nm5231: i don't know about you but when i was a student the earlier we started 
the earlier we were in the pub so er there'll be minimal delay here are we 
happy everyone's here
ss: yes
nm5231: okay well good afternoon my name's Doctor namex i'm one of the 
sonsultantanaesthetists over at the University Hospital er i've been asked to 
come along this afternoon and go over a couple of topics with you just to sort 
of give you the basics and have a discussion with all of you about the er the 
framework they're in what i'd like to do there are two groups who are going to 
present to us i'd like to structure this that we have a presentation from your 
colleagues first and then a couple of slides from me on the topic and then we 
throw it open to the floor for a discussion how does that sound yeah i think 
the legal maxim is qui tacet consentire silence gives consent so in the first 
instance we are going to look at pre-operative assessment so i'd like to my 
colleagues he-, colleagues over there to come down and give us a presentation 
of a patient they saw along these lines
sf5235: good afternoon er while Doug is setting up er i'm just going to 
introduce our topic as Doctor Furlong said we're going to talk about pre-
operative assessment and the lady we're going to talk to you about today is Mrs 
P and she's a lady that we saw er who was referred to the breast surgical team 
at Walsgrave Hospital where Doug and I are currently attached er she's eighty-
two years old well i'm just going to run through the history and then Doug is 
going to talk briefly about what her pre-operative assessment involved er she's 
a retired desk clerk and she presented to what okay sorry she presented to the 
breast clinic with a six week history of a bloody discharge from her right 
nipple er she had no tenderness and she found no lumps on self-examination at 
the clinic er following examination of her breast a er firm well-defined mass 
was identified about one centimetre from her right nipple at about three 
o'clock if you can picture it er a biopsy was carried out which was 
inconclusive and a mammogram and an ultrasound were carried out as well which 
later confirmed an elongated lobulated mass about ten millimetres in diameter 
er there are no changes er since the breast clinic and there are no new 
developments in her left breast either now in terms of questions directly 
related to breast disease er she is currently in the menopause and has been 
since she was fifty-tw-, fifty-four she has two children who er she did not 
breast feed and she has not been on H-R-T now before i go into the past medical 
history er diagnosis of breast cancer like other cancers involves er what's 
called a triple diagnosis and that's based on the clinical impression which is 
er designated P and radiological appearance of the lump which is R and tissue 
biopsy which is B now this lady based on the clinical impression er it was 
designated P-three from a scale from one to five where one is a benign lesion 
and five is cancerous three would be sort of like suspicious but not probably 
not cancer er and she was designated R-three as well and based on the fact that 
the biopsy was inconclusive it was designated B-one so the most probable 
diagnosis in her case is a ductal carcinoma in situ er in terms of her past 
medical history she suffers from osteoarthritis and osteoporosis she has had 
four hip op-, hip operations in the past three on her right side and one on her 
left er she has hypertension which is currently controlled by medications and 
she had a hernia operation six years ago she is currently taking medication for 
her hypertension as i mentioned and those are atenolol lisinopril and 
bendrofluazide and she's allergic to penicillin she has no family history of 
breast or ovarian cancer so there's no genetic pre-disposition there in terms 
of her social history she lives alone in a bungalow and her son lives across 
the street so he comes over and visits quite frequently er she doesn't drink or 
smoke and she's a fairly independent lady er but she has limited mobility due 
to the fact that she's had her four hip operations and she requires a stick to 
walk so basically due to the fact that she has this ductal carcinoma in situ 
she er was going to have a wide local excision with auxiliary sampling so Doug 
is just going to briefly highlight what pre-operative assessment involved in 
this particular case
sm5232: pre-operative assess-, assessment is done for anybody undergoing 
surgery basically er but the clinic that we went to was specific for breast 
care and patients undergoing breast surgery er i think it's okay that we say 
now that her breast surgery that was going to be done or is done already is a 
wide local excision which is basically taking out a lump out of the breast with 
a two centimetre peripheral breast tissue excision as well so in the past it 
would just be cal-, it would just it would be just called a lumpectomy whereby 
you just take the lump out and no surrounding breast tissue round the lump but 
because of a high level of remittance and just a therapeutic strategy they just 
take about two centimetres two to three centimetres of the normal breast tissue 
surrounding the lump to prevent recurrence anyways er the pre-op assessment is 
