Baby MO Pocket

Guide (version 2.2)

Department of Anaesthesia
and Intensive Care
 FOREWORD

Welcome to the Department of Anaesthesia and SICU. This is a pocket guide to

help you through the first few weeks of your first anaesthesia posting. The
learning curve in the first month is steep, so we hope this guide will make the
climb easier! The content here is by no means exhaustive. Please fill in any
knowledge gaps by referring to any of the recommended textbooks or
reputable anesthesiology websites.

Here are a few mantras to keep in mind and recite to keep calm:

1. Think always of the patient’s safety and do no harm.

2. Provide comfort and adequate pain relief for patients.

3. Be vigilant with the monitoring (you are the patient’s best monitor)

4. Be meticulous with documentation (medicolegal implications)

5. Be a hardworking team player

6. Be courteous, especially to nurses

7. Be punctual. MOs are expected to attend all department meetings

unless they have urgent OT / SICU duties

8. When in doubt, ask. Asking for help is not a sign of weakness, but
reflects self-awareness and maturity

Have a pleasant posting and make the best use of your time here!

Cheers from the team,

Dr Chong Shin Yuet
Dr Mah Chou Liang
Dr Lee Si Jia
Dr Loy Shun Ting
Dr Angie Au Yong
Dr Edwin Lim
Dr Lydia Lee

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 TABLE OF CONTENTS
 Foreword -------------------------------------------------------------------------------------------------1
 General OT guidelines ---------------------------------------------------------------------------------3

A DAY IN THE LIFE OF AN ANESTHESIA MO

 The day before – How to see premeds ------------------------------------------------------------4
 What to do on a typical day in OT ------------------------------------------------------------------6
o Reporting time
o How to prepare OT
o Where can everything be found?
o How to screen patients

CONDUCT OF ANAESTHESIA
 General anaesthesia -----------------------------------------------------------------------------------8
o IV induction agents --------------------------------------------------------------------------------9
o Airway management ----------------------------------------------------------------------------10
o Mechanical ventilation -------------------------------------------------------------------------14
 Conduct of Regional anaesthesia -----------------------------------------------------------------18
 How to manage emergence ------------------------------------------------------------------------19
 How to organise PCA pumps -----------------------------------------------------------------------20
 Anaesthetic crises -------------------------------------------------------------------------------------21

AFTER ANAESTHESIA
 How to manage patients in PACU -----------------------------------------------------------------22
 PACC workflow ----------------------------------------------------------------------------------------25
 How to do post op reviews -------------------------------------------------------------------------27

OTHERS
 Anaesthesia Services ---------------------------------------------------------------------------------28
 Teaching -------------------------------------------------------------------------------------------------29
 IT guidelines --------------------------------------------------------------------------------------------30
 Roster/Leave/MC Issues ----------------------------------------------------------------------------31
 Education resources----------------------------------------------------------------------------------33
 SICU ------------------------------------------------------------------------------------------------------34
 Acute Pain Service ------------------------------------------------------------------------------------36
 Preoperative Anesthetic Evaluation/Assessment Clinic -------------------------------------39
 Drug Doses Table -------------------------------------------------------------------------------------40
 Blood List Workflow (MOs doing cardiac list in NHC-OT) -----------------------------------41
 OT and Change Room Layout ----------------------------------------------------------------------42

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 GENERAL GUIDELINES IN OT
1. All MOs will be supervised by the consultant of the OT – do not start or
end a case or do procedures by yourself unless otherwise instructed.

2. Equipment and machines should be handled with care. Learn how to do

a machine check from one of the seniors. The anaesthesia machine is
the most important thing keeping the patient alive, besides yourself.

3. Anticipate problems early and call for help if needed. Doing your
homework thoroughly plays an important part in your life.

4. Do not leave patients under anaesthesia (regional or general)

unattended, even in the induction room after RA is done.

5. MOs should follow the exchange relief protocol during relief of work
(SBAR – Situation; Background; Assessment; Recommendation) and
passing of patients to the recovery team in the recovery area.

6. All MOs are expected to be contactable by mobile phones during office

hours. All calls are to be responded to promptly.

7. MOs who have finished their daily elective lists are to report to the
roster master. MOs are also expected to report back to the senior staff
in the OT after finishing pre-medication rounds, to check whether they
are needed back in the OT.

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 A DAY IN THE LIFE OF AN ANAESTHESIA MO
The day before: Premeds

 To assess the patients for surgery the following day. It is reasonable to begin premeds at
about 3-330pm as most patients would have been admitted to their wards.

 Inform seniors of difficult or major cases, potential problems, patients ASA 3 and above
and potential cancellations. Never cancel a case on your own. When starting out, you
may wish to go through the whole list and learn what are the important points the
senior wants to know.

 Take a detailed history

 Perform a focused examination
 Create and fill online preop anesthesia assessment
HISTORY
IHD – incl Inx findings (lung function test, cath, MIBI, 2DE)
Cardiac Hx
Interventions done, current NYHA status
Recent URTI/ LRTI, asthma, COPD etc – inhalers/ steroids
Respiratory Hx OSA (AHI index, whether pt is on CPAP, look out for 2DE and
ECG for evidence of R heart strain)
DM control (include Hba1c results) and complications
Endocrine Hx
Thyroid disease  ensure recent TFT done
Look at old AU charts for airway management, problems
Anesthetic Hx encountered during surgery (e.g. refractory hypotension,
bronchospasm, difficult spinal etc)
Previous CVA, functional status
Parkinson’s  how severe, level of function
Neurology
Epilepsy  when was last breakthrough seizure, what meds,
any f/u with neurology
Miscellaneous GERD
Surgical history & type of E.g. R TKR 2002 under spinal; wound debridement of foot in
anaesthesia 2010 under popliteal /saphenous nerve block

EXAMINATION
Heart: listen for murmurs, peripheral oedema
Cardio/Resp Lungs: wheeze. creps, air entry
Check ability to lie flat
Neurology GCS , mental capacity, focal neurological deficits
Airway See airway assessment (below)
Physically check for loose teeth – instruct team to refer
Dentition
dental if pt has loose dentition

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 FASTING GUIDELINES
INSTRUCTIONS – what do I write in the form? Full meal (e.g. nasi lemak) 8hrs
Light meal (e.g. porridge, bread) 6hrs
 INVESTIGATIONS
Clear feeds (water, clear juice) 2hrs
o FBC, UECr, PT/PTT only if indicated
o TFT, HBa1c, hypocount monitoring if pt has the relevant endocrine problems
o CXR for age > 50 years, major surgeries (laparotomies) or suspected lung
pathology
o Ask for repeat bloods if electrolytes are deranged (e.g. K>5 or <3, Na<130 or
>150). Different consultants have different thresholds for biochemical
derangements. Always check with them if unsure.
o ECG for age > 50 years or if patient has risk factors for coronary heart disease
e.g. DM, hypertension, hyperlipidemia, smoker
 Instruct on medications to omit/continue (see table below)
 Ensure valid GXM and standby blood products – for major surgeries eg. Spine
surgery, laparotomies
 POST OP MANAGEMENT
o HD/SICU – SGH we will need to book SICU bed on a separate online system.
HD beds can be arranged by the primary team. For CGH pts, just indicate in
the AU form for the nurses to book the SICU/HD beds.
MEDICATIONS – Which ones to stop and which ones to continue?
 Continue all beta blockers, CCB, diuretics (based on volume status)
CARDIO meds  +/- Omit ACE/ARB inhibitors
 Review anti hypertensives with consultant if BP not well controlled
 Continue all inhalers, may need neb ventolin on call to OT and periop
IV hydrocortisone if frequent episodic asthma
RESP meds
 If active exacerbation of asthma/COPD , inform consultant as op
likely to be postponed
ENDOCRINE  Omit all OHGA and long acting insulin on op day, suggest start sliding
 DM scale (SGH intranet diabetes fasting guidelines)
 Thyroid  Continue all thyroid meds
Anti-platelets/  Aspirin (5-7 days)  Dabigatran (5 days)
Anti-Coagulants  Clopidogrel (7-10 days)  Rivaroxaban/Apixaban (2 days)
(Duration to stop  Ticlopidine (10- 14 days)  Prasugrel (7-10 days)
before op)
 Warfarin  stop 4- 5 days before op, may need heparin cover for
mechanical valve or existing PE/DVT treatment. Usually if warfarin is
for AF, no need heparin cover
Anti-coagulation
 LMWH heparin  treatment (omit 24hr); prophylactic (omit 12hr)
 Dabigatran /Rivoroxaban speak to haematologist + anaes
consultant, avoid central neuroaxial blocks regardless
Continue omeprazole, H2 antagonists (e.g. ranitidine, famotidine)
GASTRO If pt has high risk of aspiration, may consider maxalon and sodium
citrate on as premeds morning of op day
TCM traditional medicines, gingko, ginseng or garlic

