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UCLAnaesthesia

ANAESTHESIAANDCRITICALCARE

SpecialStudiesModule2019

RoyalFree&UniversityCollegeMedicalSchoolUNIVERSITYCOLLEGELONDON

CONTENTS

Page

• INTRODUCTION 1

• OBJECTIVES 3

• SCHEDULE 4

• TOPICS1. PreoperativeAssessment 72. AirwayManagement 123. ConductofAnaesthesia 164. OxygenDelivery 215. Peri-operativeFluidTherapy 286. PainandAnalgesia 357. PerioperativeComplications 408. Basic&AdvancedLifeSupport 439. SickPatientScenarios 51

• PROCEDURESCHECKLIST 59

• ATTENDANCECHECKLIST 60

• ASSESSMENTFORMS 62

• FEEDBACKFORM 63

1

Introduction

Welcome to your SSC in Anaesthesia and Critical Care. We appreciate thatanaesthesia isverydifferenttotheothersubjectsyoustudy,butall thestaffareheretohelpyougainagoodintroductiontothisbroadfield.Mostofyourtimewillbespentintheatresandonthewardwithconsultants andtraineeanaesthetists,aswellascriticalcare,nursing,theatreandrecovery staff.Dobepro-activeandusethisopportunitytoseeawiderangeofcasesandlearnfromthedifferentmembersofstaff.Sometimesjustwatchingisavalidtool,butfeelfreetoaskquestionsandthinkaboutwhywedothingsinacertainway.There are freely downloadable short articles on the students section of ourwebsite at www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students that willsupportthebooklet.VisitourYoutubesite(google‘youtubeuclanaesthesia’– it’sthetoplink)forourvideos!Moretraditionalresourcesarestillimportant,andtheCruciform library has a good selection of anaesthetic and critical care books.Therearealsothelatest journalsandaccesstotheinternetandevidencebasedmedicine.This booklet is intended as a guide to your learning; use it in conjunctionwiththeatre teaching and the tutorials youwill have. Some of themain points youneedtocoverarehighlightedandthereisalsoachecklistofpracticalproceduresyoushouldgetsignedoffonceyouhaveseenordonethem.ThisSSC isagreatopportunity to gain valuable experience in airway management and IVcannulationandyoushouldtrytoseeanddoasmuchaspossible.Thebooklet includes9main topics, eachofwhich forms thebasisof a tutorial.Oneortwowillpresentasummaryofthemainpoints,butyoushouldallprepareinadvanceandbereadytodiscussthesubjectaswewillbeassessingyouonyourparticipationinthesetutorialsaswellasintheatre.Therearealsoscenariosandquestionsforeachtopictoreinforceyourlearningeitherinthebookletoronline.Therewillbeaformalassessmentattheendoftheattachmentintheformofacasebaseddiscussionorpeer topeer teaching session for theYear4 students.Thetopictutorialsandthecasereportorteachingsessionconstitutetheprojectworkthatthemedicalschoolspecifiesyoumustdotopassthemodule.

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Wearealwaystryingtoimprovethismodule:thiscanonlybeachievedwith yourfeedback.Sopleasefillintheassessmentformattheendofyourtime.Wehaveanonlinerotayoucanviewathttps://uclh.clwrota.comUsernamemedical.s1 PasswordStudent1We have a training tool in Perioperative Medicine mostly for when you're atWestmorlandStreet.Youcandotanytimeonyourown.Gotohttps://versal.comandregister.FindIntroductiontoPerioperativeMedicineforMedicalStudentsorgototheaddress: https://versal.com/learn/jgjmnk/introduction

Finally, enjoy your time here. Anaesthesia and Perioperative Medicine is anexciting field to work in and we believe you can learn a lot during yourattachmentanddevelopskillsandknowledge that will really help you as a newdoctor. If at any time you haveconcerns or need to raise an issue do get intouchwith the educational fellowAnthonyormyself,RobStephens.

Rob 07946742344 [email protected]

07988431346 antonyodwyer@gmail.comConsultantDrLizCerviwillbehelpingwithsomesessions

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OBJECTIVESAt the end of your four-week special studymodule in anaestheticsandcriticalcareyoushouldbeableto:

1. Assess and prepare patients undergoing emergency and electiveanaesthesiaforavarietyofsurgicalconditions.

2. Understandpostoperativecareofthesurgicalpatientincluding painmanagement,fluidandoxygentherapy.

3. Appropriately identify patients who require a higher level of carethancanbeprovidedonthewardandneedreferraltothe intensivecareandhighdependencyunits.

4. Have an understanding of anaesthetic drugs and equipment andwhenandhowtousethem.

5. Carryoutthefollowingprocedures

! Basicairwaymanagement! IVcannulation

4

ProvisionalSCHEDULETherearefourblocks;WeekA,B,CandD.

Youwillsplitupandspendaweekineachandrotatethrough.WeekA UCHEmergencyTheatresandCriticalCareJoinTraumaandEmergencyList(Theatre1)Anaestheticteamhandoverat0745outsidetheatre1.Contacts:AnaestheticSHO&SpR(bleep4300&4600),EducationFelloworRobStephens.Trytoseeasmanypatientspre-operativelyandpost-operativelywiththeteam.FeelfreetoflitbetweenTheatres,DutySpR(4600),ICU,CPEx(CardiopulmonaryExercisetesting)andPainrounds.

Regularteachingsessions

Monday 0900 Preopexercisetestingintermittentlyallday(Pod1ClinicA–roomA4)–callon70162/[email protected].

1300 ICUcasepresentationsintheICUSeminarRoomTuesday 0830 JournalClubICUThursday 0800 ICUWardRoundinCoffeeRoomorseminarroomfollowedby 0830

0900CoretopicsteachingICUPreopexercisetestingintermittentlyallday(Pod1clinicA–roomA4)–callon70162/[email protected].

0915 ConsultantTeachingWardRoundICU 1230 MultidisciplinaryRoundICU

1300 ‘GrandRound’intheICUSeminarRoom 1600 WardroundICUFriday 0800 AnaesthesiaDeptMeeting

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WeekB NationalHospitalforNeurologyandNeurosurgery,Queen Square,TheatresandITUContacts:PleasedonothesitatetocontactDrAminifthereareanyissueswithliststoattendwhilstatNHNN.DrYogiAmin(07539-212638)orAnaestheticRegistrar(bleep8131)orMei(TheatreAnaestheticManager)02034484711Ontheatredaysarriveat07:45andpresenttothefloorconsultanttointroduceyourself.Listswillbeallocatedfromhere.