quite similar regardless of what surgery you do er the heart rate is taken your 
blood pressure is taken and for Mrs P was forty-eight beats per minute and a 
hundred and sixty-three over eighty-one and a whole list of different types of 
physical assessments were done which is standard throughout all pre-o-, pre-
operative assessments for example safety issues such as if the patient is fit 
for doing surgery er that has implications for putting her under whether it's 
general anaesthetics or local anaesthetics pain is assessed in her case she has 
osteoarthritis and nutritional status is also taken her weight her height and 
as well her mobility and her appetite is taken as well as we discussed before 
her mobility is also assessed for obvious reasons because you know once you do 
surgery you're not able to move round as much and that has implications for 
discharge her breathing is also assessed in terms of how far she can go before 
she undergoes shortness of breath so in this case it was three flights of 
stairs before she has the minimal shortness of breath her sleep is okay and 
she's also independent in terms of her hygiene as we discussed before she'd 
also assessed orally meaning they want to check if her teeth are okay if she 
has false teeth because as you know a lot of times when they go into surgery 
they take the false teeth out in order to put the t-, put the tube in and her 
elimination is also assessed just as just for er to make sure everything is 
covered i guess i don't really know why her vision and hearing and language is 
also assessed er language is important because when you explain to the patient 
what her situation is the diagnosis and also the different type of treatments 
that she can undergo you might need an interpreter if she doesn't speak the 
language very well or you might need to call a family member in to help her 
understand so she can make a good decision on what type of treatment she wants 
and as well of course the psychological assessment er it's esp-, it's 
especially important in this case because things such as body image is very 
pertinent factor in in this type of surgery whether or not the person wants to 
just take the lump out or take the entire breast out there's obvious body image 
issues here and there are specialised nurses breast care nurses that take care 
of this and help the person go through the process of grief and loss and and 
what not er as well the emotional state of the patient is is noted and is in 
this case Mrs P was slightly anxious but she has quite an understanding of what 
was involved a general physical examination is done as would be with any 
patient and there are really no signs that were that were worth noting other 
than the fact that she had Heberden nodes because of her osteoarthritis i mean 
her chest was fine her heart was fine an investigation's also done er based on 
each patient for example er an E-C-G is done for her because she's on 
betablockers and they found out she has sinus bradycardia er blood tests are 
done basically your normal F-B-C's L-F-T's and depending on the patient if she 
has lung problems if she has C-O-P-D they might do a lung function test and 
things of that sort but that's basically it for the pre-op assessment
nm5231: yeah go on give them a clap
nm5231: okay well done thank you the pre-operative assessment that was 
excellent of a patient is multi-factorial you'll have heard a lot of stuff 
there that if you imagine how long it took these two people to go through one 
patient you could never get everything done for a whole operating list the 
nursing team themselves go through half of it so they tend to do er social 
support at home expressing your sexuality things like this and the surgical 
team will go through the scar they're going to produce and should activate 
prosthesis support and things like then the anaesthetist will come along and 
look after the rest of it now i put that up just out of interest er 
anaesthesia's bizarre it's all postgraduate you don't get to do much as an 
undergraduate i think i did two weeks and that was it most of that was spent in 
the pub when er you talk to the public they don't really know who the 
anaesthetist is and a friend of mine told me that er she'd been to patient pre-
operatively and she said can i just ask my son tried to get into dentistry and 
didn't so he thought he'd be an anaesthetist now i can't tell you the rude 
words that produced from my colleague but what exactly is an anaesthetist any 
offers silence we all watch Holby City no sign of an anaesthetist we all watch 
Casualty no sign of an anaesthetist but in the real hospital we're everywhere 
what is an anaesthetist is it the surgeon's assistant or some bloke reading the 
paper at the top of the table now again if you watch some of the er current 
dramas er the surgeons start shouting numbers and fluids and things and this 
little mouse of a person at the top goes okay squeezes it in that's not quite 
how it happens seriously though the role of the anaesthetist er is actually the 
perioperative physician okay there is a pre-op a per-op and a post-op element 
to this at the end of the day i never thought i'd end up being a physician but 
you end up looking after the medical conditions of these patients for the 
