2024.1 Day 1 VIVA 6

General Anaesthesia and Sedation

The patient you have asleep on the table is a 60-year-old man who is having a bilateral laparoscopic inguinal hernia repair. Past medical history: Transient Ischaemic Attack – 2 years ago; Diet-controlled Type 2 diabetes. Medications: Aspirin 100mg mane, Perindopril 5mg mane, Atorvastatin 40mg nocte. Allergies – Nil. Prior to the operation, the patient reported he took a long time to wake from a previous anaesthetic for shoulder surgery.

Please discuss the intraoperative monitoring you will you use for this patient?

Standard Monitoring (ANZCA PG07):

• ECG: TIA → arrhythmia detection critical.

• SpO₂/NIBP/Capnography/Temp → essential per guidelines.

• Capnography particularly relevant for laparoscopy (↑ CO₂ → respiratory acidosis risk).

Advanced Monitoring:

• TOF

  • Essential due to prior delayed emergence + risk of bradycardia from pneumoperitoneum.

  • Scenarioville has no ICU → residual paralysis dangerous.

• BIS/EEG

  • Consider for depth titration.

  • Not routinely available (Scenarioville lacks BIS; rely on clinical signs).

• Art Line?

  • Not indicated unless intraop instability arises (e.g., prolonged hypotension, significant cardiac history).

Common Pitfalls:

• Not using TOF → residual NMB in post-op recovery (→ airway risk).

• Ignoring ETCO₂ drift → may miss CO₂ retention.

Why is TOF monitoring non-negotiable?

Delayed emergence in past → may indicate pseudocholinesterase deficiency or inadequate reversal.

• Laparoscopy: vagal stimulation → bradycardia → unopposed without full reversal.

• No ICU: reintubation post-extubation difficult + unsafe.

What if BIS is unavailable?

• Use HR/BP/eye signs/movement → titrate volatile agents accordingly.

• Consider gas concentration trends, MAC-age adjustments.

What are the resource-specific considerations in Scenarioville?

• No BIS, no ICU, limited blood products (no platelets), no ROTEM.

• Must anticipate and avoid complications that require tertiary support.

• Any escalation must consider 2hr retrieval delay.

Your patient develops severe bradycardia during pneumoperitoneum. What now?

Immediate Management:

• Stop CO₂ insufflation, reduce pressure.

• Atropine 500 mcg IV (↑ HR via vagal antagonism).

• Refractory? → Adrenaline 10–20 mcg boluses.

Investigate Triggers:

• Check capnography (CO₂ embolism vs hypercapnia).

• SpO₂, EtCO₂, ECG, BP trends.

Prevent Recurrence:

• Glycopyrrolate pre-emptively in vagally-sensitive or bradycardia-prone patients.

Pitfalls:

• Delaying desufflation → ongoing vagal stimulus.

• Missing gas embolism signs (↓ EtCO₂, hypoxia, CV collapse).

What if HR remains 30 after atropine?

• Administer adrenaline.

• Prepare for temporary pacing if unresponsive and unstable.

• Start retrieval process early (Scenarioville = 2hr delay).

Mechanism of bradycardia during laparoscopy?

• ↑ Intra-abdominal pressure → peritoneal stretch → vagal activation.

• CO₂ → acidosis → further vagal tone increas

Would you abort surgery?

• Only if bradycardia persists despite desufflation + drugs.

• Otherwise, proceed at lower IAP, continuous monitoring.

TIA history relevance?

• Avoid hypotension, bradycardia → cerebral hypoperfusion.

• Maintain MAP >80 mmHg.

Patient remains apnoeic post-op. You suspect rocuronium was given instead of neostigmine. What now?

Immediate Management:

• Re-sedate with propofol to prevent intraoperative awareness.

• Re-intubate if extubated.

• Confirm with TOF (expect 0/4).

• If sugammadex available → 16 mg/kg.

• In Scenarioville: no sugammadex? → Neostigmine 50 mcg/kg + glycopyrrolate.

• Ventilate, monitor in SCU.

Psychological Considerations:

• Suspect awareness → debrief post-op.

• Arrange follow-up with mental health team.

System Fixes:

• Color-coded labels, pre-filled reversal syringes.

• Double-check protocols at drug administration.

Pitfalls:

• Waiting to “see if they wake up.”

• Not sedating while paralyzed → risk of awareness.

• Giving neostigmine with deep blockade → ineffective reversal.

Sugammadex not stocked. What’s your plan?

• Use neostigmine/glycopyrrolate.

• TOF must be ≥2/4 before admin.

• Prolonged monitoring in SCU (no ICU beds).

What are your discharge criteria post-drug error?

• Full TOF recovery, sustained SpO₂ on room air, normal LOC.

• Post-event psychological screening mandatory.

Approach to Future prevention?

• Theatre drug reconciliation process.

• Simulation training for drug error drills.

Are there Any medicolegal considerations?

• Full disclosure to patient and family.

• Document event, file incident report.

• Follow-up with local governance.

Phrases Examiners Expect

• "TOF monitoring is non-negotiable due to risk of residual paralysis."

• "In the absence of sugammadex, use neostigmine only if TOF ≥2/4."

• "Bradycardia + pneumoperitoneum = stop insufflation first."

• "This is Scenarioville – no ICU and 2-hour retrieval → anticipate and prevent deterioration."