Monday: TheatredayTuesday: TheatredayWednesday: TheatredayThursday: Arrive 08.30, find registrar on SurgicalITU, Identify and clerk a patient to

present onwardroundat10.00Friday: Arrive0900,MedicalITUwithDr.Amin

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WeekC PerioperativeWeek:UCHTheatresatWestmorelandStreet&UCH

Thisweekcombinestime:

• withthePerioperativeFellowsatWestmorelandStreet(WSt)ITU,(TheoldHeartHospital)

• atPre-operativeAssessmentClinic@UCH,

• Seeing“atrisk”patientswiththePERRTteam

• Followingathoraciccaseortwofromsurgerythroughtopost-operativerecoverytounderstandindetailthepatientjourney

YouarealsoexpectedtocompletetheOnlinelearningmodule:PerioperativeRiskandSafetyforMedStudents,atwww.versal.comthisisfactoredintothetimeallocated(seebelow).Youcancreateanaccountforfreeyourselfwhichallowsyoutoaccessthismodule.Ifyouaredoingthisweekasapair,pleaseallocateyourselftoStudentAorStudentBrolesasthiswillmakesureyougetthemostoutofthisweek.Contacts:AtWestmorelandStreet:1stfloorCriticalCareUnit,PerioperativeFellowbleepholder2261orDutyConsultantatWestmorelandStreet(bothavailableviamobileviaswitchboard).AtUCHRobStephensorEducationfellow.PERRTteam–pleaseemailPERRTUCH2@uclh.nhs.uktoconfirmwheretomeettheDAYbeforeyouarerosteredtobewiththem

Monday: StudentA:@UCHPre-assessmentclinic:Peri-operativeRiskOnlineLearningpmStudentB:PERRTteammorning@UCH:Peri-operativeRiskOnlineLearningpm

Tuesday: StudentA:@WStCCUWRShadowPerioperativeFellow-reportforhandoverat8am,level1.OfficeatfarendofcriticalcareunitStudentB:@WStThoracicTheatreslevel1,0730-0800ameitherTh1orTh4,followpatientthroughtorecovery/post-anaestheticcareunit/ITU

Wednesday:StudentA:@WStThoracicTheatreslevel1,0730-0800ameitherTh1orTh4,followpatientthroughtorecovery/post-anaestheticcareunit/ITUStudentB:@WStCCUWRShadowPerioperativeFellow-reportforhandoverat8am,level1.Officeatfarendofcriticalcareunit

Thursday: StudentA:PERRTteammorning@UCH:Peri-operativeRiskOnlineLearningpmStudentB:UCHPre-assessmentclinicam:Peri-operativeRiskOnlineLearningpm

Friday: StudentsA&BWestmorelandCriticalCareTeaching8am–reporttolevel1

Afterthisyoucandomoreofwhatyou’vemostenjoyed:attendtheatresformorethoraciccasesorseearoboticsurgery,followthepainnursesorfollowtheperioperativefellow,andmakesureyouhavecompletedyouronlinelearning!

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WeekD UCHTheatres

Checkthemedicalstudentrotaforsuitabletheatrestojoin(availableontheUCLAnaesthesiasite:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students)Trytojointheanaestheticteampre-assessingtheirpatientsbeforetheatrestarts.Contacts:DrRobertStephens,EducationFellow,AnaestheticSHOorRegistrar(bleep4300 and4600)ordutyAnaesthesiaConsultant(07944139718)Trytoattendsome“outoftheatres”lists,e.g.Endoscopyonlevel2tounderstandthechallengesofanaesthesiaoutsideoftheatrePleasealsofeelfreetoattendjournalclubwhichisonThursdaysat2.30pmintheanaestheticcoffeeroom.

AdditionalActivities

Duringyourtimehere,wecanalsoarrangeforyoutoattendorspendtimewiththefollowing:• PainTeam–usually2roundsaday(c9:30and1:30)• Obstetricanaesthesia• CPET:CardiopulmonaryExerciseTestinginSurgicalPreassessment/K-POD• CriticalCareinT3• Staylatewiththetheatre7teamonceuntil(eg2300)• Potentialtoseesomecardiacanaesthesia–pleaselettheEducationFellowknowifthis

issomethingyouwishtodoasapandwewillattempttoarrangeit

Tutorials

Tutorialsshalltakeplaceatdifferenttimesduringthe4weekswithdifferentsupervisorsandthedetailsshallbeemailedtoyou.Whicheverallocationyouareon,youshouldallprepare forandattendthetutorials.

Website:Wehaveawebsitewithasectionformedicalstudents,withdownloadableteachingmaterialaccessibleat:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students

IfyouhaveanysuggestionformoredownloadableteachingaidsorchangesintheSSM pleasedo contact Rob Stephens on [email protected] - we are always looking toimprove!

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PRE-OPERATIVEASSESSMENTLearningObjectives

! Realisetheimportanceofpre-assessmenttotheanaesthetist.

! AnunderstandingasyourroleasasurgicalFYinpre-assessment.

! Theabilitytorecognise,investigateandreferappropriatehigh riskpatients.

Pointstocover

• Anaestheticconsiderationsinthehistory• Fastingguidelines• ASAgrading• Importantanaestheticconsiderationsintheexamination• Airwayassessment• Premedication• Relevantpre-opinvestigations

Webresources:

YoutubePodcast:Anaestheticpre-operativeassessmentandthepre-operativevisit

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KeyTutorialLearningPoints

• Pre-assessmentbyAnaesthetistestablishestherapeuticrelationship

withthepatient,andallowsdiscussionofchoicesofanaesthetictechnique.

• Astructuredapproachshouldbeadopted(applicabletoallmedicalspecialties!)withattentiongiventothepatient’shistory,examinationandrelevantinvestigations.

• Particularattentionshouldbegiventotakingasystems-basedhistorywithemphasisondetectingconditionswhichmayinfluencetheconductofanaesthesia(especcardio/resp/renal/GI/musculoskeletal)

• Astandardphysicalexaminationformspartofallanaestheticpre-assessmentbutattentionshouldalsobefocusedontheairwayassessment.

• Investigationsmayincluderoutinebloods,ECG,CXRand/ormorespecialisedtestse.g.Echocardiogrambasedonpatientshistoryandphysicalexamination.

• OverallAnaestheticimpressionofpatientshealthgivenbyanASA(AmericanSocietyofAnaesthesiologists)gradeafterassessingpatient.

• AirwayassessmentshouldberecordedinbasicformbyaMallampatiscore,butmoreadvancedassessmentse.g.“Wilson’sscore”maybeusefulinthosewithasuspected“difficultairway”.

• Fastingguidelineswillgenerallybeoftheorderof6hoursforsolids(includesmilk)and2hoursforclearfluids.Thismaybealteredbydelayedgastricemptyinge.g,Pain,opiates,autonomicneuropathy.