duration of the operative period and you'd be surprised how involved you have 
to get sixty per cent of hospital activity is the responsibility of the 
anaesthetist so beware be very aware of what you're going to be in for in the 
future let's have a quick look at er the pre-operative assessment then that we 
would use oops whatever you're asked in an exam situation the answer is always 
history examination and special investigations and let's have a look at the 
history some people do actually display a history of severe post-operative 
nausea and vomiting there is a significant proportion of the population who 
have an enzyme deficiency and something called and there are other problems 
they've been failed intubations difficult airways and this is the chance for 
the patient to say ooh last time er i had an operation the doctor said 
afterwards i nearly died er and they go into a great gory description of 
whatever they're proud of and you can have er a long chat to them get to the 
bottom get the facts and then hopefully be safe during your anaesthetic my 
colleagues have already drawn from the patient the er relevant past medical 
history this is important the population is increasingly old six per cent of 
forty year olds and a hundred per cent of sixty year olds have aschemic heart 
disease that is at post-mortem even if they deny symptoms when you are asking 
them about chest pain exercise tolerance you may not get an overt history or 
something that's been picked up by a GP this is either due to i'm sorry to say 
poor attendance at the General Practice or lack of exercise there are a lot 
couch potatoes who don't do enough exercise to expose the symptoms we're also 
interested in the respiratory side of things because that's going to be the 
main vector through which we keep the patient asleep in most cases we look at 
the drug history and the allergies because we're interested in interactions 
between what we're going to give as the anaesthetist to keep them asleep and 
also keep them comfortable afterwards when looking at the patient's total body 
we ask about er whether they have caps crowns dentures classically in the text 
books it says you ask because the nurse will take them out when you go down to 
the theatre er i assume you're all reasonable young and none of you actually 
have a full set of dentures but when you talk to the patients most of the old 
women er with dentures are mortified at the thought of taking their dentures 
out my colleague actually mentioned expressing sexuality and all the rest of it 
these ladies are terrified they won't open their mouth they won't speak because 
they don't want anybody to see them without their teeth in it's only a small 
point but it's worth paying attention to so what i've gone full circle now and 
i say to them leave them in come down that way you will answer the questions 
give appropriate answers and tell us if you're worried if they need to come out 
i will take them out while you're asleep and put them back in when you wake up 
or just before you wake up and the issue of the dominant hand we're going to 
need intravenous access in these guys that is for the anaesthetic episode but 
the drip will probably stay in post-operatively for fluids and it's all about 
the thought that goes into it if you're right-handed and they put a drip in 
your right hand when you go to sleep when you've woken up and you're feeling a 
bit better you're going to want a drink you've got a a big drip hanging off the 
arm so you'll end up using the wrong hand attention to detail er we are 
interested in regurgitation dyspepsia because there is a phenomena of 
aspiration of acidic gastric contents into the pulmonary tract when the gag 
reflex is suppressed by anaesthesia that can cause a terrible chemical bronchi-,
bronchiolitis basically and we can be in a an extreme arrest situation if 
we're not careful right the examination day surgery is a very new and evolving 
sub-speciality er to decide whether somebody is fit in inverted commas it's 
looking at it statistically so the statistics game aims towards the the er body 
mass index if you put the weight over the height squared er you will come up 
with a figure now er we can say it because we're Coventry now Birmingham where 
i did a lot of work er you'd have to move things down a little bit normal for 
Birmingham is probably about thirty-five and further over it it's actually 
clinically important because the higher your fat content peripherally the more 
you will s-, er store and slowly re-anaesthetize yourself with there are 
factors in vessels there are factors in metabolic rate there are factors in 
regurgitation so the weight is incredibly important at the end of it some 
patients we've dealt with have been too heavy for the standard surgical table 
it's to be thought about so take a good measurement of the wei-, weight and the 
height the nursing staff should do that for you now when assessing the cardio-
vascular system er we've already alluded to the blood pressure and the pulse 
the nurse is going to take it and say to you is this normal so er the nurse 
took my blood pressure and it's one sixty-five over ninety is that normal one 
sixty-five over ninety would you tell the nurse that was normal 