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Anaesthetic counselling – What should I tell patients?
COMMON RISKS for counselling (generic, non-exhaustive)
GA AMI, CVA, PONV, dental/oral trauma
Infection, bleeding , PDPH, hematoma, paralysis (1:200,000, failure
Spinal/Epidural
and need for conversion to GA
Infection, bleeding, damage to surrounding structures, nerve
Peripheral nerve
injury, LA toxicity, motor blockade, failure with risk of conversion
blocks
to GA
Infection, bleeding, damage to surrounding structures, permanent
Truncal nerve blocks
nerve damage, LA toxicity, pneumothorax, microperforation to
(e.g. TAP, intercostal)
bowel
Teach pt how to use; Risks: sedation, respiratory depression,
PCA
giddiness, nausea/vomiting

WHAT TO DO ON A TYPICAL DAY in OT

 Reporting time
MOs should arrive in OT by 0800hrs. Most patients will reach the induction room by
0815hrs and are ready for induction on table at 0830hrs. Please be vigilant to check
OTM as certain lists do start earlier. The surgical team will usually inform the senior
anaesthetist of that list. The onus is on you to double check.

 Check white board at display area (SGH)

There is often redeployment of manpower when people are absent from work (MC,
worked past midnight, emergency leave), or swapping of OTs due to logistical reasons.
This will be written on the whiteboard. The roster maker will usually send an SMS to
inform you of redeployment, if any. Changes are usually up on the board by 0815h.

CGH: The roster maker will inform the relevant staff of the changes if there are swaps to
be made.

 How to prepare the OT

1. Check anesthetic machine
2. Prepare IV cannulation tray
3. Draw up drugs for the 1st case (in
the GA tray)
4. Ensure resus drugs are readily
available (phenylephrine,
ephedrine, atropine, adrenaline)
but do not draw into syringes for
SGH (Please draw them into
syringes for standby only in CGH)

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 How to screen patients when they arrive in the induction room
Most patients would have already been seen in PEC or in the wards the day before as a
premed. Your job in the OT is to check the preop assessment form, know the
background of the pt, and when the pt has arrived in the induction room, quickly screen
through the following points to ensure pt is fit to proceed with surgery:
 Confirm drug allergies
 Confirm fasting time (8hrs for solids, 2 hrs for water)
 Ensure no recent URTI
 Ensure surgical and anaesthesia consent are both taken
 Quick assessment of airway and dentition (ensure no loose teeth as this can
sometimes be missed in clinic – ask patient to wiggle teeth as history may be
unreliable)
 Quick examination of heart and lungs
 Inform pts of the likely anesthetic plan and quick reiteration of the risks involved
 Set IV drip: usually on the L hand (unless contraindicated)
o Contraindications to IV drip setting: AVF/AVG in ESRF patients, previous breast
surgery, thrombosis of upper limb

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 CONDUCT OF GENERAL ANAESTHESIA
Note: In CGH to please key all cases done in OT into OTMS.
TYPES OF ANAESTHESIA
The types of anaesthesia can be broadly divided into the following types:
1. General anaesthesia (GA)
2. Regional anaesthesia (RA)
3. Local anaesthesia (LA)
4. Monitored anaesthetic care (MAC) aka sedation

TYPES OF GA
Spontaneous respiration (SR) IPPV
No muscle relaxant Muscle relaxant is used – pt is paralysed
Pt can breathe on their own Airway management: ETT
Airway management: LMA/ETT
Induction Induction agents: Propofol/etomidate/ketamine/thiopentone
Co-induction agents:
Midazolam, fentanyl, morphine

Volatile agents Volatile agents

sevoflurane, desflurane +/- N2O sevoflurane, desflurane +/- N2O
Muscle relaxants
May need to top up mm relaxants
intermittently (no top up if intraop nerve
stimulation required)
Maintenance TIVA/TCI
 Maintenance of GA can also be through propofol (instead of volatiles)
 The pumps deliver a continuous infusion of propofol according to the
dialled dosage
TIVA(propofol): 6-8mg/kg/hr (terumo pump)
TCI (propofol) (Schneider model, effect site concentration) 3-5.5 mcg/ml
Remifentanil: 0.02-0.2mcg/kg/min (terumo pump) or Minto model (TCI pump)
Bagmode OR VCV (Volume controlled ventilation) or
Ventilator
PSV (pressure support vent) OR PCV (Pressure controlled ventilation)
settings
SIMV (synchronised-intermittent)
Short , minor surgeries where Airway protection against aspiration (e.g.
muscle relaxation not required (e.g. GERD)
breast surgery, lump excisions, Head and neck op
knee surgeries) Obesity
Indications Unusual positioning: e.g. prone, sitting
Long and major surgeries (e.g.>4hrs)
Hemodynamically unstable pts
Laparoscopic surgeries involving
pneumoperitoneum creation

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 IV INDUCTION AGENTS
Propofol Etomidate Thiopentone Ketamine Midazolam
Presented as a 1 imidazole Sodium salt , Derivative of Benzodiazepine ,
or 2% aqueous ester, barbiturate, phencyclidine modulates GABA
emulsion presented as a dilute with receptor
containing soya lipid emulsion sterile water to
Chemistry
oil, egg produce
phosphatide 25mg/ml
and glycerol solution

Onset Rapid Rapid Rapid Fast Intermediate

Dose mg/kg 2-3 0.3 3-7 0.5-2.0 0.05-0.15 (sedation)
(induction) 0.15-0.2 (induction)
EFFECTS
↓cerebral ↓cerebral ↓cerebral Dissociative Amnesic,
blood flow, blood flow, blood flow, anesthesia, anticonvulsant,
CMRO2, anti- CMRO2 CMRO2, analgesic muscle relaxant
CNS convulsant , anticonvulsant properties,
produces emergence
pleasant delirium
dreams
Profound Causes less Decrease MAP Sympathetic Slight depression
hypotension , hypotension and CO stimulation,
CVS
decrease SVR, increase MAP,
MAP HR, CVP, PAP
Apnea, blunts Less blunting ↓RR and TV, Maintain Slight depression
upper airway of airway then apnea, pharyngeal and
reflex reflexes, may laryngeal laryngeal
Respiratory cause hiccups reflexes reflexes,
maintained at increase
usual dose secretions ,
bronchodilator
Pain on Pain on Histamine Vivid dreams, Useful as premed
injection, can injection, can release nightmares, for anxious
cause myoclonic cause hallucinations patients, can be
jerks, myoclonic given intranasally
Others
antiemetic jerks; PONV to children
properties Paradoxical effects
in elderly and
children
Most commonly For induction Drug of choice Avoid in raised Cannot be used as
used induction of pts with in E-LSCS, ECT ICP, pts with sole induction
agent poor EF, Contraindicated poor heart agent. Often used
Indications
hemodynamic In acute function. Has as co-induction,
instability intermittent analgesic and for sedation
porphyria effects

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 AIRWAY MANAGEMENT
Assessment
 Thyromental distance (> 4FB)
o Measured from thyroid notch to tip of jaw with head in extended)
 Neck extension
o May be limited in pts with previous radiotherapy to neck, cervical spondylosis
o Note any neurological symptoms, e.g. numbness at extremes of neck movement
that might suggest cervical myelopathy
 Mouth opening (> 3FB)
 Mallampati (ask pt to open mouth as wide as possible and stick tongue out)
 Cormack and Lehane grade (can only be assessed upon laryngoscopy)

Mallampati

Cormack and Lehane

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 Nasopharygeal airway and oral airway (Guedel’s)
- For opening up the airway and facilitate bag-mask ventilation
- Can also be left insitu in sedated pts who are spontaneously breathing (to prevent tongue from
falling backwards and causing upper airway obstruction