• Pre-medicationislesscommon-placenowadaysbutstillusedincardiacsurgery,paediatricsandtheanxiouspatient.(Pre-medicationmayalsoincludeanalgesics,pro-kineticsandantacidsratherthanjustanxiolysis!)

• Referralforfurtherinvestigations/furtherassessmentshouldbebasedonapatient’smedicalstatusattimeofpre-assessment.

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Freespacefortutorialnotes:

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Scenario1

Mr Tolu ALIKI a 65 year old gentleman is attending the pre-assessment clinic prior to hisscheduledrightinguinalherniarepairoperation.Hetellsyouthathehashighbloodpressureforwhichhetakesa‘watertablet’andthathegetsshortofbreathafterclimbing2flightsofstairs.HisBPtodayis170/87.He isa lifelongsmokerof20cigarettesadayandhasachronicproductivecough.He livesaloneinaflatonthe6thfloorbutcopesindependentlyforallhisactivitiesofdailyliving.Heisverykeentohavethisdoneasadaycase.Questions;

1) Ishisbloodpressureadequatelycontrolled?2) Whatarethecriteriaforpatientstobedoneasdaycases?3) Isheasuitablecandidatefordaycasesurgery?Why?4) Whatwouldyoutellhimaboutbeingdoneasadaycase?

1.

2.

3.

4.

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Scenario2MrMartinBruce,67 isa retired constructionworkerwhohas come in for a right totalhipreplacement.Hehasahistoryofchronicrenalfailureandhashaemodialysistwiceaweekathis local hospital. He has hypertension secondary to his renal disease but this is wellcontrolledon50mgatenololoncedaily.Questions;

1) Whatthreepreoperativeinvestigationswouldyouorderforhimandwhy?2) Whichhospitalteamsshouldbeinvolvedwithhisperi-operativecare?3) Shouldhehavepre-operativehaemodialysis?4) Whereshouldapatientlikehimrecoverpost-operatively?Explainyouranswer.

1.

2.

3.

4.

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AIRWAYMANAGEMENTLearningObjectives

! Reviseairwayanatomy

! Beablemanageanairwayusingsimplemanoeuvresandaids

! Anawarenessofthedifferentequipmentinvolvedinairwaymanagement

! UnderstandtheprinciplesinvolvedinendotrachealintubationPointstocover

• Airwayassessment• Facemaskventilation• Oropharyngealairways• Nasopharyngealairways• Laryngealmaskairways(LMA)• Endotrachealtubes(ETT)• Laryngoscopes• Gradesofintubation• Difficultintubations• Tracheostomy

Webresources:

• ‘TheAirway’• ‘Howtoinsertanemergencyairway’• UCLCentreforAnaesthesiaPodcaston ‘ManagingAirwayObstruction’on

youtubeAllinvia:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students

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1) Mallampatiscoreofbasicairwayassessment.

2) Recognitionofthosewithlikelydifficultairwaysi.ePre-existingconditions(AnkylosingSpondylitis,Rheumatoiddisease,thyroiddisease,morbidobesity)andacuteconditions(facialfractures,c-spineinjuries,epiglottitis.)

3) Basicairwaymanagement(headpositioning,jawthrust,

chinlift)

4) Simpleairwayadjuncts(oropharyngealandnasopharyngealairwaysandhowtosizethemforeachpatient).

5) Moreadvancedairwaysi.etheLaryngealMaskAirway

(LMA)andindications/contraindicationsfortheiruse.

6) Indicationsforendotrachealintubation(pre-existingconditions/typeofsurgery/acuteconditions).

7) Gradingsystemoflaryngoscopyandrelevancetofuture

anaesthetics.

8) “Difficult”airwaysexistandifanticipated,meticulousplanningmustbeusedtoensuresafeintubationoftheairwayi.eawakefibre-opticintubation.

9) A“failedintubation”drillexistsandallAnaesthetistsmust

befullyconversantwithit.

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16

Scenario1YouarehelpingaConsultantanaesthetistwitha68yroldmanwho isscheduled tohavealaparoscopichemicolectomyundergeneralanaesthetic.Heweighs98kgandis1.6mtall.Hehasapasthistoryofrefluxandofaduodenalulcerforwhichhetakesranitidine150mgbd.Otherwiseheisfitandwell.Hehasbeenappropriatelystarvedpre-operatively.Questions;

1) Whatproblemscanyouforeseewithhisairway?2) What threepiecesof airwayequipmentwouldyouprepare for use to anaesthetise

himandwhy?3) Whatairwaytoolsmaybeusefulinmaintainingapatentairwayonceheisasleepbut

notyetintubated?4) What twootherpiecesof equipmentwouldbeuseful for laparoscopic procedures?

Why?

1.

2.

3.

4.

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CONDUCTOFANAESTHESIALearningObjectives

! Anunderstandingoftheprinciplesinvolvedinadministeringgeneralanaesthesia

! Anawarenessofthevariousclassesofanaestheticdrugsused

! Anunderstandingoftheequipmentused

Pointstocover

• Monitoringrequirements• Induction• Rapidsequenceinduction• Maintenance• Wakeningthepatient• Criteriafordischargefromrecovery• Potentialproblemsinrecoveryandtheircauses• Post-operativenauseaandvomitingcausesandtreatment

WebResources

• ‘BasicsofAnaesthesia’atwww.ucl.ac.uk/anaesthesia/StudentsandTrainees/students

• RecommendationsforstandardsofmonitoringduringAnaesthesiaandrecovery:4theditionatwww.aagbi.org/publications/publications-guidelines/S/Z

• Podcaston‘ConductofAnaesthesia’-Youtube

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• Classesofanaestheticdrugs:Hypnotics,analgesics,muscle

relaxants.

• Minimumstandardsofmonitoringduringinductionofanaesthesia.

• Indicationsforrapidsequenceinduction(RSI)of

anaesthesia.

• Maintenanceofanaesthesia(Gaseousandintravenous).

• Depthofanaesthesiamonitoringand“awareness”duringanaesthesia.

• Wakingthepatientfromanaesthesia(awakeversusdeep

extubationandindicationsforboth).

• TransfertoITUforhighrisk/sickcases.

• Equipmentfortransfertorecoveryandmonitoringwithinrecovery.

• Treatmentofpost-opnauseaandvomiting(PONV)in

recoveryandcriteriafordischargefromrecoverytoward.

• “Analgesicladder”fortreatmentof acute post-operativepain.

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20

Scenario1

YouaretheA&ESHOoncall.MrNazımYılmazattendsA&Einfastatrialfibrillationwithaheartarateof168bpm.ThedutymedicalregistrarwantstoattemptDCcardioversionbackintosinusrhythm.Youtalktotheanaesthetisttoarrangeageneralanaestheticforthisprocedure.Heasksyoutosortoutsomemonitoringforthecardioversionprocedure.Questions:

1) Whatispurposeofmonitoringthispatient?2) Whatmonitoringmodeswouldyouliketocommenceonthepatient?3) Whatequipmentwouldhelpyoutoachievethis?4) Whataretheshortcomingsofeachofyourchosenmonitoringmodes?

