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."

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