Oral airway

Nasal airway

Laryngeal airway mask (LMA)

- Supraglottic device that maintains a seal around the laryngeal inlet, may have
accompanying drainage tube for insertion of nasogastric tube
- Can be used in both spont vent and controlled ventilation pts at pressures up to 20
cmH2O
- Contraindications:
o Prone position
o High risks of aspiration (e.g. intestinal obstruction, GERD, morbidly obese pts)
- 2 main types used in SGH
o Proseal: reusable, can be used in all pts except infectious cases
o Supreme: disposable, has a preformed shape, and a bite block made of hard
plastic. Easier to insert, but higher risk of dental damage if patient bites on it

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ETT
- Intubation is the gold standard for secure
airway
- Types:
o Normal PVC
o Preformed  north rae, south
rae (for head and neck and ENT
cases)
o Armoured  flexible tube, used
sometimes in prone or sitting
positions
o Nasal: insert through the nostrils
(for surgeries involving
oropharynx)

Laryngoscopes
- Macintosh (curved blade)
- Miller (straight blade)
- Eclipse

Intubating adjuncts
- Bougie
- Mcgrath
- Glidescope
- Bonfils

Glidescope – for use in Macintosh Blade – curved

anticipated difficult airway #3 for most adults; #4 in taller adults

SIZING
Male Female
Oral airway 4 (yellow) 3 (green)
Nasal
7 or 8 6 or 7
airway
LMA 4 or 5 3 or 4
ETT (oral) 8 7 or 7.5
ETT (nasal) 7 or 7.5 6 or 6.5

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 Intubation Steps
1. Preoxygenate for 3-5 mins
2. Give IV agents: fentanyl, propofol, muscle relaxant
3. Position pt in head tilt, chin lift, jaw thrust
4. Turn on volatile agent and bag & mask pt until muscle relaxants
take effect (2-3mins for atracurium; 1min for rocuronium)
5. insert laryngoscope from R and sweep tongue to left
6. insert blade in the vallecula, just ant to the epiglottis and lift up
7. Visualise cords (may use external laryngeal pressure to improve
cords view)
8. Insert ETT past black line (usually 20-22cm at lips)
9. Remove laryngoscope
10. Connect ETT to circuit, cuff up balloon (check cuff pressure)
11. Bag and check ETT placement via auscultation of bilat lung bases
and stomach (3 points). Check for ETCO2 tracing on monitor.
12. Secure ETT. Turn on ventilator and gas

Rapid Sequence Induction (RSI)

INDICATIONS
- Essentially any patients with high risk of aspiration
o inadequate fasting time
o severe GERD
o obese pts (BMI >40)
o trauma pts with possible delayed gastric emptying
o Certain abdominal surgeries (e.g. appendicitis, intestinal
obstruction, perforated viscus)
CONDUCT
- Ensure good IV access and suction prepared and ready
- Preoxygenate with 100% oxygen for 3-5mins, or take 5 vital
capacity breaths – ensure EToxygen is > 85%
- Apply cricoid pressure at the onset of induction and keep it on till
ETT position is confirmed and cuff inflated
- Pre-calculate the amount of induction agent required (fentanyl (1-
2mcg/kg), propofol(2-3mg/kg), suxamethonium (1-1.5mg/kg) or
rocuronium 0.9-1mg/kg))
- Intubate when fasciculation ends (with sux) or after 60sec with
rocuronium (0.8-1mg/kg)
MECHANICAL
- Confirm ETT placement VENTILATION (basic modes)
(ausculate lungs, capnograph)
- Connect to ventilator, turn on inhalationals

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Mode Description Parameters to set
Used in completely apneic pts (paralysed).
VCV
Ventilator takes complete control and delivers a fixed
Volume
rate and tidal vol of breaths to the patient base on FiO2, VT, RR, PEEP
CMV – controlled
what is set.
controlled
It does not allow pt to breathe on their own efforts
mandatory
PCV Similar to VCV, except the volume of each breath
ventilation
Pressure delivered is based on the preset Peak airway pressure.
FiO2, RR, Pinsp, PEEP
controlled The Vt delivered is determined by the pressure. As
such the tidal vol may vary, but prevents barotrauma.
Ventilator is set to deliver prefixed rate and Vt
SIMV – synchronised
These breaths are synchronised with pt’s inspiratory FiO2, VT, RR, PEEP, PS
intermittent mandatory
efforts level
ventilation
Pt is allowed to breath above the set rate (+/- support)
Pt is allowed to breathe freely
Each pt-initiated breath is supported by the ventilator
PSV – pressure support
to a preset pressure support level FiO2, PS level, PEEP
ventilation
Used in spontaneously breathing pts with small
unsupported tidal volumes
Pt breathes spontaneously. A PEEP is supplied to
CPAP FiO2, PEEP
minimise collapse of alveoli during expiration
Spontaneous Pt is breathing entirely on own effort Ensure APL valve is fully
ventilation Ventilator is switched to bag mode open

How to set the ventilator

PARAMETERS NORMAL RANGE REMARKS
under GA
fraction of inspired 0.3-0.6 Avoid 100% for prolonged periods as this
FiO2
oxygen may cause lung atelectasis
Tidal volume 6-8ml/kg ↑ if ETCO2 is rising
VT
350-600ml
RR Respiratory rate 8-16
Peak end expiratory 5-10 Usually start at 5
pressure Slowly ↑to 10 if oxygenation is an issue
PEEP
Caution high PEEP use in pts with
COPD/asthma
Peak Inspired 15-26 in IPPV Varies with the compliance of the lung
Pinsp pressure ↑in obese pts, abdominal splinting,
bronchospasm
Tinsp Inspiration time 1-1.8s Dependent on RR
PS Pressure support 8-14 If on PSVPro or SIMV
I:E ratio Insp: exp ratio 1:2 Normal IE ratio is 1:2
MV Minute ventilation 4-8 MV = RR x VT

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 EQUIPMENT – ANESTHETIC MACHINES
There are 2 types of anaesthesia machines in CGH, namely the Aestiva and Avance.
SGH uses several types of anaesthesia machines:
1. Aestiva
2. Avance, Aespire
3. Blease Sirius
4. Datex Ohmeda with Clare ventilator
5. Priumus (Uro OT)
6. Macquet

Please check the machine properly before the start of the list to detect any problems that
might compromise patient safety. It is also good practice to check for leaks before every
case. Some machines have automated self-checks while others require manual checking.
Contact our friendly AU technicians, Johari, Say Kiat, Farhan and Chiok Joo (SGH) for
assistance if you encounter any equipment problems. For CGH, inform the AU nurses who
will call upon the technicians on duty.

vaporisors

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Checking the Anaesthetic Machine

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 CONDUCT OF REGIONAL ANAESTHESIA
Regional anaesthesia involves the infiltration of a particular nerve supplying the affected
area, to make a specific part of the body (e.g. arm, foot) insensate to
surgical stimulus
Local anaesthesia involves the direct injection of local anaesthetic to the area
immediately surrounding the op site by infiltration

Common Types of Regional Anaesthesia

1. Neuraxial blocks
- Subarachnoid block (spinal)
- Epidural
- Combined spinal epidural (CSE)
2. Peripheral nerve blocks
- Truncal: intercostals, TAP, ilioinguinal, paravertebral
- Upper limb nerve blocks: supraclavicular, infraclavicular, axillary
- Lower limb nerve blocks: popliteal, saphenous, femoral, ankle

SPINAL (SUBARACHNOID BLOCK)

Involves injection of LA into the CSF within the spinal canal
Position: either lateral or sitting up
Type of LA: bupivacaine 0.5% (heavy or plain)
Volume: 1.5 – 3ml depending on pt and surgical factors
Additives: may add fentanyl 10-15mcg to enhance quality and prolongs duration of
analgesia
Level of insertion: L3/4 or L4/5 (use iliac crest as reference)
Monitoring: After administration of the spinal, always monitor BP every 2.5-3 min as a drop
in BP is to be expected due to sympathetic blockade. Standby phenylephrine or ephedrine,
and load with fluids (caution fluid administration in CCF, ESRF pts)