1.

2.

3.

4.

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Scenario2

MsJuliaHarrisisa23yearoldballetdancerwhopresentswithasuspectedruptured ectopicpregnancy.You,thesurgicalSHO,areaskedtoassessherpriortohercomingtotheatreasanemergency.Whenyouseeheron theward she lookspale, sweatyand is ratherquiet.Herobservationsare:BP 80/40HR130SpO293%onroomair

Theanaestheticregistrarhasaskedyoutoputanintravenouslineintothepatient.

Questions;1) Whatfurtherassessmentwouldyouliketomakeonthispatient?2) WhattypeandsizeIVcannulawouldyouuseinhercase?3) WherewouldyouideallyplacetheIVcannulaandwhy?4) Namethreecomplicationsthatcanensuefromperipheralvenouscannulation.How

canthesebeavoided?

1.

2.

3.

4.

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Oxygen Delivery

Learning Objectives

! Anunderstandingofthevarioustypesofoxygendeliverydevice,theirapplicationsandlimitations.

! Revisedthebasicaspectsofrespiratoryphysiologyandrealised their

relevanceinclinicalpractice.

! Understood the causesof postoperativehypoxia andhavea rationale fortreatingthem.

! Anawarenessofthelungasarouteofdrugadministration.

! An awareness of the importance of humidification, pulmonary toilet and

physiotherapyinclinicalpractice.

Pointstocover

• Differentdevicescanbeusedtodeliveroxygen• Definitionofhypoxiaandclassification• Oxygencascade• Oxygencarriagebyblood• Ventilation/perfusionmismatchandshunt• Effectsofanaesthesiaonoxygencascade• Post-operativeoxygenrequirement

WebResources

• Article“Oxygendeliveryandconsumption”.

www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students• Podcasts-‘Hypoxia’and‘ABGinterpretation’

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• 4classesofhypoxia.(Cellular/cytotoxic,anaemic,stagnant

andhypoxaemic).

• Deliveryanduptakeofoxygentothepatientisbasedonbasicphysiologicalprinciples(oxygencascade,ventilation/perfusionandhaemoglobinuptake/delivery).

• Causesofhypoxaemiaunderanaesthesia(pre-existing

causesandfactorsrelatedtothetypeofsurgeryandanaesthesia).

• Waysofimprovingoxygenationunderanaesthesia(

increasedFIO2,effectsofPEEPandincreasingminuteventilation).

• Waysofgivingsupplementaloxygenontheward(Venturi

principles)andrecognisewhentorefertoITUforfurtherventilatorysupport.

• Howtoprescribesupplementaloxygenforwardpatients.

• Howtointerpretrespiratoryfailureonbloodgasanalysis.

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Scenario1

Youarehelpingtoanaesthetisea36yroldman,whoisfitandactivewithnomedicalhistory.Heishavinganelectiveinguinalherniarepair.Hehasundergoneanuneventfulgeneralanaestheticandhasbeenstablethroughout.At theend of theoperation the consultant anaesthetistwaits until he is awake and removes theLMA.Sheasksyoutoescortthepatienttorecovery.Onarrivalinrecoverythenurseasksyouaboutoxygentherapy.Questions;

1)Whydoesthispatientrequiresupplementaryoxygenintherecoveryroom?2) Howmuchoxygenwouldyougive?3) Howlongshouldhehavesupplementaloxygeninrecoveryandhowwouldyou

monitorhim?4) Whatdevicesareavailableforoxygendeliverytopatientsinrecovery?5)Whichdevicewouldsuithimbest?Why?

1.

2. 3.

4. 5.

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Scenario2You are bleeped toA&E to see an asthmatic girl.When you arrive you find the 16 yr old,Emily,lookingpale,sweatyandanxious.Sheisextremelyshortofbreathbutshemanages totell you her name and address. The nurses have put some monitoring on her and haveobtainedthefollowingvalues:Pulse120bpm Respiratoryrate35minBP140/90 SpO292%Questions;

1) Whatotherinformationwouldbehelpfulinassessingher?2) Whatisyourfirststepinhermanagement?Why?3) AnarterialbloodgasshowsherPaO2is8.5kPa.Isshehypoxaemic?4) Whatsubsequentstepsinmanagementwouldyouinstitute?5) Howwouldyouassessherresponsetotherapy?

1. 2.

3.

4. 5.

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1.

2.

3.

4. 5.

Scenario3Youareaskedyoutoseea78yroldladyontheward.Shewasadmittedtwodaysagowithaninfectiveexacerbationofherchronicairwaysdisease.Sheisnormallyonhomeoxygenandiswheelchairbound.Shehasnotimprovedwiththerapysofar.Youwanttotakeasetofbloodgasesonthiswomanon28%oxygen.Questions;

1) Howareyougoingtoensurethatsheisbreathing28%oxygen?2) Whyisitimportanttotakethebloodgasesat28%oxygen?

HerABGsare:pH7.39pCO28.0kPa,pO27.5kPa,HCO334,BE+2.4.

3) Isshehypoxaemic?4) CommentonthePaCO2andHCO3.5) Howmuchsupplementaloxygenshouldshenowhave?

1.

2.

3.

4. 5.

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Scenario4Cmdr Walter Smith is a 68 yr old retired naval officer who was a heavy smoker untilhestoppedtenyearsago.Hehasapermanenttracheostomysincehehadatotal laryngectomysevenyearsagoforacarcinoma.Hehasbeen admittedwitha chest infectionasa result of sputumretention. Hehasbeentreatedwith intravenousantibioticsandsupplementaloxygenviaatracheostomymask fortwodays.Althoughheisimprovingtheprogressisslow.Questions;

1) Whyissputumretentionaprobleminthiscase?2) Whatothertherapeuticmanoeuvresmayspeeduphisrecovery?3) Whyshouldhissupplementaloxygenbehumidified?4) Whatmethodsarethereforhumidificationofoxygen?

1.

2.

3.

4.

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PERI-OPFLUIDTHERAPYLearningObjectives

! Revisethebasicphysiologyofwaterandelectrolytecompositioninadults.

! Anunderstandingofthecompositionofvariousintravenousfluidsandbloodproductsavailableforuse,andtherationalefortheiruse.

! UnderstandtheNationalInstituteofClinicalExcellence(NICE)5Rsof

prescribingfluid

Resuscitation RoutineMaintenanceReplacement Re-distribution Reassessment

! Asimplerationaleforprescribingfluidtherapyintheperi-operativeperiod.

