2024.2 Day 1 VIVA 8

Resuscitation and Trauma

An 18-year-old patient with a BMI of 23 has sepsis from a perforated appendix and requires an urgent laparoscopic appendectomy.

The patient’s current observations are:

• HR 120 bpm,

• BP 80/50 mmHg,

• Capillary refill 4 seconds,

• Respiratory Rate 18 bpm,

• Oxygen Saturation 96% on 2L via nasal cannulae,

• Glasgow Coma Score (GCS) 15.

Please describe your initial anaesthetic assessment and plan.

Stabilisation:

• Immediate ABCDE assessment:

  • Airway: GCS 15 → no immediate threat (but prep for RSI due to sepsis)

  • Breathing: RR 18, SpO₂ 96% → early NIV/HFNC if deteriorates

  • Circulation:

    • BP 80/50 + CRT 4s → septic shock (qSOFA 3)

    • Prioritise 2x14G IVs + IO if needed (Scenarioville has IO kits)

  • Disability: GCS 15 → no neuro sepsis signs yet

  • Exposure: Temp likely low (warm fluids/forced air warmer ready)

• Resuscitation priorities:

  • 30ml/kg crystalloid bolus (2L Hartmann’s) – but reassess after 1L

  • Noradrenaline infusion if MAP <65 post-fluid (central line preferred)

  • Bloods: Lactate, VBG, cultures, FBC/U&E/coag (Scenarioville: no ROTEM)

  • Early agressive broad spectrum antibiotics

• Anaesthetic plan:

  • RSI with ketamine 1-2mg/kg + rocuronium 1mg/kg (avoid propofol in shock)

  • Arterial line pre-induction if time (limited in Scenarioville – only 2 anaesthetists)

  • Post-intubation: Ventilate with low PEEP (5cmH₂O) to avoid RV strain

Critical Phrases:

• "RSI with hemodynamically neutral agents"

• "Fluid responsiveness assessment before bolus completion"

• "Early vasopressors per Sepsis-6"

The patient’s GCS has dropped to 10. How does this alter your immediate management priorities?

Airway:

• Immediate RSI with dual suction setup (Yankauer + catheter)

• Ketamine 1.5mg/kg (105mg) + rocuronium 1.2mg/kg (84mg) - avoids hypotension

• Cricoid pressure only if trained assistant available (risk of airway distortion)

Breathing:

• Pre-oxygenate with HFNC at 60L/min FiO₂ 1.0 for 3 minutes

• Target SpO₂ >95% before laryngoscopy

Circulation:

• Run noradrenaline through peripheral line (6mg in 50ml @ 5ml/hr) while securing central access

• Limit fluid bolus to 500ml aliquots - assess for crackles after each

Disability:

• Exclude hypoglycemia (BM check)

• Consider sepsis-induced encephalopathy vs undiagnosed head injury

Exposure:

• Active warming with forced air warmer (target core temp >36°C)

• Remove wet clothing - likely diaphoretic

Critical Actions:

• "RSI within 5 minutes of GCS drop"

• "Peripheral vasopressors bridge to central access"

• "Hypotension is not a contraindication to intubation in sepsis"

The lactate is 5.2mmol/L and the surgeon is pressing for immediate theatre. How do you reconcile resuscitation with source control?

Time-Critical Interventions:

• Administer antibiotics NOW (piperacillin-tazobactam 4.5g IV) - this is non-negotiable

• Simultaneous tasks:

  • Anaesthetist: Insert arterial line (left radial) while fluids running

  • Nurse: Draw bloods (lactate repeat, cultures, VBG)

  • Surgeon: Prep patient in parallel

Hemodynamic Targets:

• Accept MAP 60-65 for transfer (vs >65 normally)

• Titrate noradrenaline to maintain cerebral perfusion

• Communication Framework: • "We need 7 minutes for:

  1. Antibiotic infusion completion

  2. Arterial line placement

  3. Second IV access" • Offer compromise: "Let’s wheel the patient to theatre while I complete these"

Scenarioville Constraints:

• No point-of-care lactate - must send to lab (30min turnaround)

• Single anaesthetist often - must delegate tasks clearly

The patient has received 2L crystalloid but remains hypotensive with MAP 58. How would you guide further fluid management?