CONTRAINDICATIONS to spinal
ABSOLUTE
 Coagulopathy: deranged PT/PTT, low
platelets
 Medications: If pt is on antiplatelets such
as clopidogrel, ticlid or anti-coagulants
such as warfarin, dabigatran
 Broken or infected skin over the area of
intended
Ccc spinal administration
 Patient
Commonly
refusalused local anaesthet Lignocaine Bupivacaine Ropivacaine
Duration of Short Long Long
RELATIVE
action (1-2hrs) (3-8hrs) (3-8hrs)
 Prev spinal instrumentation or severe
Toxic Dose 3 (7 with
back deformities e.g scoliosis 2 3
 Ongoing persistent back pain
(mg/kg) adrenaline)
 Recent positive blood cultures

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 HOW TO MANAGE EMERGENCE
LMA
 Usual practice is to keep LMA insitu and send patient to PACU
 Turn up FiO2 to 100% at high flows when op is over (to wash out volatile anaesthetics)
 Establish spontaneous respiration
 Turn off volatile agent (just before transferring)
 Before disconnecting from circuit and pushing pt out to recovery, ALWAYS:
- Establish spontaneous respiration
- Regular RR (>8)
- Adequate tidal volumes >200mls
- SpO2 > 98%
 When would you remove LMA in OT?
- If pt has loose dentition and you would like to ensure atraumatic removal
- Pt has brittle airway (e.g. keeps going into laryngospasm/bronchospasm easily)
- Consultant preference

ETT
 Turn up oxygen to 100%
 Turn off volatile agent
 Turn up oxygen flows to > 8L/min to wash out the anesthetic gas
 Suction oral secretions
 Ensure bite block inserted (not required for edentulous pts)
 Give reversal agents
o Neostigmine (2.5mg)
o Atropine (0.9mg) OR glycopyrrolate (0.4mg, if tachycardia undesirable or in
elderly)
 Avoid stimulation when pt is in Stage 2 of anaesthestic plane
 Common problems encountered during extubation/emergence
o Patient is “croaking”! (laryngospasm)
 Often occurs because pt is stimulated (e.g. secretions, transferring)
during a light plane of anesthesia
 Management: High flow 100% oxygen with CPAP, stop stimulation,
Larson’s manoeuvre (press hard with finger against mastoid process),
consider small propofol bolus 20-30mls and sux 10-20 mg
o Patient is biting on tubing!
 Insert bite block before reversal and turning off volatile agent
 If pt has bitten  try to deepen pt (↑volatiles or give small propofol
boluses, deflate ETT cuff), then try to insert bite block once pt stops
biting
o Tachycardia
 Often multifactorial – reversal agent, pain, lightening of anaesthetics
 Unless tachycardia is sustained, usually will resolve and nothing needs to
be done. Give reversal agents slowly (over 3-5 mins) to minimise
tachycardia
 In pts with significant cardiac hx (IHD, or valvular disease) where
tachycardia may be detrimental, esmolol/remifentanil is sometimes used
during extubation

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 HOW TO ORGANISE PCA PUMPS
 SGH: Patients who have undergone major surgery will require a PCA post op. PCA
pumps are located in Recovery 2 behind the nurse’s station.
 There are 2 types of PCA pumps; CADD and Solis
 CGH: Just ask our friendly AU nurse and the pumps will be brought to you. CGH
uses the B-Braun pumps
 PCAs can be fentanyl or morphine based
 The passcode for the respective pumps is indicated at the back of the pumps/check
with recovery AU nurses
o MORPHINE:
 Preparation dilute 5 vials of morphine in NS to make up 50mls total
vol (1mg/ml)
 Setting: 1mg per bolus, 5 min lock out time, no basal infusion, 6-
10mg/hr limit – depending on patient factors (lower limit for elderly,
CRF)
o FENTANYL
Preparation: Dilute 5 or 10 vials of fentanyl in NS to make up 50mls
total vol (dilution can be 10 or 20mcg/ml)
 Setting: 10 or 20mcg per bolus, 5 min lock out time, no basal infusion,
100-200mcg/hr limit
 Order the PCA pump on the IMR so that the APS can review the pt in the ward the
following day. There are templates under the anesthesia dept

B-BRAUN (below) – load a

prediluted 50ml syringe of morphine
into pump
CADD – need to fill the
SOLIS – similar to CADD
chamber with 50mls of
diluted opioid.

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 ANAESTHESIA CRISES
Always call for help, following basic principles of ABC
HYPERTENSION HYPOTENSION
CAUSES: pain, inadequate anaesthetic depth, poorly CAUSES:
controlled HTN, full bladder, inappropriate pressure Hypovolaemia: dehydration, bleeding, ↓venous
cuff size, inaccurate level of IA transducer return due to positioning;
Cardiogenic: poor EF, arrhythmias
ACTION Obstructive: cardiac tamponade, embolism
Verify BP is accurate Distributive: sepsis, anaphylaxis
Treat pain, ↑anaesthetic depth
Consider anti-HTN (labetalol, hydralazine, esmolol) ACTION:
Decrease volatile agent slightly
DESATURATION Hypovolaemia: replace fluids/blood
CAUSES: airway obstruction, bronchospasm, Cardiogenic: ephedrine, consider starting inotropes
laryngospasm, bronchial intubation, pre-existing lung Distributive: phenylephrine, consider vasopressor
disease- COPD, pulmonary oedema, pleural effusion, infusion
aspiration, equipment malfunction
ACTION: increase FiO2 100%, auscultate lungs, check TACHYARRHYTHMIAS/BRADYCARDIA
ETT, check machine to find out cause TACHYARRHYTHMIAS: sinus tachy, AF/Aflut most
common
Laryngospasm: FiO2 100%, deepen anaesthetic, CAUSES: pain, inadequate anesthetic depth,
Larson’s manoeuvre – apply firm pressure to area ant hypercarbia, hypoxia, fever, hypovolaemia
to mastoid process, small bolus 10-20mg propofol, ACTION: treat the underlying cause, consider beta
small dose suxamethonium (10-20mg) if persistent blockers, amiodarone if indicated

Bronchospasm: FiO2 100%, deliver salbutamol via ACE BRADYCARDIA

(aerosol cloud enhancer) to ETT CAUSES: drug-induced (fentanyl, beta blockade,
anesthetic agents), vagal stimulation from
Atelectasis: increase PEEP, perform lung recruitment peritoneal/eye/neck traction
ACTION: stop surgical stimulus, atropine 0.3mg or
glycopyrrolate 0.2mg

21 | P a g e
 HOW TO MANAGE PATIENTS IN PACU

- Accompany the transfer of patients, ensure pt is breathing (if LMA insitu) by looking for chest
rise and fall, feeling for breath over the LMA
- Upon arrival, administer oxygen via Hudson’s mask or connect T-piece (if LMA) + apply monitors
- Summarise and hand over cases to the recovery nurses. Your summary should include:
o Nature of surgery
o Type of anesthesia performed (GA, block given etc)
o Intraoperative analgesia used
o Intraop issues if any: e.g. refractory hypotension, tachycardia
o Pt issues: loose teeth, drug allergies, AVF (in ESRF pts), breast surgery (implications on
BP monitoring)
o Disposition: GW vs HD/ICA, management of lines (in SGH only patients going to ICA
facility can keep their IA line)

PACU stands for Post Anesthesia Care Unit. Patients are being monitored on a 1:1 or 1:2 nurse to
patient ratio in the recovery area. Their vital signs are being monitored and charted Q5min. In
general, patients are kept in PACU for 30mins and if they fulfil the discharge criteria, they can be
discharged back to their designated wards. Most PACUs have discharge criteria to guide the nurses
and doctors on when a patient is fit for discharge. The 2 most commonly used ones are the Modified
Aldrete (see below) and the modified Post Anesthesia Discharge Scoring System (PADSS). In SGH

MODIFIED ALDRETE SCORING SYSTEM (A score of ≥ 9 indicates readiness for discharge)

22 | P a g e
 Left: SGH PACU discharge criteria,
Below: CGH PACU discharge criteria (PADS)

The job as a recovery MO (either as a residency posting or as the most junior MO oncall) is
to troubleshoot these problems, ensure patients are safe at all times and optimise them
prior to discharge. There is an anesthetic trolley with common drugs available for use in
these patients. ALWAYS check patients’ history and anesthetic chart for intraoperative
events and drugs that have been given, to avoid overdose.