Pointstocover• Normalfluidbalanceanddistribution• Howthenormalbalancecanbeaffectedperi-operatively–inparticular

losses• IVfluidsandBloodproductscommonlyused• Howtoassessfluidbalanceincludingperi-operativeacutebloodloss

WebsiteResources

• BasicsofFluidandAnalgesia• Article:“Howtodo:BloodTransfusion”• Article:“HowtoprescribeFluidTherapy”• NICEGuidanceward-basedfluidguidelinesalgorithm2013• NICECompositionofFluids• NICEDiagramofongoingLosses• “Hypotension”–brieflearningsheet

Allfoundat:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students

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KeyTutoriallearningpoints:

• Distributionoffluidsintointracellularandextracellularcompartments.

• Understandhowfluiddistributionbetweencompartmentsrelatesto“Starling’sequation”(influenceofhydrostaticandoncoticpressures).

• Understandhowdiseasestatesinfluencethedistributionoffluidswithin

compartments(heartfailure,sepsis,nephriticsyndromesetc).

• Understandthedifferencebetweencrystalloidandcolloidsolutionsandhowtoprescribefluidtherapyforthepost-oppatient.

• Understandindicationsforbloodtransfusionperi-operativelyandhazardsof

transfusion.

• UnderstandtheuseofbloodproductssuchasFreshFrozenPlasma,platelets,cryoprecipitateinthetreatmentofperi-operativecoagulopathy.

• Understandclinicalassessmentoffluidbalanceintheperi-operativepatient(

BP,pulse,capillaryrefill,jugularvenouspressure,urineoutput)andhowtoresuscitatethehypovolaemicpost-oppatient.

• Understandthatfluidadministrationmaybeguidedbyinvasivemethods

(centralvenouslinepressuremonitoring,oesophagealDopplercardiacoutputassessment)inthecriticallyillpatient.

• Understandtherelationshipbetweenguidedfluidadministration(i.eviacentral

venouspressuremonitoring)andcardiacoutput:Starling’slaw

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Scenario1

MrsKiranBalhasbeenadmittedwithsuspectedcholecystitis.Sheistoreceiveanalgesiaandundergo further investigations.She is to be kept nil bymouth until the investigations arecomplete.Sheis1.56mtallandweighs80kg.Shehasnosignificantpastmedicalhistory.

Questions;

1) Whatareherestimatedintra-vascularvolume,extra-vascularvolumeandtotalbodywater?

2) Whatisherlikelymaintenancefluidrequirement?Howdidyoucalculateit?3) WhattypeofIVfluidswouldbebestformaintenanceinhercase?4) Writebelowanappropriatefluidregimeforherforthenext12hoursbearinginmind

yourpreviousanswers.

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Scenario2

Mr John Wilson is a 58 year old gentleman who had an elective hemicolectomy thisafternoon.Heisonthepost-operativesurgicalwardbuthasnothadanyIVfluidsprescribedforhim.Thewardsisterasksyoutoprescribehimsomepostoperativefluids.Questions;

1) Whatfurtherinformationyouwouldlikeaboutthispatient?2) Howwouldyouestimatehislikelyfluidstatus?3) Whatwouldyouexpectthisfluidstatustobeandwhy?4) Ishelikelytohaveanelectrolyteimbalance?Ifso,whatandwhy?5) Onthechartbelowprescribearegimeforthenext24hours.

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Scenario3

Dr Jane Summers is brought intoA&Ewith amassiveante-partumhaemorrhage. She tellsyouthatshewoketofindthebedcoveredinblood.Accordingtotheparamedicsshehaslostatleastafurther2litresofbloodintheambulance.Asyouaretakingahistoryfromhersheisbecomesvagueandgoesquiet.Youcanonlyfeelveryafeebleradialpulse.Questions;

1) Whatwouldyourfirststepinhermanagementbe?Why?2) Howwouldyoucalculateherpercentagebloodloss?3) WhatIVfluidswouldbebesttoimmediatelyreplacethelostvolumeandwhy?4) Howmuchfluidwouldyougiveherandhowfast?5) Howwouldyouascertainwhethersheneedsabloodtransfusion?

1.

2.

3.

4. 5.

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Scenario4

MrsRoseAcornisa64yroldlady,weighing75kg,whohadatotalabdominalhysterectomyyesterday. Her postoperative haemoglobin (Hb) is 7.6g/dl today. Previously her Hb was13.5g/dl.Shewaswellpreoperativelyandhasnospecificcomplaintsatpresent.Questions;

1) Howcanyouestimateherbloodloss?2) Doyouthinksheneedsabloodtransfusion?Explainyourreasoning.3) Howwouldyouobtainbloodfortransfusionifyourequiredit?4) Nametwocomplicationsassociatedwithbloodtransfusions.5) Whatthreeprecautionswouldyoutakebeforeadministeringbloodtoanypatient?

1.

2.

3.

4.

5.

36

PAIN&ANALGESIALearningObjectives

! Revisethephysiologyandpharmacologyofpain

! Understandhowtoprescribeeffectiveanalgesia

! Basicknowledgeofacutepainmanagementinperi-operativepatients

! Understandingofyourdutyasadoctorinprovidingeffectiveanalgesia.

Pointstocover

• Painreceptors• Painpathways• Analgesicladder• Mechanismofactionofparacetamol,NSAIDs,codeine, tramadol,

morphine• Mechanism of action of gabapentin, ketamine, TENS, local

anaesthetics• Side-effectsofthedifferentanalgesics• Patient-controlledanalgesia• Epiduralanalgesia

WebResources• Article:“HowtoprescribePerioperativeAnalgesia”• Article:“HowtolookafteranEpiduralontheWard”• Podcast:“Mechanism of Acute Pain”

Allfoundin:www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students:

37

Keytutoriallearningpoints

• Painmaybetargetedatanypointinafferentpathwayfromperipheralreceptortohighercorticalcentres.

• Understandbasicclassesofanalgesics(NSAIDS,opiates,paracetamoland

adjunctsi.eketamine,amitryptiline,gabapentin).

• Allanalgesicshaveside-effectsandanalgesiamustbetailoredtotheindividualpatient.

• An“analgesicladder”shouldbeconsideredinthepost-operative

treatmentofpainforallsurgicalpatients.

• Painmayalsobecontrolledpost-operativelybyperipheralnerveblocksorcentralneuroaxialblocks(epiduralorspinalinjections)performedbytheAnaesthetistintheatre.

• Centralneuroaxialblock(spinal,epidural)havecontra-indications

incertainpatientsandconditions.

• Patient-controlledanalgesia(PCA)mayprovideanalternativeformofanalgesiawherepainissevereorifneuroaxialblockhasbeenunavailable.