• Dynamic Assessment: • Passive leg raise test (PLR) with arterial waveform analysis:

  • 10% increase in pulse pressure = fluid responsive

  • Requires 45° head elevation → 45° leg elevation for 1min • Ultrasound evaluation:

  • IVC collapsibility >50% during sniff suggests responsiveness

  • LVOT VTI variation >15% (if transesophageal echo available)

• Fluid Selection: • Balanced crystalloid (Hartmann's) preferred over 0.9% saline:

  • Lower risk of hyperchloremic acidosis

  • 250ml aliquots with reassessment after each • Consider 5% albumin if ongoing losses:

  • 100-200ml boluses in septic shock

  • Scenarioville stock: 4 bottles available

• Termination Points: • Crackles on auscultation • CVP >12mmHg (if central line in situ) • Plateau on stroke volume variation

Critical Actions:

• "Dynamic over static parameters for fluid responsiveness"

• "Smaller aliquots in established septic shock"

Blood gas shows pH 7.18, lactate 6.8, K⁺ 5.9. What specific interventions would you prioritise?

• Metabolic Acidosis Management: • Sodium bicarbonate 50-100mmol IV if pH <7.2:

  • Dilute 8.4% solution 1:1 with sterile water

  • Administer over 30min via central line • Correct underlying cause:

  • Ensure antibiotics administered (time-to-antibiotics critical)

  • Surgical source control within 6hrs

• Hyperkalemia Protocol:

  1. Calcium gluconate 10% 10ml IV over 5min (membrane stabilisation)

  2. Actrapid 10IU + 50ml 50% dextrose IV over 15min

  3. Salbutamol 5mg nebulised

  4. Consider dialysis consult if anuric

• Monitoring: • Continuous ECG for peaked T waves/QRS widening • Repeat K⁺ after 30min

Scenarioville Constraints:

• No renal replacement therapy onsite

• Limited insulin/glucose kits - must prepare manually

The surgeon reports purulent peritonitis and requests a 6-hour postoperative ICU bed. How would you approach this given Scenarioville's resources?

Resource Negotiation: • Immediate actions:

• Activate HDU protocol (1:2 nursing ratio)

• Pre-emptively contact retrieval service (2hr response time) • Modified care plan:

• Extended recovery room stay (8hrs instead of 4)

• Consultant anaesthetist to remain onsite

• Therapeutic Adjustments: • Early vasopressor weaning target (noradrenaline <0.05mcg/kg/min by 4hrs) • Aggressive diuresis if fluid overloaded (furosemide infusion)

• Contingency Planning: • If deteriorating:

  • Transfer to theatre for re-look laparotomy

  • Mobilise private ICU bed (costs borne by hospital)

Critical Phrases:

• "Proactive escalation beats reactive crisis management"

• "HDU is our modified ICU in resource limitation"

During pneumoperitoneum, the patient develops hypertension (180/110) and tachycardia (HR 140). Outline your management.

Immediate actions:

• Reduce insufflation pressure (<12mmHg if possible)

• Confirm ETCO₂ (likely >50mmHg) – increase minute ventilation

• Check anaesthetic depth: Increase sevoflurane/bolus fentanyl

Differential diagnosis:

• CO₂ absorption → hypercapnia (most likely)

• Light anaesthesia (BIS <40 target)

• Pheochromocytoma (unlikely but catastrophic if missed)

Scenarioville-specific:

• No in-house ABGs – rely on ETCO₂ trends

• Limited vasodilators: Labetalol 5mg IV aliquots available

Critical Phrases:

• "Exclude hypercapnia first"

• "Stepwise approach to hemodynamic control"

• "Surgical communication imperative"

The ETCO₂ suddenly drops from 38mmHg to 12mmHg with concurrent hypotension. What’s your systematic approach?