PACU protocols
1. Nurse-controlled analgesia (NCA) protocol
2. APN discharge protocol

23 | P a g e
 Common Problems encountered in patients recovering in PACU
PROBLEM Thought Process SOLUTION
Ascertain site of pain, check intraop IV Morphine, fentanyl, pethidine, IV/PO
Pain chart and supplement with more paracetamol, PO naproxen
analgesia.
Exclude hypotension in patients who Can give ondansetron (up to 0.1mg/kg) ,
Post op nausea and
have received neuraxial blocks (e.g. metoclopramide, dexamethasone
vomiting (PONV)
spinal/CSE or epidural).
Common causes: airway Increase oxygen supplementation, oral airway,
obstruction, pulmonary congestion, support jaw. May need support with a T-piece or
Desaturation
atelectasis, mucus plugging, non-invasive ventilation (NIV). NIV is available in
bronchospasm, pneumothorax – esp the front cubicles of recovery. Order CXR,
after central line insertion May need reintubation if all above measures fail.
Rule out secondary causes of Treat with oral or IV anti-hypertensive agents
hypertension (e.g. pain) (PO amlodipine, IV labetalol 2.5-5mg boluses or
IV hydralazine 2mg boluses). If the patient did
Hypotension/
not take their morning anti-hypertensive, you
hypertension
may consider serving their usual meds by
obtaining from pharmacy (need to fill up a green
form)
Exclude pain, electrolyte Treat pain
disturbances (can do istat) Correct electrolytes
Tachycardia, Check patient’s baseline ad intraop Check cardiac enzymes and do 12 lead ECGs
bradycardia HR If fast AF, may consider amiodarone, beta
Tachyarrhythmias or blockers (inform primary anesthetist)
cardiac events If NSTEMI suspected  inform surgical team
and pri anesthetist, consult on call CVM reg
early
Causes: residual anesthesia, Check ABG for PCO2, hypocount, Flumazenil or
Persistent opioid/benzo overdose, CO2 naloxone if overdose is suspected
drowsiness narcosis, CVA, hypoglycaemia,
incomplete reversal
Hypothermia/ Exclude convulsions IV pethidine 10-20mg or tramadol
Shivering Bair hugger, warmed fluids
Pain, full bladder, hypoxia, Treat the underlying cause (analgesia,
hypercarbia, polypharmacy, pre- catheterise to empty bladder, orientating cues –
existing dementia explain to patient in a famililar language,
Post op delirium provide hearing aids/visual aids, allow family
member to come into recovery.

IV Haloperidol 2.5mg boluses (titrate to effect)

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 PACU CRITICAL CARE (PACC) ADMISSION GUIDELINES
& WORKFLOW (SGH)

PACU patients may be converted to PACC status at the discretion of the Sr/Nurse in-charge in the
following scenarios:
- PACU stay > 2h due to delay in medical fitness for discharge
(except for prolonged stay due to Pain/PONV with no CNS/CVS/Respiratory compromise)
- Awaiting ICU bed
- Deterioration requiring intubation and/or continuous inotrope infusion for
cardiorespiratory support

Admission Requirements Patient Exclusion

Interval organ support  Immediate post-operative
 Patients requiring airway/ventilator support (extubation requirements
aimed for within 6 hrs) o Inotropes other than
 Dopamine (Max 10mcg/kg/min) Dopamine(max 10mcg/kg/min)
o Isolation nursing e.g. those on
Intensive monitoring due to droplet precautions, Multi Drug
 Patient /Surgical factors Resistant Organisms, VRE etc.
o ASA 3, moderate to high surgical risk o Initiation of dialysis
o Obstructive Sleep Apnoea or surgery with airway concerns o Initiation of Chemotherapy

 Significant intraoperative events with rapidly reversible

 Surgical Discipline
sequelae such as
o Cardiac surgery
o Respiratory events
o Neurosurgery (except for spine
o Transient hemodynamic instability
surgery)
o Transient arrhythmias, ST changes
o Blood Loss up to 20% total blood volume
o Prolonged surgery (≥6h) with significant fluid shifts
o Drug Reactions

Consider ICU admission for patients if physiological

derangements are severe enough to require more than 12
hours of PACC stay

Planned (Elective/Remote) Unplanned

Booking by Anaesthetist @0830h - EOT/Elective/Remote
morning of surgery

Inform PACU Nurse-in-charge

Confirm Bed Availability

25 | P a g e
 END OF SURGERY
Anaesthetist to complete PACC admission form
Indicate on Citrix, medications to be given in PACC

Theatre/Floater Nurse to collect Stryker Bed from SDA SRS cubicle 28 &29

Admission to PACC

Review 4 hourly by Primary Anaesthetist /EOT Registrar (after hours)

and Surgical Team (if surgical concerns) for discharge

Consider ICU admission Stable for discharge to ICA/HD

If condition not improving / deteriorating (Surgical Team to arrange bed)

Anaesthetist to complete PACC discharge Anaesthetist to complete

form and ICU admission form PACC discharge form

ICU ICA/HD

CONVERSION OF PACU STATUS TO PACC

PACU patients may be converted to PACC status at the discretion of the PACU Sr/Nurse in-
charge IF
- PACU stay > 2h due to delay in medical fitness for discharge (except for prolonged
stay due to Pain/PONV with no CNS/CVS/Respiratory compromise)
- Awaiting ICU bed
- Deterioration requiring intubation and/or continuous inotrope infusion for
cardiorespiratory support

BED AVAILABILITY
4 Beds: 8am – 8pm
2 Beds: After 8pm

26 | P a g e
 HOW TO DO POST OP REVIEWS (SGH)
All patients whom you have provided anesthesia for should be reviewed either by visiting
them in the wards or giving them a call the next day (if already discharged or ASC pts).
Patients on PCA will be reviewed by the acute pain team. Feedback is important for
improvement and picking up complications early.

THINGS TO LOOK OUT FOR

GA: PONV/sore throat/sedation level/IV cannulation sites for phlebitis
RA: numbness/weakness/injection site
Pain score: on movement and at rest
Any other concerns pertinent to events that happened during surgery; satisfaction scores
May consider adding anti-emetics or analgesia to optimise post op care

HOW TO CREATE APS FORMS

Click on Flowsheets tab >> Click on ‘+’ button> type ANA>>create Acute pain service form >>
Right click to add single time column>> fill up the respective parameters >> save

27 | P a g e
 ANAESTHESIA SERVICES
 Major OT
 Day surgery
 Pain service
o Acute pain : see below
o Chronic pain: Our dept runs a regular Pain Clinic. All chronic pain cases are seen
on a referral basis at these clinics. MOs may be rostered to the pain clinic to
assist the pain specialist.
 Cardiac Anesthesia (SGH)
o Dr Kenny Loh is the director of cardiac anesthetic service. The daily cardiac list is
rotated amongst the cardiac anesthetists: A/Prof Ong Biauw Chi, Prof Hwang
Nian Chih, Dr Leong Choy Kuen, Dr Goh Meng Huat, Dr Ruban Poopalalingam,
Dr Kong Chee Fai, Dr Sophia Chew, Dr Harikrishnan, Dr Shital Kumar, Dr Suneel
Ramesh, Dr Jerry Tan and Dr Priscilla Phoon. As a new anesthesia MO, you are
unlikely to be assigned to a cardiac list until nearer the end of your posting with
us. However, you may be asked to help with premeds. If rostered to the cardiac
list, please check with the consultant-in-charge regarding pre-operative
preparation of the patient and OT preparation.
 SICU
o When you are assigned to SICU, you should familiarize yourself with the various
ICU protocols and work processes (including admission and discharge paper
work). SICU consultants include:

28 | P a g e
  SGH: Dr Ng Shin Yi (director), Prof Lim Boon Leng, Dr Chee Huei Leng, Dr
Andrew Kong, Dr Sharon Ong and Dr Lee Pang, Dr Ho Vui Kian, Dr Lie Sui
An, Dr Suhitharan and Dr Claudia Tien.
 NICU (SGH)
o Our department provides consultant coverage. You may be rotated to NICU for
a week during your posting. There are no calls during your week in NICU but
you are expected to round on weekends and handover to the fellow
neurosurgical MO. The NICU consultants include: Dr June Goh, Dr Tan Tong
Khee, Dr Sharon Ong and Dr Andrew Kong and Dr Jolin Wong.
 BICU (SGH)
o The Burns ICU is located within the burns ward (W43). You may be rotated to
the Burns ICU/OT for one week during your posting. You are expected to come
back for weekend rounds and burn emergencies out of hours. The burns
consultants are: Prof Tay Sook Muay, Dr Gregory Meredith, Dr Yew Woon Si and
Dr Chong Shin Yuet.