• Epiduralanalgesiashouldbemonitoredcloselypost-operativelyforsigns

ofneurologicalcompromisewhichcouldindicateepiduralabscessorhaematoma,whichareemergenciesrequiringimmediatetreatment.

• Anypatientreceivingopiateanalgesiashouldbemonitoredfor

respiratorydepressionandknowledgeoftheadministrationofnaloxoneforrespiratoryopiate-sensitivityshouldbeheldbyalldoctors.

38


39

Scenario1

Youarereviewingpatientsonthepost-operativeward.YouareseeingMrRogerEvanswhohad an appendicectomy earlier today. He is to remain nil by mouth on IV fluids for thenextfewdays.Hehasnosignificantmedicalhistory.Questions:

1) Whatanalgesiawouldyouprescribeforhimfortoday?2) Whatisananalgesicladder?Howaretheyusefulinpainmanagement?3) WhatanalgesiawouldyouprescribeforhimonDay3postoperativelyandwhy?

1.

2.

3.

4.

40

Scenario2

MrsAbeoKuti , 78yrsold, is scheduled tohavea left total knee replacement forosteoarthritis.Sheisveryworriedaboutpostoperativepain.Shealreadytakescodydramoland‘ibuprofen’regularly.Sheasksyouaboutoptionsforpost-operativepainrelief.Questions;

1) WhatareCodydramoland‘ibuprofen’?Howdotheywork?2) Wouldthesedrugsbehelpfulinmanagingherpost-operativepain?3) Whatotheragentsandoptionswouldyoutellheraboutformanagingpost-operative

pain?4) Whataretheadvantagesanddisadvantagesofeachofyouroptions?5) WhichoptionsdoyouthinkwouldsuitMrsKutibest?

1.

2.

3.

4.

5.

41

Peri-operativeComplications,RiskandSafety

Learningobjectives:• Understandtheincidenceofmortalityandmorbidityassociatedwith

surgery

• Recognizetheimportanceofidentifyingkeyriskfactorsforpost-operativecomplicationsinapatient’spastmedicalhistory

• Theabilitytoidentifykeyopportunitiestopreventpost-operative

complicationsinthepatientjourney

• Specificandassociatedcomplicationsofanaesthesiaandsurgery

• UnderstandtheconceptofEnhancedRecoveryAfterSurgery(ERAS)pathways

• UnderstandtheconceptofRisk&CommunicatingRisktopatients(Online

Course-Week3)

• Scoringsystemsforriskinanaesthesiae.g.P-Possum,SORTsurgery(OnlineCourse–Week3)

• Definitionofa“NeverEvent”inaccordancewithNHSEnglandassociated

withAnaesthesiaandSurgery(OnlineCourse-Week3)

42

PointstoCover• Riskfactorsforperi-operativehaemorrhage• Definitionofoliguriaandclassification• Causesofpost-operativepyrexia–“thesevenCs”• Classificationofpost-operativeinfections• Virchow’striadandWellsScoreinDVT/PE• Effectsofanaesthesiaandsurgeryonbowelfunction• Post-operativedelirium• RoleofchecklistsinSaferSurgery• ERASpathwaymodel

WebResources• Article“IntroductiontoPost-operativeComplications”

www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students

• OnlineCoursetobecompletedduringWeek3:PerioperativeRiskandSafetyforMedStudents,www.versal.com,accessedviaGoogleChromebrowser.Passwordstocoursesupplied:[email protected].

43


44

BASIC&ADVANCEDLIFESUPPORTLearningObjectives

! RevisethecurrentBasicLifeSupport(BLS)andAdvancedLifeSupport(ALS)guidelines

! Anunderstandingoftheaetiologyandoutcomefromcardio-respiratory

arrest

! An understanding of the differences in BLS andALS algorithm for adultsandchildren

! Anunderstandingoftheuseofadefibrillator

! Arationalefortheuseofdrugsincardio-respiratoryarrest

Pointstocover

• BLSandALSalgorithms• Paediatricresuscitationguidelines• Reversiblecausesofcardiacarrest• Anaphylaxismanagement• Drugsusedinresuscitation

Webresources:

• ALS:www.resus.org.uk/pages/als.pdf• BLS:www.resus.org.uk/pages/bls.pdf• PaediatricBLS:www.resus.org.uk/pages/pbls.pdf• PaediatricALS:www.resus.org.uk/pages/pals.pdf

46


47

Scenario1

Youarealoneonatrainplatformapartfromanelderlymansittingaloneonabench.Suddenlythemanclutcheshischestandslumpsoffthebenchtothefloor.Questions;

1) Whatshouldyoudointhefirstinstance?2) Ifheshowsnoresponsetoyourinitialactionwhatisthenextstepyoushouldtake?

Whatistherationaleforthis?3) Whatdetermineshowlongshouldyouremainwithhim?4) Whatwouldyouaskthefirsthelperonthescenetodo?5) Whatisthesurvivalratefor‘outofhospital’adultcardiacarrest?

1.

2.

3.

4. 5.

48

Scenario2

Youareoutsideanewsagentwhenashoutforhelpfrominsidetheshopcatchesyourattention.Intheshopyoufindayoungboyappearstobechokingandisblue.Youcanfeelapulseofaround40bpm.Questions:

1) Whatisthefirstthingyouwilldo?Why?2) Isthereanyusefulassessmentyouwouldmakeatthisstage?

Helosesconsciousnessandstopsbreathing.Youcanstillfeelapulseof40beatsperminute.TheshopassistanthandsyouthefirstaidboxandtheAED.Theambulanceisthreeminutesaway.

3) Whathelpwouldyourequestfromtheassistantandbystanders?4) Whatinformationwouldyougivetotheambulancecrewwhentheyarrive?5) Whatfurtherhelpcantheambulancecrewsupplyontheirarrival?

1.

2.

3.

4.

5.

49

Scenario3

Youarethemedicalhouseofficeroncallatyourhospital.WhilstontheCoronaryCareUnitMr. Cesar Frank,who you admitted last nightwith unstable angina, collapses. The cardiacmonitorshowshimtobeinventricularfibrillationandheisunrousable.Questions:

1) Whatwouldyoudofirst?2) Whathelpandequipmentwouldyouaskfor?3) YoudecidetogivehimDCshocks.After2DCshocksheremainsin ventricular

fibrillation.Whatdoyoudonext?4) Wouldyougivehimanydrugs?Ifso,whichonesandwhy?5) WhatarethecurrentUKsurvivalratesfor‘inhospital’,witnessedcardiacarrest?

1.

2.

3.

4.

5.