Immediate Differential Diagnosis:

1. Circuit disconnection (most common)

2. Massive pulmonary embolism

3. Cardiac arrest

4. Severe bronchospasm

Action Sequence:

1. Disconnect check:

   • Verify circuit connections → if disconnected, manually ventilate

2. Cardiac assessment:

   • Pulse check → if absent, start CPR

   • If perfusing, assess for:

     • RV strain (JVP elevation, ECG S1Q3T3)

     • Bronchospasm (rising peak pressures, wheeze)

3. Therapeutic trials:

• Albuterol 5mg neb if wheezing

• 500ml fluid bolus if RV failure suspected

1. Scenarioville Limitations:

• No TEG/ROTEM → empiric heparin 5000IU if high PE suspicion

• Limited echo availability → rely on clinical signs

Critical Phrases:

• "Disconnect before disaster"

• "PE is a cannot-miss diagnosis"

• "Empiric heparin may be life-saving"

The power fails during pneumoperitoneum. Describe your crisis management.

Phase 1: Immediate Actions (0-30 sec):

• Call "POWER FAILURE" to activate protocol

• Hand-ventilate with Mapleson C circuit (stored with emergency O₂)

• Direct assistant to:

  • Secure phone lights over surgical field

  • Check backup generator status

Phase 2: Prioritization (30sec-2min):

• Surgical team to:

  • Clamp port valves to maintain pneumoperitoneum

  • Prepare for rapid open conversion if needed

• Anaesthesia team:

  • Switch to draw-over vaporizer if available (Scenarioville theatre 2 has one)

  • Monitor SpO₂ with battery-powered pulse oximeter

Phase 3: Decision Point (2-5min):

• If power returns:

  • Abort procedure after critical steps

  • Transport to recovery with manual ventilation

• If prolonged outage:

  • Reconfirm ventilator settings

  • Check anaesthetic depth (BIS if available)

Scenarioville Specifics:

• Backup generator takes 90sec to engage

• No battery-operated ventilators - manual only

During laparoscopic suturing, the end-tidal CO₂ abruptly rises to 65mmHg with concurrent tachycardia. Outline your management.

Differential Diagnosis:

1. CO₂ embolism (most catastrophic)

2. Pneumothorax

3. Malignant hyperthermia (unlikely without triggers)

Action Sequence:

1. Immediate communication: • "Stop insufflation!" to surgeon • "Flush abdomen with saline" to displace gas

2. Ventilator adjustments: • Increase FiO₂ to 1.0 • Maximise minute ventilation (TV 8ml/kg, RR 20)

3. Hemodynamic support: • Noradrenaline infusion if hypotension • Consider epinephrine 10-50mcg boluses for RV failure

Diagnostic Steps:

• Precordial Doppler if available (mill-wheel murmur)

• TOE gold standard but unavailable in Scenarioville

Critical Actions:

• "CO₂ embolism is a time-critical diagnosis"

• "RV failure management takes precedence"

The patient develops widespread ST elevation on ECG. How would you distinguish between real myocardial ischemia and anaphylaxis?

Clinical Differentiation: • Ischemia features:

• Regional ST changes (e.g., inferior II/III/aVF)

• Reciprocal changes

• Rising troponin trend • Anaphylaxis features:

• Rash/urticaria (if visible under drapes)

• Bronchospasm (rising peak pressures)

• Angioedema (difficult ventilation)

• Therapeutic Trials: • For ischemia:

  • GTN 50mcg boluses

  • Aspirin 300mg PR if NBM • For anaphylaxis:

  • Adrenaline 50mcg IV bolus

  • Chlorphenamine 10mg IV

• Investigations: • Point-of-care troponin (if available) • Tryptase levels at 1hr/6hr post-event

Critical Phrases:

• "Time is myocardium versus time is airway"

• "Empiric adrenaline may be diagnostic"

The surgical team encounters uncontrolled bleeding from the mesenteric vessels. What blood product strategy would you implement?

• Massive Transfusion Protocol: • Initial ratio: 6 PRBC : 4 FFP : 1 cryoprecipitate pool • Monitoring:

  • Fibrinogen q30min (target >1.5g/L)

  • Ionised calcium q15min (target >1.1mmol/L)

• Scenarioville Modifications: • No platelets → use cryoprecipitate for fibrinogen • Limited FFP stocks → prioritise surgical haemostasis

• Adjuncts: • Tranexamic acid 1g IV over 10min then infusion • Cell salvage if available (controversial in sepsis)

Critical Actions:

• "Anticipate dilutional coagulopathy early"

• "Calcium replacement is non-negotiable"

The patient reports recall of intraoperative events in recovery. How would you assess and manage this?