TEACHING & TRAINING

Be eager to learn and be humble. Tip: Pick up a textbook or get seniors’ notes to read up
before the list so you can manage the patient appropriately. You can also ask questions and
discuss the cases with your consultant, which will create a good impression. You will also
remember the facts better as it is relevant to the patients you will be managing.

1. WEEKLY STRUCTURED TEACHING PROGRAMME

Look at the weekly roster for scheduled teaching sessions for the week. These are held
between 715-815 am, with occasional lunch talks from 12-1pm. It takes a lot of effort to
prepare for these sessions, so please support your colleagues and broaden your
knowledge.

2. INTRODUCTORY LECTURES FOR NEW Residents/MOs

These are held in the 1st month of the posting for all Residents/MOs who have no
previous experience in anaesthesia or who did not work in anaesthesia just prior to this
posting. At the end of the series of lectures, there will be a written test and viva.
Practical skills will also be tested.

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 IT GUIDELINES
OTM
A system for checking of scheduled elective lists, capturing of anaesthetic data and
generating a log of cases performed. ALL cases involving an anaesthesiologist must be
entered into the system

SUNRISE
A system capturing and documentation of patients’ hospitalisation summary, tracing of
patients’ investigations, results and bed location

AIMS (SGH)
AIMS is an electronic intraoperative charting system adopted by SGH Anesthesia
department. You need to attend a user training session, to learn how to key in the relevant
anesthetic information for patients that you provide anesthesia for. The user password is
the same as Citrix/Windows login (domain is SHHQ)

E-mail
All staff are to access their MOHH e-mail account regularly for on-call roster, weekly roster,
teaching programs, MOPEX results and other important notices.

Social Media
Please use social media responsibly. Posting comments on patients, colleagues and hospital
policies is unprofessional and may infringe on patient’s right to confidentiality

Critical Incident Reporting

If there are any perioperative adverse events or unplanned ICU admissions, your consultant
may ask you to file an incident report online (RMS – Risk Management System)
anonymously so that the department can discuss these reports during the monthly Incident
Report meeting, as an ongoing quality improvement process

How to access (SGH) Singhealth intranet > IT applications > Risk Management system (new)
 same login details as Citrix/Windows.

CGH: there is an AIMS form on most of the desktops in the anesthesia MO room computers.

30 | P a g e
 ROSTER ISSUES
• CALLS • PREMED COVER • LEAVE •

 A stay-in call starts at 0830 and ends at 0830 the next day. Report to the EOT and to the
stay-in specialist at 0815, so that a handover of ongoing cases can be done. This will
ensure that the post-call team can leave on time at 0830.

 All call requests should be submitted by the 10th of the preceding month. The tentative
monthly call roster should be ready by the 15-20th of the preceding month.

 SGH: Please logon to workforce optimizer to make your call and leave requests.

 Please prioritise requests. A maximum of 3 requests (call or no-call) will be entertained.

 All Sundays and Saturdays are weekend calls while Mondays to Fridays are weekday calls
and they will be divided equally as far as possible in the tentative roster. Everyone is
free to make mutual exchanges, with the exception of compulsory assigned calls. These
changes must be done by the 23rd to facilitate the completion of the final roster by the
26th.

 All call exchanges must be between MOs of similar experience level, so that no on-call
team will end up with 2 junior MOs. Should a swap be made after the roster is finalised,
it is a courtesy to inform the specialist-on-call and the roster planner. MOs in CGH
should always inform the roster maker (Dr Jimmy Lim) for permission before making
ANY mutual swaps as there are other factors that need to be taken into consideration.

 SGH: everyone goes back to see their own premeds on Sunday, with the exception of
the Sat and Sunday on call team, senior residents and those on leave. There will be a
premed team rostered to cover premeds for these people. Cover for the postcall team’s
premeds will be arranged by the MO1 on call the following day.

RESPONSIBILITIES OF THE MOST JUNIOR MO ON CALL

 SGH:
o Pain Rounds + Recovery: If your call is a Sat/Sun call, you will need to do
pain rounds. If it is a weekday call, there is usually a pain and recovery
MO during office hours, in which case you will run L4 with the EOT
consultant till 5pm, then cover recovery after that. In the event that there
is no recovery/pain MO on that day, you will need to cover their duties.
o Food minister: It is your responsibility to distribute lunch coupons to each
OT if there is no recovery MO. (Lunch coupons can be obtained from the
anesthesia office from Anisha the secretary). You will also need to
arrange dinner for the on call team.
o Check blood: It is your duty to check the blood for the cardiac bloods in
the morning. They are stored in the blood fridge just across the staircase
(leading up from MOT change room). This involves checking the blood
cards against the blood packs (do not sign on the cards).

31 | P a g e
 LEAVE
 SGH:
Submit request at workforce optimizer. It would be helpful to put your reason for leave
application such as conference leave, wedding etc, to help the roster master prioritise
correctly.

 Those who intend to take long annual, study or exam leave should inform the roster
monster as early as possible with the exact dates ascertained.

 If you are on leave/MC, please inform the MO1 assigning the premeds that you are on
leave/MC so that the MO1 can assign someone to cover your premeds. Otherwise, you
may have to return to see your own premeds.

 Leave is usually granted based on priority and whether leave forms are submitted. In
general, professional reasons supercede social ones (e.g. Anaesthesia exam > Wedding
>Other exams > Holiday). The first-come-first-served principle will otherwise be applied.

MEDICAL CERTIFICATE (MC)

 Please inform the Roster Maker (SGH) on the morning that you are unwell before 730
am so that coverage for your OT can be arranged. Please also inform the senior staff you
are with and the MO assigning premeds.

 MCs are to be submitted to the department secretary/AA. Failure to produce a medical

certificate would result in the medical leave being considered as annual leave.

WEEKLY OT ROSTER
 The weekly roster will be printed out by the end of the preceding week. It indicates the
on-call team for a particular day of the week as well as the daily distribution of the staff
(senior and MOs) into the various areas of work. MOs whose OT list finishes before 1530
hrs are to report to Roster Maker (SGH) for further instruction.

 Please check the Weekly OT Roster for any errors (e.g. name missed, or should not have
been rostered etc) and inform the Secretary (SGH: Shu Fang) immediately.

32 | P a g e
 EDUCATION RESOURCES
The department has a collection of anaesthesia, critical care and basic sciences related
books kept in the Anesthesia Conference Room. Journals can also be accessed online from
the Singhealth Online Library.

Recommended reading list for new Medical Officers:

1. Clinical Anaesthesiology Morgan &Mikail

2. Clinical Anaesthesia Procedures Kenneth Davison et al

of the Massachusetts General Hospital
3. Textbook of Anaesthesia A R Aitkenhead

4. Guide to immediate Anaesthetic Reaction J Watkins

5. Essentials of Anaesthetic Equipment B A-l- Sheikh

6. Manual of Anaesthesia Lee Choon Yee

Recommended anesthesiology and ICU websites

1. www.anaesthesiauk.com
2. www.asahq.org/
3. www.anzca.edu.au/
4. www.ccmtutorials

33 | P a g e
 SURGICAL INTENSIVE CARE UNIT (SICU)
SGH
SICU is located opposite the MOT on block 3 level 2. There are 10 beds available. There is
also a CTSICU (run by CTS), Ward 52 NICU (run by anaesthesia and neurosurgery), Ward 43
BICU (run by anaesthesia)

The telephone extensions to the area are:

SGH
ICU 4222
SICU MO shares the same OT call room as the OT on call team (on level 3 within MOT
complex, stairwell next to M5)

General Duties of MOs in SICU

 The rotation for MOs varies from 2 to 4 weeks
 During office hours, the consultant will distribute the SICU patients to be seen. All
relevant information pertaining to the patient’s condition should be available before the
morning round.
 The post call MO will present the cases during the morning hand over round, and can be
dismissed only after changes have been done.
 Daily hand overs will occur at 8.30 am and 4 pm, with the exception of PH and
weekends, where only the morning hand over round is conducted. The on call
anaesthesia team is expected to attend the afternoon handover rounds during
weekdays, and the morning handover during weekends/PH.
 The on call MO will attend to unstable patients in the HD if requested by the nurse in
charge after office hours, while the surgical team on call is being contacted.
 The SICU team will respond to requests for emergency airway management from other
Departments according to hospital policy.