50

Scenario4Youarethemedicalhouseofficeroncall.Thecardiacarrestbleepgoesoff.Youhavebeen inpostfor5monthsandthemedicalregistrardecidesthatyoushouldleadthenextarrestaspractice.YouarecarryingouttheALSaccordingtocurrentprotocol.Duringthearrestthepatienthasthesethreerhythms.Questions:

1) Identifyeachrhythmandstatehowyouwouldcontinuewithresuscitationfaced witheachrhythm.

2) Regardingrhythm1,whatassessmentwouldyoumakeofthepatient?Why?3) Regardingrhythm2,whatdrugswouldyouuse?Why?4) Whatinvestigationsorassessmentwouldyoumakeifthepatientwasinrhythm3

Rhythm1:

Rhythm2:

Rhythm3:

51

Scenario5Youareattendingapaediatriccardiacarrest inA&Eyouhavehad2attemptsatperipheralintravenous canulationwithno success. The2year old child still doesnothaveapalpablecardiacoutput.Questions:

1) Whyisitimperativetoobtainvenousaccess?2) Whatothermodeofaccesscouldyouorthepaediatricteamattempt?3) Whataretherisksassociatedwiththisprocedure?4) Canyousubsequentlygivedrugsthroughthisroute?

1.

2.

3.

4.

52

SICKPATIENTSCENARIOSLearningObjectives

! Revisebasicaspectsofrespiratory,renalandcardiovascularphysiology

! Recognizetheimportanceofbasicphysiologicalmonitoring

! Theabilitytorecognizeunwellpatients

! Astepwiseapproachtothemanagementofthecriticallyunwellpatient

! Knowledgeofwhen,howandwhotorefercriticallyillpatientstoPointstocover

• Shock• Sepsis• Hypoxia• HowtointerpretArterialBloodGasses• GlasgowComaScore

WebsiteResources

• Article“recogniseCriticalIllness”• Briefdocument:“BasicsofIntensiveCare”• Briefdocument:“BasicsofRenalfailure”• Podcast“recognisingthecriticallyillpatient’

www.ucl.ac.uk/anaesthesia/StudentsandTrainees/students

53

KeyTutoriallearningpoints:

• Takingabasichistory,examiningthepatientandrequestingpertinent

investigationsallowsidentificationofthecriticallyillpatientinneedofsupportfromIntensiveCare.

• ManywardpatientssubsequentlyrequiringadmissiontoITUwillhave

demonstratedseveralhoursofdeclineintheirwardobservations.

• Basicphysiologicalwardscoringsystems(NEWSetc)havebeendevisedtoallowearlyidentificationofpatientdeteriorationandsubsequentreferralforprompttreatment.

• ITUmayprovidesingleorganormulti-organsupportforpatientsunableto

respondtosimplemeasures(i.efluidresuscitation,supplementaloxygenetc)ontheward.

• IntensiveCarepatientmanagementisbasedonasystems-basedmodelwithstrict

attentionpaiddailytopatientCVS,Resp,GI,Renal,Neuro,Microbiologicalandpharmacologicalparameters.

• Inadditiontobasicobservations,patientsmayreceivemoreinvasivemonitoring

toguidetherapysuchasarterialbloodpressurerecording,centralvenouspressurerecordingandcardiacoutputmonitoring(OesophagealDoppler,thermodilutorymeasuresi.epulmonaryarterycatheterdevices).

• Circulatorysupportoftenrequirestheuseofinotropesand/orvasopressorsanda

thoroughunderstandingofcardiacphysiologyandpharmacologyiscentraltopatienttreatment.

54

Scenario1

YouaretheA&EFY2askedtoseea23-year-oldwomaninthedepartment.


55

Scenario1

Awomanwhoappearsinher40’swasfoundonthestreetunconsciousandbroughtinbyanambulance.Whenyouseehersheislyingonherbackinresus.Sheisunkemptandsmellsofalcohol.Sheopenshereyeswhenyousqueezeher fingernailsbutpullsherhandawayandgroansincoherently.

Herobservationsare,BP140/90,P110,SpO296%,RR8andT35.8C.

Questions:1) WhatisherGlasgowcomascore?Whyisthisassessmentrelevant?2) WhatwouldyoudoinresponsetohavingassessedherGCS?3) Whatassessmentandinformationwouldbeusefultoyou?4) Whatdoyouthinkisthemajorproblemwithher?5) Whatshouldthenextstepinhermanagementbe?

1.

2.

3.

4. 5.

56

Scenario3

Scenario2YouarethesurgicalFY1whoisaskedtoseeoneofthepost-operativepatientsbythenursingstaff. He is a 72-year-old man who had a laparotomy for an elective resection coloniccarcinomathreedaysago.HeremainsnilbymouthandhasbeenhavingIVfluidssincetheoperation.Whenyouseehimheisdrowsyandcannotrememberwhatdayitis.Hisobservationsare;BP80/60,Pulse120,SaO294%onair,Resp28andTemp38.6oC.Questions:

1) Onthisassessment,whatarethemainissueswiththispatient?Isthereanythingthatyoushoulddoimmediately?

2) Whatotherinformationandinvestigationswouldbehelpful?3) Whatdoyouthinkisthelikelydiagnosis?4) Whatisthispatients’qSOFAscore?5) Doeshehavesepsis?6) Whereisthepotentialsourceofinfection?

1.

2.

3. 4.

5.

57

Scenario3You are asked to see a 62 yr old man who had an elective total knee replacement doneyesterday morning. He has no urinary catheter in situ. He is bed-bound because of theoperation andhas thereforebeingusing abottle. Thenursing staff are concernedbecauseaccordingtothe24hrfluidcharthehasonlypassed68mlsofurine.Questions;

1) Whatisthe24hoururineoutputexpectedtobeinahealthyadultman?2) Givethreepossiblereasonswhythecharted24hoururineisonly68mlsinthisman?3) Whatinvestigationswouldhelpyoutofindoutthecause?4) Doesheneedacatheter?Explainyourreason.5) Howwouldyouensurethathehasagoodurineoutputinthesubsequent24hours?

1.

2. 3.

4.

5.

54

Scenario4YouareaskedtoseeMrsFlorenceHarper,a78-year-oldwoman.Shehasbeenadmittedwithbreathing difficulty. She has been increasingly short of breath for four days and has beendiagnosedwithachestinfectionandhasstartedantibiotictherapy.Whenyouseeheronthewardshelooksdistressed,herobservationsare,BP150/90,Pulse92,Resps20,andTemp36.8oC.HerarterialbloodgasonairshowspH7.36,pCO24.5kPa,pO27.8kPa,Bicarb34,BE2.0Questions:

1) IsMrs.Harperhypoxic?Explainyouranswer.2) Whatshouldyourfirstinterventionbe?Why?3) Arethereanyfurtherinvestigationsyouwouldaskfor?4) Howcouldyouassessifyourinterventionwasmakinganimprovementinher

condition?5) Doessheneedventilatoryassistanceatthisstage?Towhomshouldshebereferred?