sm5236: a bit high
nm5231: a bit high which bit and why
sm5236: er 
nm5231: there's lots of whispering go on who's whispering someone want to stick 
a hand up anyone brave it's usually a girl go on let's have a girl put their 
hand up no any offers sorry sorry
su: 
nm5231: it is er the systolic element is they're both actually up okay ball 
park when you read the text books blood pressure should be a hundred and twenty 
over eighty when you join the real world the systolic is usually age plus a 
hundred okay now there are trends in everything in medicine er the German's 
have actually started to treat blood pressure if you're too low as far as 
they're concerned so if your systolic is too low they will give you an agonist 
to increase it we are aware classically hypertension is the diastolic up and 
we've got American er cardiac guidelines on that which we all follow does 
anybody understand why that's dangerous no i can hear lots of whispering come 
on it's only me sorry
nm5231: it's to do with the mean pressure or the flow pressure and the tissues 
it's going through okay it can be damaging you're also looking at perfusion 
pressure for the rest of the tissues around the blood supply okay and also the 
work that the ventricle's having to do to provide the pressure you're seeing so 
there are three aspects to it and at the end of the day it's a balancing trick 
so the pressure of one sixty-five over ninety i am not sixty-five even though i 
feel it sometimes and ninety is a little high so we pay attention to that the 
heart rate does everybody have the same influence of their physiology on their 
heart rate that's a terrible question it's obviously loaded no they don't both 
extremes of age you are very rate dependent because you can't produce a 
difference in your ventricular outflow okay in the middle which hopefully i am 
you should be able to respond with a ventricular response so taking a heart 
rate if i've got a seventy-five year old lady whose heart rate is fifty because 
of betablockers i'm actually quite worried about her i don't think she will 
mount a tachycardic response if she has a problem so i may look at the degree 
of blockades she's got okay let's move on a bit because you want to get out of 
here hydration we need background fluids if they haven't had any because 
they've been fasting they're going to be intravascularly empty and they may 
have more hypotension way to assess it skin turgor urine and pulse and 
respiration some of the most fun i ever had was giving a lecture to surgeons on 
respiratory rate and i asked a surgeon who was outrageously arrogant what the 
normal rate was and he said the normal rate's twenty-eight and i said are you 
sure and he said course i'm sure i'm a surgeon and i thought right okay and i 
got the person next to him to get their watch out and i said you time him you 
breathe at a rate of twenty-eight and see how you do within about three minutes 
he was knackered there was just no way he was going to continue and this is 
important if there are the patient's respiratory rate is high it's for a reason 
and it's a massive clinical indicator and it's one of the few things that's 
often missed at examination so be very aware of that you can look at rest of 
the tree air entry and wheeze i'm trying to speed up a bit now access yes where 
are the veins the investigations bloods at the end of the day there will be a 
sheet of just about everything the houseman's done when most senior medics come 
to assess the patient there will be a small number they're really interested in 
er i personally am looking for the haemoglobin to make sure they've got optimum 
oxygen carriage and next to that i'm looking for the haematocrit to see how 
accurate that haemoglobin is we've all watched er the American medical er films 
and they're always asking for the 'crit doctor aren't they the 'crit what's the 
'crit if you ask most English medics for the 'crit they'll look at you blankly 
this is an idea of the dilution if you've got the haemoglobin and the dilution 
together you've got a better idea of what exactly the oxygen carrying capacity 
of this patient is all the membranes are excitable potassium is part of that 
and so i want to know the potassium in the sick patient i might want urea and 
creatinine to look at renal function and there are other specific entities 
right on the E-C-G again it's going to be age er dependent i'll be looking for 
signs of aschemic heart disease or abnormal rhythms but again you don't need me 
to tell you about those if the basics are abnormal or i'm concerned on the 
basis of history then yes we move on to more a-, advanced investigations such 
as an echo or a vitalograph and to be honest they should have been picked up by 
a a chat by the nurse pre-operatively the difficult ones should be flagged up 
to a consultant and you should be able to have a meeting about them with the 
staff and tell them what you need to be done so you can assess them properly 
that's a very quick whiz through or there any questions is everybody happy just 
ball park roughly going over the patient any questions no okay let's have a 
look so i would ask my other colleagues to come and give us a short 
presentation on shock 
