outline all the frameworks we'll talk about
i'll provide examples and context as we go through these frameworks firstly the pre-op interop
post-op framework and the anaesthesia surgical and patient issues frameworks are always useful but
i think we can supercharge this to make it more detailed some questions are best suited to one or
the other but i find a chronological approach is best to give a complete answer so we'll start with
that so chronologically pre-op interop post-op works very well pre-op starts with the assessment
you're called to attend the patient now that first decision is are they sick or well if they're sick
you go through the deteriorating patient framework which we'll go through in another session if they
are relatively well and stable the assessment of the well patient is with history examination and
investigations the amy assessment framework is s s c c t and that stands for severity stability
cause complications and treatment the additional cancer assessment is the 5ms framework mass
mets medications metabolic and mental state now causes of anything this is not exhaustive but
helps to consider random causes and that's the scandit framework so s s-c-a-n-e-d-i-t
now the next part of pre-op we've already done assessment the next part of pre-op is scope
s-c-o-p-e so after assessment all of these tasks before we go to theater are s for suitability
c for consulting medical and surgical teams o for optimize p for pre-med and if explain or consent
the intraop framework is primate time and finally post-op is simply a d or analgesia and disposition
now this is not an exhaustive list but i'm being brief and i will go through each section in far
more detail in future videos and podcasts so number one the assessment of the well-patient
framework how do you assess this patient's pain how do you assess this patient's fluid status and
how do you assess this patient's airway the answer is always history examination investigations now
side note it's important to emphasize that this is for the well-patient as soon as a patient
looks unwell or you're unsure if they're well you have to use the deteriorating patient framework
the deteriorating patient framework allows you to identify and treat problems rapidly
to keep a patient safe before going into the details of a definitive diagnosis
for example if the airway is obstructed you apply maneuvers adjuncts and advanced techniques to
remedy this if the sats are low in breathing apply oxygen and assist ventilation as required etc
so if you're patient as well i would assess using a history examination investigation approach
this is often a throwaway line but imagine if you were to forget one of these crucial
elements in an exam or in real life so i often ask trainees about how they would assess this
airway and it's very easy to forget that the best indicator of a difficult airway is rarely
the examination findings it's the previous airway management history that's on any anesthetic chart
a complete answer to that question would sound like i'd do a history examination investigation
of the airway i'd review the patient's previous history for a record of prior anesthesia issues
and look for any medical surgical other causes for a difficult airway often trauma abscesses
rheumatoid arthritis and mass lesions come to mind i would then examine first with the general
inspection then assess the mouth opening mallet patty score neck extension thyromental distance
and jaw protrusion and if relevant investigate with the ct neck nasaendoscopy or lateral neck
x-ray depending on these issues identified and that's done i've done the full airway assessment
using history examination investigations now imagine the cost of not completing this
answer in the exam forgetting to mention past history could be up to half the marks and worse
in real life not browsing the previous anesthesia chart could have revealed a previous known grade
three or four airway that could have easily been planned for with a video laryngoscope so that's
that that's the assessment of the patient number two aim of your assessment framework or s s c
c t severity stability cause complications and treatment now we came up with this pretty complete
assessment framework during our second past study over a decade ago and i still use it even now
even though history examination and investigation are great information gathering tools i feel that
presenting the information in the same way doesn't address your aims whenever you assess a patient or
problem i would argue that the most important data is how severe the disease is and its stability
severity often guides management and is linked to morbidity and mortality events so really
our goal is to make a judgment call about this so imagine this example assessing an 80 year old male
with heart failure you would ask all your heart failure questions about dyspnea orthopnea exercise
tolerance edema etc and then examine the heart lungs and periphery and maybe review an echo
at the end of all of that a meaningful way to communicate this is the nyha score for
heart failure maybe you are investigating a disease and you don't know the score you
can just call it as mild moderate or severe and still communicate so much information
so that's severity stability gives me an idea of how rapidly the disease can deteriorate so
obviously relevant to whether this patient needs to be stabilized prior to elective surgery now
imagine our patient having objectively nyha 102 heart failure but currently having uncontrolled
thyroid dysfunction or anemia this ability to suddenly deteriorate means everything when we
need to consider whether to proceed with surgery or postpone and stabilize so that's severity and
stability cause and complications is about looking back to what causes disease and then forward to
the future what this disease is doing or could do to your patient in the future if i assess my 80
year old patient's heart failure alone and forget to check whether this was due to something needing
further investigation like myocardial ischemia or reversible such as anemia or thyroid disease
i'm again missing a deep part of the problem each disease has its set of causes and i need to search
for these each disease also has its set of common complications so in this heart failure example
failing to look for something like renal impairment leading to high potassium could have
little consequences especially if i gave sucks methodium to this patient or maybe the heart is
now dilated leading to atrial fibrillation and now i need to check for the need for anticoagulation
and how to arrange cessation prior to surgery so complications are vital problems to identify
so that's sscec finally t for treatment the reason i specifically think of treatments is that we have
so many treatments with serious side effects and complications that these are worth noting
in this case of heart failure the electrolyte imbalance with diuretics or the implantation of
a pacemaker are things to look for that could dramatically change my anesthesia management
patients are not always the best historians so i need to be thorough in searching for these
treatments and their potential complications so there it is after a thorough history examination
investigations i communicate this information by stating the disease severity stability causes and