How?

1.

2.

3.

4.

5.

Things todo in theatre thatwillmakeyouamoreconfidentandcompetentMedicalstudentAND….FY1.Therearelotsofopportunitiesduringcasesintheatreforyoutolearn/practicesomeskillsthatwillbeinvaluableforyouinfinalsandmakeyouabetterFY1!

• DOasktoperformcannulationsonasleeppatients.ThereisnobettertimetolearnthisessentialskillbeforeyoufindyourselfoncallasaFY1.

• If thepatient requiresurinarycatheterizationdotakethisopportunitytolearn(getpatientconsentfirst!).

• Look at the different types of IV cannulae, their gauge andmaximumflowrates(hasbeenaskedinfinals).

• Discuss blood gas results and define respiratory and metabolicacidoses/alkaloses.

• Look at common IV fluids given in theatre and discuss theconstituentsofcrystalloidsandcolloidswiththeAnaesthetist.

• DiscusswiththeAnaesthetisthowbloodisprescribedandadministeredandhowitisrequestedinemergencysituations.

• Fillinaroutineprescriptionchartfortheward.Gothroughprescribinga sliding scale for insulin and how to prescribe warfarin andantibiotics(whichwouldneedmonitoringoflevelssuchasGentamicin).

• Discuss prescription of “maintenance” fluids for a ward patient andwhatfluidstoprescribefor“fluidresuscitation”.

• Discuss DVT prophylaxis for the surgical patient and prescribe it onthedrugchartwhereappropriate

• Set up monitoring for transfer of a critical patient and practicetransferringpatientstorecovery.

• Discuss prescription of post-opoxygen for the surgical patient. Relateoxygen prescription to pre-existing conditions i.e COPD. Look atdifferentdevices(i.eVenturimasks)forgivingoxygen.

• Prescribe post-operative analgesia and discuss the “pain ladder” ofanalgesicprescription.

PROCEDURESCHECKLIST

Procedure Seen Done SupervisedbyAirwaymanoeuvres/maintenance.

Bagvalvemaskventilation

InsertionGuedelairway

Insertionnasopharyngealairway

InsertionLMA

Oraltrachealintubation

Nasalintubation

Fibre-opticintubation

Rapid-sequenceinduction

InsertionNGtube

IVcannulation:22G20G18G16G14G

Arterialline

Centralline

Runthroughfluidgivingset

PreparationIVdrugs

PreparationIVdruginfusions

Attachandstartmonitoringpre-induction

Aseptictechniqueforprocedures

Pre-opassessment

Spinalanaesthetic

Epidural

Nerveblock

WHOchecklist

Cardiacoutputmonitoring

Intra-hospitalpatienttransfer

Cardiacarrest

ATTENDANCECHECKLIST

Week1 Location SupervisorsignatureMonday

Tuesday

Wednesday

Thursday

Friday


Tuesday

Wednesday

Thursday

Friday


Tuesday

Wednesday

Thursday

Friday


Tuesday

Wednesday

Thursday

Friday

Tutorial SupervisorsignaturePre-opAssessment

AirwayManagement

ConductofAnaesthesia

Peri-opFluidTherapy

OxygenDelivery

PainandAnalgesia

Peri-operativeComplications

BasicandAdvancedLifeSupport

SickPatientScenarios

CASEBASEDDISCUSSIONStudentName:

Module:Date:AssessorGrade: Cons

SpR

TrustGrade SHO PRHO

Setting: OPClinicPatient: Age:

IPSex:

A&E GPsessionM F

Pleaseusethemarkingguidetohelpwithyourassessment Belowexpected

standard(tick)

Achievingexpectedstandard(tick)

Exceedingexpectedstandard(tick)

Domain 1 2 3 4 5 6 NotassessedHistory

Examination

DiagnosisandManagement

Overallclinicaljudgement

Insightintoaspect(s)ofcase

Recordkeeping

TotalMark:Pointsofgoodperformance:

Pointsforaction:(pleaseindicatespecificproblemsifassigningamarkof1-2)

Signed: Assessor Student

Bysigningthisform,theassessoraffirmsthatthestudenthasbeengivenfeedbackandthestudentagreesthathe/sheagreeswiththeresultoftheassessmentandthefeedbackgiven.

1 2 3 4 5 6

History Verydeficient incontent

Lackingindetail Systematic.Fewomissions

Good.Allaspectscomplete

Verygooddetail Superbandcompletelyaccurate

Examination Unableto elicitordescribeanyfindings

Unabletoelicitordescribemany aspects.Manyomissions

Relevantexaminationperformedbutwithfewomissions

Goodexaminationwithgoodunderstanding

Verygood andableto discussmeaningofabnormalityeasily

Excellent.Completeunderstanding oftheexamination

Diagnosis /management

Noattemptmade

Onlylimiteddiagnosis,differentialormanagement

Adequate.Identifies majorprobablydiagnosesandmanagement

Good. Identifiesmost probablydiagnosesandmanagement

Verygood.Identifiesallprobablydiagnosesandmanagement

Excellent. Identifiesallprobablediagnosesandmanagement withcompleteunderstanding

Overalljudgement

Nounderstandingofpatient’sdiagnosisorproblems

Limitedunderstandingof patient’sdiagnosisorproblems

Reasonableunderstandingofpatient’sdiagnosisorproblems

Goodunderstandingofpatient’sdiagnosisorproblems

Verygoodunderstandingofpatient’sdiagnosisorproblems

Completeunderstandingofpatient’sdiagnosisorproblems

Insight /reflection

Noreflectionundertaken

Reflectiveaspectconsidered verybriefly

Abletodiscussareflectiveaspect

Goodinsightintoa reflectiveaspectofcare

Detailed insightintoa reflectiveaspectofcare

Comprehensiveandprofoundinsightintoareflectiveaspectofcare

Recordkeeping

Deficientincontent withmanyomissionsorillegible

Lackingin detail.Notsystematic

Coversmainpintsand nomajoromissions

Gooddetail andnoomissions

Verywellrecorded andclearly aboveaverage

Superb,excellentandcomprehensive

FEEDBACKFORMDateofModule:

Week Rating1-5(5Excellent1Poor)

Comments

UCHMainTheatres

UCHEmergencyTheatre

PerioperativeWeek

QueenSquare

Tutorial Rating1-5

(5Excellent1Poor)Comments

Pre-opAssessment

AirwayManagement

ConductofAnaesthesia

Peri-opFluidTherapy

OxygenDelivery

PainandAnalgesia

PerioperativeComplications

LifeSupport

SickPatientScenarios

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