Immediate assessment:

• Document exact recall (procedural vs pain memory)

• Check anaesthetic chart:

  • End-tidal volatile concentration (aim >0.7MAC)

  • Opioid doses (fentanyl ≥2mcg/kg given?)

  • BIS monitoring not available in Scenarioville

Management:

• Apologise sincerely + explain investigation process

• Offer psychology referral (limited in Scenarioville – telehealth option)

• Report via hospital incident system

The patient reports vivid recall of the surgeon saying 'I can’t find the appendix'. How do you investigate this?

Verification Process:

1. Corroborate recall:

   1. Review theatre notes for recorded conversations

   2. Interview scrub nurse/surgeon about verbal exchanges

2. Anaesthetic audit:

   1. Check drug log for:

      • Volatile concentrations (minimum 0.7MAC documented)

        • Opioid doses (fentanyl ≥2mcg/kg expected)

        • Muscle relaxant monitoring (no twitches documented)

3. Technology review:

   1. Download ventilator data if available (minute volume adequacy)

1. Psychological Assessment:

   1. Use Modified Brice Questionnaire:

      1. "What was the last thing you remember before going to sleep?"

      2. "Did you feel pain or have dreams?"

   2. Score using Iowa Awareness Classification

Medicolegal Essentials:

• Document discussion verbatim in incident report

• Inform hospital risk management within 24hrs

The family is distraught about the awareness event. How do you conduct this conversation?

Structured Disclosure:

1. Setting: • Private room with senior nurse present • All pagers/phones silenced

2. Content: • "I want to discuss what happened during your son’s surgery" • "We take this extremely seriously and are investigating thoroughly" • Avoid defensive language ("mistake" vs "unintended event")

3. Follow-Up Plan: • Offer same-day psychology consultation • Schedule 48hr follow-up meeting with consultant anaesthetist

• Support Mechanisms: • Provide written summary of discussion • Connect with patient advocacy groups (Awareness Under Anaesthesia UK)

Critical Documentation:

• "Patient recalled surgeon’s voice stating X at approximate time Y"

• "No pain recollection but clear auditory memory"

Twelve hours post-op, the patient becomes agitated with a GCS of 11. What's your differential and management?

• Delirium Differential:

  1. Sepsis-associated encephalopathy

  2. Alcohol withdrawal (even without prior history)

  3. Undiagnosed head injury

• Assessment Protocol: • 4AT score administration:

  • Alertness (0-4)

  • AMT4 (0-4)

  • Attention (0-4)

  • Acute change/fluctuation (0-4) • Investigations:

  • Blood alcohol level

  • CT head if focal signs

• Management: • Dexmedetomidine infusion 0.2-0.7mcg/kg/hr • Haloperidol 0.5-1mg IV PRN

Critical Phrases:

• "Delirium is a symptom, not a diagnosis"

• "4AT score guides intervention urgency"

The nursing staff reports suspected anaphylaxis to piperacillin-tazobactam. How would you investigate this retrospectively?

• Diagnostic Pathway:

  1. Serum tryptase:

     • Peak at 1-2hr post-event

     • Baseline at 24hr

  2. Skin testing (6 weeks post-event):

     • Prick testing with diluted antibiotic

     • Intradermal testing if negative

  3. Graded challenge if equivocal

• Documentation Essentials: • Drug batch numbers • Timing relative to administration

Critical Actions:

• "Tryptase must be drawn within 2 hours"

• "False negatives common in antibiotic reactions"

The patient develops oliguria with a creatinine rise to 180μmol/L. Outline your renal protection strategy.

• KDIGO Bundle Implementation:

  1. Optimize perfusion:

     • MAP >65 with noradrenaline

     • CVP 8-12mmHg

  2. Nephrotoxin avoidance:

     • No NSAIDs

     • Gentamicin level monitoring

  3. Early nutrition:

     • Enteral feeding within 24hrs

• Scenarioville Adaptations: • No renal replacement therapy → early furosemide stress test • Limited ICU → strict fluid balance charts

Critical Phrases:

• "Oliguria is the last sign of AKI"

• "Prevention beats rescue therapy"