complications and the relevance of any treatments and their complications of side effects ssct
now just to complete this assessment the cancer assessment can have its own set of
challenges and nuances so i think of the 5ms framework which is mass or mass effect
mets metastatic disease medications metabolic and mental state again it provides a great framework
to add relevant information in a viva short answer question and things to search for in real life now
imagine an unfortunate patient with a mediastinal mass not only do i think about sscct but i can't
forget about the mass effect is it near vascular respiratory structures compressing life-giving
organs or is it adherent to large vessels and at risk of causing catastrophic blood loss metastatic
disease does the colon cancer patient have mets to the lung affecting oxygenation and ventilation
or medications is my lung cancer patient on bleomycin and at risk of aids with high
oxygen administration or maybe they're on immunosuppressive meds and are at high risk
of surgical infection for metabolic is the bowel tumor actually carcinoid
and about to cause incredible instability of blood pressure and even bronchospasm
finally i always consider the mental state of a patient going through the most difficult
time of their life so that's the 5ms mass mets medication metabolic and mental state it's the
causes of anything or scanned it s-c-a-n-e-d i must admit that i don't use this often in real
life practice but as a technique for the written exam it can be really useful for example if asked
about what you want to know on airway assessment i can very quickly talk about past anesthesia
and any surgical congenital autoimmune neoplastic endocrine or drug infective or trauma issues that
are relevant usually these don't need a structure in real life because they're very self-evident on
presentation but can be a useful exam technique so that's scanned it for the cause of anything
so after assessment there's a lot in the anesthesia journey and the mnemonic passed down to
me and now modified is scope primate time ad so to fit this into our pre-intro and post-op framework
pre-op is assessment that we've just gone through and scope seope interop is primade
time p-r-i-m-a-d-e-t-i-m-e and post-op is ad let's go through this in a bit more detail
now imagine you ask a really broad question in the exam this ensures that i cover absolutely
everything imagine a short answer question that asks about a heart failure patient undergoing a
laparotomy for bowel cancer presenting to a small peripheral hospital after a significant episode
of pr bleeding and say the question could be something like what are the anesthetic issues
after a thorough assessment and summary statement i could write pre-op interop and post-op as
headings to my answer and write the letters scope primate time ad in the margin so i remember to
write a comprehensive answer so let's go with scope s is for suitability this requires urgent
transfer to a tertiary hospital with blood bank and icu and oncology service you may also think
about futility palliation and whether the patient needs surgery at all c is for consult i'm thinking
about consulting with a medical team about optimizing heart failure ischemic heart disease
atrial fibrillation and renal issues and also with the surgical team so now encompassing a lot of the
surgical issues in this one area of my journey so this with the surgical team i'd consult about
the time of the case blood loss issues positioning issues if do they need antibiotics dvt prophylaxis
and any other equipment relevant to the surgeons for example cell saver these special airway
devices a throat pack avoidance of paralysis or whatever is relevant for that particular surgery
o is for optimize the patient which in this situation means transfuse and resuscitate
p is for pre-med and maybe you might give a beta blocker if the patient was tachycardic
and at you know an in danger of ischemic heart disease maybe midazolam in the anesthetic room
for lines placement and in pediatrics is always relevant for the anxious child
e is for explain or consent of the patient is that scope and essentially between assessment and scope
that's all of your pre-op issues intraoperative issues can be broken down into primate time let's
go from the beginning so p is for positioning and this situation is nothing too unusual
but can get a bit more complicated if it's a prone case or sitting case r is for recess equipment and
it's often just a formality but things to note in unstable cases or in remote environments
eyes for iv access and very relevant depending on the amount of blood loss and the cardiovascular
status of the patient and always want too large by iv cannula for a unstable or blood loss case
m is for monitoring in this case standard and an arterial line would be relevant and other types
of monitoring i'd consider include cvc maybe even biz monitoring temperature monitoring idc
uh transesophageal echo and neuromuscular monitoring a is for assistance and depending on
the stability of the patient i'll need more staff to manage the blood loss and massive transfusion
these for drugs and again it's a prompt to ensure that i think of the right combination
of medications for example this induction can be very unstable so i'll need to maintain
preload after load and contractility with a combination of the right medications
e is for equipment and i might add here the need for other specialized kit
if my patient was a difficult airway the need for fiber optic shoot intubation for example
so that's primade finally time t-i-m-e t is for transport or transfer i for induction and
for maintenance and e for emergence so transfer is very relevant in an unstable patient so worthwhile
mentioning i've already addressed induction but you can go into more details suggesting
that maybe a ketamine midazolam induction with fentanyl giving ephedrine and running
metaraminol to maintain preload and afterload and contractility might be worthwhile mentioning
in maintenance i'm able to offer other points such as the length of the case
particular events during the case like cross clamp in a aaa repair and also analgesia regime
e is for emergence and a standard here but again more relevant in cases of difficult intubations
or the need for say rapid assessment of a neurological state after carotid endarterectomy
so think about that that's all your intro issues in primate time
now for post our post-op is ad i would now think about a the analgesia plan and d disposition
so for the analgesia plan will they need the acute pain service a pca regional nerve catheters
ketamine even and finally d for disposition where's the patient headed is it the ward icu hdu
or even another hospital so that's my quick summary of frameworks from start to finish of
an anesthesia journey as you can see the patient's anesthesia surgical factors are embedded within
the framework and can still be a useful framework in its own right depending on the question asked
so use your judgment in future videos and podcasts i'll go through the other frameworks such as the
deterring patient basic life support advanced life support and problem solving and crisis
management in anesthesia as always please ask any questions by emailing me at abcs of anesthesia
gmail.com and feel free to comment and subscribe for more content see you next time
you