sm5233: hiya er Fiona and myself are going to talk for a few minutes about 
shock the patient that we're going to present is a gentleman who came into 
hospital for an entirely different reason but later on became a really good 
example of of hypovolaemic shock this is mister S he's a fifty-nine year old 
man a retired industrial cleaner and was admitted to Walsgrave on the twelfth 
of March this year his presenting complaint on admission was parasthesia pins 
and needles in his arms and legs this began suddenly three weeks prior to his 
admission and progressed and gradually became so bad that his neurological 
deficit which was both sensory and motor meant that he couldn't even walk he'd 
had a couple of consultations with his G-P and then eventually he was admit-, 
admitted to hospital presently he's still a patient at Walsgrave and his 
neurological symptoms haven't changed and he's bedridden because of it er on 
the twenty-fourth of April this year he was started on warfarin for a possible 
D-V-T in his past medical history there's not really anything of note except 
for a left inguinal hernia repair in ninety-five his drug history he's not 
normally taking any drugs or any prescription medication and he's got no known 
drug allergies he's got no relevant family history and normally he lives with 
his wife and six children from whom he has great social support er he's got a a 
strong history of smoking he has a forty pack year history and he's a non-
drinker Fiona's now going to talk a little bit about what happened to Mr S 
while he was in hospital
sf5234: okay Mr S had been in hospital for about six weeks er until the twenty-
sixth of April which was a very big day for him er very early in the morning he 
started er passing lots of blood P-R er it was a painless P-R bleed er lots of 
fresh blood er lots of clots and he had no history of melaena any passing mucus 
and he'd had no previous change in his bowel habits er at that time his blood 
pressure dropped about ninety over sixty and his pulse went up to a hundred and 
ten his I-N-R was seven er related to the fact that he'd had er he'd been on 
Warfarin treatment er for a possible D-V-T it since turned out that he didn't 
have a D-V-T er so obviously there was too much Warfarin kicking about which is 
bad er and his C-V-P went down to minus two centimetres of water er to correct 
that he was given vitamin K and fresh frozen plasma which er consequently 
brought the I-N-R to er two er later on in the day his haemoglobin dropped to 
three point six er and he had to be given twelve units of blood and four units 
of fresh frozen plasma just to try and er keep his blood pressure up basically 
er because of the urgency of the situation that he was continuing to pass a lot 
of blood P-R there wasn't er time to do all the normal investigations that 
you'd want to do for somebody with a P-R bleed so he didn't have the urgent O-G-
T as you'd expect er as we all learnt last week er and he went straight to 
theatre to do an exploratory surgery it was found during the surgery that he 
had masses of blood fresh blood in the colon but nowhere else er and it was 
decided to perform a sub-total colectomy er at that time er just for your 
information er he had to have a further six units of blood four units of F-F-P 
and six units of crystalloid during the operation so he was pretty sick really 
er the next day things stabilised quite a lot er after his colon was been taken 
out and his blood pressure was one-hundred-eight over fifty-three his pulse had 
gone back down to ninety and his C-V-P had er gone up to a sort of more 
respectable three centimetres of water er and he remained stable and quite well 
with an I-N-R for quite some time after that er the pathology on his colon 
actually revealed er a vasculitis which is er thought to be er polyarteritis 
nodosa er where basically lots of er micro-aneurysms have ruptured causing the 
bleed and that may actually be related to his neurological problems although 
that's not been er diagnosed yet he actually had er a bit of a blip in his 
recovery process he had a repeat bleed on the nineteenth of May er and his 
haemoglobin dropped at that time er and he also started passing faecal fluid P-
R which you might think is a bit odd seeing as he doesn't have a colon and it's 
thought that he might have formed a fissula with the small bowel but that's not 
known yet er our examination of Mr S is really not an awful lot of value 
because we saw him quite a lot of time after time after he was in shock so i'm 
just going to briefly run through what we saw er in him when we when we spoke 
to him and when we examined him and then Gerry's going to talk a little bit 
more about er what signs you would expect in somebody that's in hypovolaemic 
shock er so he was a pale man er he was very cachexic although he's comfortable 
at rest er no jaundice and er clubbing cyanosis oedema or lymphadenopathy his 
chest was clear his heart sounds were normal and his pulse's were all er 
regular at about ninety er just generally on his on his abdominal exam there 
was an obvious scar where he had his er sub-total colectomy and a stoma present 
also er he wasn't tender and palpation there were no masses to be found he was 
a bit tender and percussion but with resonance throughout er and it was really 