Criteria to fulfill before ICU posting:

 Should have completed BCLS, ACLS and FCCS course
 GS MOs should attend the SICU topics with the Anaesthesia MOs
 Participation in ICU case or topic presentations, trauma rounds and ID rounds is required
 ICU guidelines and protocols are available at the nursing counter. Please refer to these
documents when in doubt. Topics include inotropic dilution, CRRT, vasopressin use in
septic shock, HOTA

Documentation
 All patients’ case notes should be kept up-to-date, including the admission summary,
laboratory results forms, etc. Much of the notes keeping involve filling in blanks as guided
by the various organ systems, do not omit data unless it is irrelevant.

34 | P a g e
 All entries into the casenotes, patient assessment, IMR, patient admission notes should be
legibly initialled and dated as hospital policy.
 Please be proactive to complete APACHE form early. Upon patient discharge from SICU, the
photocopied APACHE form should be kept in the SICU file.

Mortality
 The SICU MO will summarise the case notes of patients who die in ICU within 24 hours of
admission. However, for coroner’s cases, the summary has to be done immediately by the
on-call MO because the case sheet will be dispatched to the coroner.
 All Mortalities have to be presented during the monthly M & M session. The relevant
softcopies should be obtained from the respective department Secretary for this purpose.
All presented M&M reports should be passed to secretary for archiving.

Communication
 Information regarding patient’s condition should only be communicated to 1or 2 next-of-
kin/immediate relatives/guardians/friends as the case warrants. Telephone communication
is discouraged.
 Consultation with doctors from other departments must be prompt and clear.
 All forms of communication must be well documented.
 Consent for procedures should be obtained as per hospital policy.

35 | P a g e
 ACUTE PAIN SERVICE (APS) – GENERAL PRINCIPLES
CADD Solis: press reports >
PCA morphine/fentanyl dose and usage

 Assess pain levels (commonly use the numerical pain score 0-10) CADD legacy: press the NEXT
button until you reach number
 Note down the cumulative dose which patient has used of doses given (do not record
 Assess for side effects of opioids the number of doses
attempted)
o Drowsiness/respiratory depression
o Urinary retention Graseby: press history button

o Nausea/vomiting – ensure ondansetron 4mg TDS +/- metoclopramide

 Consider adding supplementary analgesia
o If pain not optimised, review whether you can add on other modalities of
analgesia. We should attempt to ensure all patients are on paracetamol to
reduce opioid requirements unless contraindicated
o Paracetamol (IV or PO) – some pts will still be kept NBM, check with team if
oral meds can be allowed before prescribing IV paracetamol and limit it to 1-
2 days with instructions to switch to oral once allowed
o NSAIDS/COX2 – check for contraindications: gastric bleeding, renal
impairment, allergy, spine surgery etc. Check for history of heart
problems/recent CABG before prescribing COX2 inhibitors
o Tramadol – contraindications include epilepsy. Reduce dose in renal and liver
impaired. Do not prescribe if pt on MAO inhibitors
o Gabapentin – discuss with senior before starting
o Some chronic pain patients may fall into your scope of acute pain after they
go for surgery (e.g. chronic wounds requiring repeated operations to
debride/VAC/SSG) – these patients have a higher analgesic requirement
generally due to chronic opioid use. Consult with reg if unsure of what to add
for these cases. Inform the chronic pain team so that they can review their
chronic pain meds.
 When to stop PCA:
o Can consider taking out PCA when patient is POD 2-3, ambulating well, taking
orally
o Minimal usage
o Patient refusal
o Patient getting discharged
o Remember to discuss with patient about taking away the PCA – some may
think you are taking away their only source of analgesia otherwise
o Discontinue the PCA order in the system after you have filled up the APS form

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Epidurals

 Let the ICU reg on call know where the patients are
 Get the ice block from the fridge in the ward
 Things to note when looking through patient file
o What op, how many days postop (and thus how old is the epidural catheter)
o Inserted at which level, how many cm in situ
o BP trend – any hypotensive episodes
 How to assess patient
o Pain score, any side effects of opioids (if there is fentanyl in the infusion),
headache
o Using ice block, test loss to cold sensation to see which dermatomes are
covered – it should adequately cover the length of the wound
o Any motor block – if profound, may need to speak to reg and consider
reducing infusion concentration
o Look at catheter site 1) whether any signs of infection which necessitates
removal 2) catheter marking – whether it has moved 3) whether a dressing
change required
o If the block is patchy or doesn’t exist, inform reg to troubleshoot. Do not
inject anything into epidural space by yourself.
o Usually need to plan to remove by D4-5. PT/PTT and platelets need to be
checked and corrected before removal, esp if they are on anticoagulants, or
are septic etc. Clexane needs to be stopped for 24h before removal.
 Post labour epidurals
o These women will usually be in W53 after delivering their baby
o Ask about PDPH, urinary retention, motor blockade, patchy or insufficient
block, back pain (symptoms of infection/epidural abscess) and address any
other concerns they may have
o If there are any major problems, need to alert the ICU specialist-on-call and
the doctor who inserted the epidural

Perineural infusions

 These commonly include brachial plexus blocks for hand surgeries

 How to assess patient
o Similar to epidurals, check whether catheter has migrated
o any signs of infection that necessitate removal
o loss to cold sensation
 Ward nurses can call you to top up the epidural/perineural infusions – check the
order in Citrix and ensure you have the correct concentration, dosage, additives
carefully

37 | P a g e
 ACUTE PAIN SERVICE (SGH)
WORKFLOW
The acute pain team consists of acute pain nurses Er Biaw Thean, Jeslyn Foo, Januari Tan,
the acute pain MO if there is a resident assigned to pain block, and the MOs from PEC who
have been sent to help with pain rounds (usually all but the 1 st name on the roster). On
Mondays, there will also be a reg who may see the more complicated patients with you. For
any issues with epidurals/complicated patients requiring consultation, the pain MOs may
call the ICU reg on call.

Pain rounds start at 830am (gather in the Anaesthesia office at 8am to distribute the work).
Remember to go to the labour ward on Block 5 Level 2 to get the post-epidural forms too.
The PEC MOs should be allocated no more than 5-6 patients as they have to go back to clinic
at 930 am.

Weekend Postop Rounds

On Saturdays, MO4 and those who are rostered will do the round. The list of patients to be
seen includes both Acute Pain Orders and Postop Follow-ups. On Sunday, MO3 will do the
acute pain round alone.

DOCUMENTATION
How to generate pain flowsheet
 Go to File>> print reports>> Acute Pain Orders
 This list will have PCA morphine, PCA fentanyl, epidurals, continuous perineural
infusions, single shot injections
 Charge forms: Take the charge form from the anesthesia office and paste a patient
sticker for everyone you saw after the round, return the charge form to SICU counter
drawer
 Post epidural forms have to be filled up both in the patient file and on the carbon
copy. Return the carbon copy to SICU labour epidural file.

Similar to post op reviews,

Click on Flowsheets tab >> Click on ‘+’ button>> type ANA>>create Acute pain service form
>> Right click to add single time column>> fill up the respective parameters >> save

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 PREOPERATIVE EVALUATION CLINIC (PEC.SGH)

This is the equivalent of the PAAC in CGH. It is located between block 5 and 3 level 1 just
beside the Specialist Outpatient Clinics. The PEC MOs are expected to report at 830 am.

The sister will usually give you a quick brief before you start. We use the outpatient 1 queue
system to facilitate work flow. Feel free to ask the nurses about any workflow problems. If
you have any queries regarding patient care, there is a daily PEC blue letter consultant and
often a senior resident as part of the team.