located to where his scar was and he had er some abnormal bowel sounds but 
that's really not that abnormal when you consider he doesn't have a colon so er 
Gerry's just going to talk a bit more about signs you would expect to see in 
somebody in hypovolaemic shock
sm5233: this is just very quickly er in a patient with hypovolaemic shock the 
things you'd normally expect to see because of hypovolaemia you've lost volume 
and as a consequence you lose blood pressure and you get inadequate tissue 
perfusion so in the skin you'd expect the patient to be cold and pale to be 
cyanosed and to have an increased capillary refill time that's greater then two 
seconds which is generally taken to be the normal time to be less than two 
seconds because of poor kidney perfusion you'd have a lower urine output and 
also because of cerebral ischmeia you'd have confusion and restlessness in the 
patient as well er the drop in blood pressure and blood volume leads to a 
reflex increase in sympathetic tone and as a consequence you get a tachycardia 
which is er one the important things to note in hypovolaemia and also as was 
mentioned earlier you get because of the ischemia metabolic acidosis which are 
a consequence as a consequence you get a compensatory increase in respiratory 
rate and i'll hand over to Doctor Furlong
nm5231: well thanks very much guys that was an excellent presentation well done 
nm5231: i think shock is one of the most important clinical situations that you 
will come across there are very few times where you are called upon to use what 
little physiology you remember from medical school to actually save somebody's 
life this is one of them so it's worth remembering what is shock any offers
su: acute circulatory failure 
nm5231: acute circulatory failure not bad any more let's have a bloke this time 
you either volunteer or i choose someone this is an interactive session whether 
you like it or not going once going twice thank you sir what's shock 
sm5237: it's me it's inadequate er circulation the er tissues such as vital 
organs
nm5231: yeah there are lots of actual definitions thank you that was well done 
at the end of the day the final one you you appertain to failure of oxygen 
delivery to the tissues okay you get all sorts of weird er statements like er 
shock is what happens when i walk on the ward wearing a pink shirt shock is 
what happens when you say how big your overdraft is those of things and there 
are physiological similarities what is oxygen delivery to the tissues now this 
is where it starts to get grown up what factors do you think actually influence 
he says with the formula behind him on the wall anybody think about what things 
are measured in cardiac output's in litres isn't it haemoglobin is in grams per 
decilitre hence the ten is just to normalise things the one point three four is 
called the Hufner Constant and it's the amount of oxygen that one gram of 
haemoglobin can carry in normal atmospheric pressure so that particular formula 
i won't bore you with the rest of it but if you ever come and play in 
anaesthesia this will be your bread and butter basically and it gives you an 
idea of the factors that may be able to influence the actual oxygen delivery if 
you have the drop in heart rate what's cardiac output heart rate by
nm5231: thank you so if either of those fall cardiac goes down so does oxygen 
delivery if the haemoglobin falls so therefore does the ability to carry oxygen 
and the saturations so they're the factors that's why i it's worth putting it 
up what sort of classification of shock are you aware of er let's start on the 
left sorry i don't know your name Tim what sorry
su: cardiogenic
nm5231: cardiogenic next to you hypovolaemic
su: 
nm5231: sorry
su: 
nm5231: er not quite no good effort septic yeah 
sf5239: anaphylactic
nm5231: anaphylactic yeah sorry
su: neurogenic
nm5231: neurogenic fantastic hypovolaemic so we've basically got a situation 
where you've lost volume don't forgot it's not always blood in a patient with 
profound burns your skin is a water-proof bag you are sixty to seventy per cent 
water if that bag's not working you can lose the water and become just as 
hypovolaemic i spent the morning trying to educate people about various fluids 
and we were discussing the fact that are three litres of water in your five 
litres blood volume you could lose that very quickly if you are not exactly 
water-tight right septic we touched on cardiogenic the pump just won't work 
very common post-infarcted and then the rest of them are bagged together really 
er anaphylactic things like adrenacortical insufficiency er until you see it 
you'll never believe it but there are mechanisms that mimic shock for endocrine 
and pharmacological reasons nice little table here to try and can everybody see 
that is it clear just to try and describe how it actually looks and the 
different types of shock differ in their clinical presentation right so the 
most common is which one do you think 
su: 
nm5231: excellent what happens to the heart rate increased er stroke volume no 
change or decrease cardiac output no change or decreased and then the S-V-R 
that is the systemic vascular resistance that's how tight you are peripherally 