Steps before seeing patient:

Take a patient blue file from the nursing station

Log on to outpatient 1 queue system
Screen the patient details from Citrix/ OTM - Look at HIDS, blood tests, CXR etc
Look at ECG attached and sign.
Open up the anaesthetic assessment form by clicking ‘documents’ > ‘create new’ > type
‘A’ > ‘anaesthetic assessment V2’

During the consult:

Ask questions as per anaesthetic assessment

If you foresee that regional technique is an option, can counsel on both GA and RA
Forewarn that op may be cancelled if they are having URTI symptoms – call up and inform
us
You can make referrals to dentist, OPS for hypertension/diabetes control, cardiology if
there are abnormal physical findings/ECGs
If unsure, consult Dr Eugene Chin, the senior consultant who works at PEC or other senior
staff assigned to PEC on that day. Inform the senior anaesthetist of any patients with
potential issues, e.g difficult airway when the roster is out – the sister will get you to paste
a sticker in a file for tracing and the PEC MO will follow up

Hard copies of guidelines are available in every room and on intranet:

Please refer to these guidelines and adhere to them. Unexpected cancellations on the day of
surgery for patients who are not properly screened in PEC causes much unhappiness for
patient, surgeon and the senior anesthetist doing the list.

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 DRUG DOSES
DOSES IN PRACTICE
DILUTIONS CONCENTRATION
(PER KG) (BOLUSES)
INDUCTION AGENTS
Propofol 2-3mg/kg 10-20mg Neat 10mg/ml
Etomidate 0.2-0.3mg/kg Neat 2mg/ml
0.5mg – 2mg/ kg 5-10mg
Ketamine 1ml (contains 50mg) dilute to 10mls 5mg/ ml
(induction) (analgesia)
Thiopentone 3-7mg/kg 0.5mg dilute to 20mls 25mg/ml
SEDATION
0.05-0.15mg/kg 1-2mg
Midazolam Neat 1mg/ml
(co-induction)
Loading: 0.5-1mcg/kg over 20mins
Dexmedetomidine
Maintenance: 0.2-0.7mcg/kg/ hr
INHALATIONAL AGENTS
Sevoflurane 2.0% (MAC in 100% Fi02)
Desflurane 6.0% (MAC in 100% Fi02)
Isoflurane 1.15% (MAC in 100% Fi02)
OPOIDS
Fentanyl 1-2 mcg/kg 25-50mcg Neat 50mcg/ml
Morphine 0.1-0.2mg/kg 1- 2mg 1ml (contains 10mg) dilute to 10mls 1mg/ml
TCI (minto) 0.5 – 5 ng/ml 1-2mg dilute to 50mls 20-40ug/ ml
Remifentanil
non TCI: 0.02-0.2 mcg/kg/min
MUSCLE RELAXANT
Suxamethonium 1-1.5 mg/kg Neat 50mg/ml
bolus: 0.5 mg/kg 10-20 mg Neat 10mg/ml
Atracurium
infusion: 0.3-0.6mg/kg/h
Mivacurium 0.15 mg/kg Neat 2mg/ml
Rocuronium 0.6-1.2 mg/kg 10-20 mg Neat 10mg/ml
REVERSAL AGENTS
Neostigmine 0.03mg-0.05mg/kg 2.5mg Neat 2.5mg/ml
Glycopyrollate 200-400mcg Neat 200mcg/ml
Atropine 0.015- 0.02mg/kg 300-900mcg Neat 600mcg/ml
2mg/kg (TOF = 2)
Suggamadex 4mg/kg (PTC = 1-2) Neat 200mg/2ml
16mg/kg (immediate)
LOCAL ANAESTHETIC
3mg/kg (toxic dose) w/o adrenaline 0.25% = 2.5mg/ml Duration:
Lignocaine
7mg/kg (toxic dose) w adrenaline 0.5% = 5mg/ml 1-2 hours
Ropivacaine 3mg/kg (toxic dose) 1% = 10mg/ml 3-8 hours
Bupivacaine 2mg/ kg (toxic dose) 2% = 20mg/ml 3- 8 hours
ANTI-EMETICS
Ondansetron 4-8mg Neat 2mg/ ml
Dexamethasone 4-8mg Neat 4mg/ ml
Metochlorpromide 10mg Neat 10mg/ 2ml
DRUGS FOR HYPOTENSION
3-5mg 1ml (contains 30mg) dilute into 10mls 3mg/ ml
Ephedrine
1ml (contains 30mg) dilute into 6mls 5mg/ml
50-100mcg usually premixed by pharmacy 100mcg/ml
Phenylephedrine
1ml (10mg/ml) dilute into 100mls
0.01- 0.2mcg/kg/min 10mcg Infusion: 2-4mg/ 50mls NS solution 0.04-0.08mg/ml
Iv bolus: 1ml (1mg) dilute to 10mls 100mcg/ml (1:10,000)
Adrenaline
Iv bolus: 0.1ml (100mcg) dilute to 10mls 10mcg/ml (1:100,000)
Block: 0.1ml (100mcg) dilute to 20mls 5mcg/ ml (1:200,000)
Noradrenaline 0.01-0.2mcg/kg/min Infusion: 2-4mg/50 mls D5 solution 0.04-0.08mg/ml
Dopamine 2-20mcg/kg/min infusion: 200mg in 50mls NS solution 4mg/ml
Dobutamine 2-20mcg/kg/min infusion: 250mg in 50mls 5mg/ml
Vasopressin 0.2-2.4 U/hour
infusion: 20 U in 20mls NS solution 1U/ml
0.01- 0.04 U/ min
DRUGS FOR HYPERTENSION
Esmolol 0.5mg/kg 5-10mg Neat
Labetalol 2.5-5mg Neat
Hydralazine 2.5- 5mg Dilute 20mg in 20mls
5-200mcg/min
GTN infusion: 30mg in 30mls 1mg/ml
5-20mcg/kg/min
ANTIDOTES
Initial: 1.5ml/kg (1min) Give max of 2 repeat bolus doses
Intralipid 20% Maintenance: 15ml/ kg/ h Continue infusion at rate or double it to 30ml/ kg/ hour
Not exceed 12ml/ kg cumulative dose
Dantrolene Initial: 2.5mg/kg 9 vials for 70kg
ACLS
Bradycardia Atropine 0.6-2.4mg
Hypotension Adrenaline 1mg
Amiodarone 150-300mg (ensure no long QTc)
Wide complex Tachycardia
lignocaine 50-100mg
Defibrillation VF/pulseless VT : 150-200J Biphasic or 360J Monophasic
EMERGENCIES
Fluids
Adrenaline 50-100mcg titrated to effect
Anaphylaxis
chlorphenamine 10mg
hydrocortisone 100-200mg
Jaw thrust
close APL to inc PEEP
Laryngospasm
Deepen with propofol/ inhalational agents
KIV suxamethonium 0.25mg/kg
Calcium Gluconate 10% 10mls
Hyperkalaemia
Insulin 10units/ 40mls dextrose 50%
Hypoglycaemia 20-40mls dextrose 50%

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 Blood List Workflow (SGH)
Clerk from W56 to fax to BBL (around 12pm-1pm) the ‘List of Operations
Requiring Blood’ filled up and signed by MO
(2 Copies: 1 NHCS, 1 SGH-MOT)

Blood List approved by blood bank lab will be fax over back to:
1. NHCS OT
2. SGH MOT

7a.m. PACU HCA will take along the approved blood list which was fax from BBL
at the NHCS OT Reception. He goes to Blood Bank Lab to collect approved blood.
Blood Box will be supplied by Blood Bank Lab.

Blood arrived will be checked & placed into the Blood Fridge by NC in-charge of
PACU.
She will document in the Elective Blood record book the number of units
received and signed.

AU-Dr(MO) assigned to CTOT 1 is responsible to check blood in Blood fridge on

the day of surgery.

7 p.m. General Porter will collect all unused blood together with the blood box to
return to Blood Bank Lab.
Upon arrival of General Porter, PACU staff to place blood into the Blood Bank Lab
Box and hand over to General Porter.
PACU staff will document into the Elective blood book the no. of units of blood
returned and signed in the record book.
Blood that needs to be retained because surgery is still in progress after 7pm will
be returned by PACU staff to Blood Bank Lab using department blood box.

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Map of the Main Operating Theatre

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Map of Route to OT Change Room
Block 5
Lobby

OT Change
Room

From MRT

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