now if i was sitting where you were i'd have twigged this is probably the only 
important bit of the lecture if you make a note of this you can probably fall 
asleep what i'm going to do i'm going to copy this and give it to your lecturer 
and i'll make available some handouts in the next day or two so don't worry too 
much er what i'd like to do is show you the difference between that and the one 
underneath septic which is perhaps the most common second most common if you 
think about er the clinical situation where a microbiological episode has got 
out of control and you have septicemia in inverted commas your normal 
mechanisms have been turned round and you can see the big difference is at the 
end here the S-V-R rather than being increased in a compensatory attempt it's 
actually decreased this has massive consequences if you look at the top you can 
see that your haemorrhage the others are fairly similar and that one is up 
absolutely totally the opposite septic shock can be catastrophic absolutely 
catastrophic so if you think about it this is a good model to remember and work 
round you can understand the mechanism of cardiogenic er if heart's not working 
well of course the stroke volume's going to be down and in compensation the S-V-
R will go up in an effort to try and maintain the cardiac output but it doesn't 
always do it so it's down a little bit and this final type of thing you've 
essentially taken off all the neurological efference afference i should say and 
so you've stripped it of all the drives and you get a picture as you see are 
there any questions about this one thing i would say i don't know how you all 
learn but i find learning a table rote learning a table pointless the way to do 
this is to understand the pathology and then be able to describe the table 
yourself so rather than sort of regurgitate that if you take a step back and 
work out why from understanding the pathology you stand a better chance of 
being able to get it right and do something about it right the clinical side of 
things let's have a bit of background history we've got a seventy kilo male 
roughly seventy mils per kilo of total body blood we're looking at five litres 
and let's look at these i've put these up deliberately we're a small country 
and America's much bigger er if you meet people abroad the English are er 
reasonably loud but the Americans and i i know there's probably some Americans 
here they do tend to talk a lot louder so we tend to listen to them now in 
medicine er the Americans like protocols they like books they like something to 
point at for medical legal reasons to say i'm covered i did what it says in the 
book you can't sue me over here we don't get sued quite as much so we're not as 
focussed on the books which i think at the moment's not a bad thing A-T-L-S the 
Advanced Trauma Life Support course was brought in er after a pilot had a crash 
and his family were in the hospital with him he was quite badly injured but he 
was so appalled at the immediate care the rest of his family got he got off the 
bed in A and E and went round and started looking after his family after this 
he he went to work with generating this this idea of having the the A-T-L-S 
these are the sort of ball park figures that they use and within reason 
flexibly they're true what i'm trying to get at is the last bit here the 
systolic if you say to most people what does shock mean they say oh drop in 
blood pressure look how far down that is with fifteen per cent loss all you 
might find is a slight tightening of the tree systemic vascular resistance will 
go up to compensate but at that stage you've lost three-quarters of a litre 
that's fairly impressive the heart rate will go up by the time you this is from 
nought to fifteen then from fifteen to thirty so on their way up to thirty per 
cent the heart rate goes up there's still no drop in blood pressure but just 
before you get the drop in blood pressure you can see you can still lose one 
and a half litres considerable loss appears hidden to people who aren't in tune 
with the symptoms and this i think is one of the important things about shock 
by the time you do get a drop in the blood pressure you're talking two litres 
okay and you really are in trouble by then is everybody reasonably happy with 
that i think that's why the one of the more important clinical aspects to take 
away what are you going to do about it again let's be er exam orientated about 
this it doesn't matter what the question is what exactly we're going to treat 
in all critical situations it could be shock it could be anything else it could 
in an infarct whatever the answer is always A-B-C because that's the safe way 
of addressing a critical situation A for airway B for breathing C for 
circulation this gives you a moment to get your thoughts together while you 
structure the answer to the best of your abilities so what are you going to do 
about the airway let's let's have some offers where did we get to we got to 
you're looking particularly bored young lady with er hand on her chin punching 
herself to keep awake
su: 
nm5231: open patent airway yeah going along the table to your oh you've er 
already had a go mate
sf5239: 
nm5231: a dual thrust well that's part of keeping the airway open yeah ok 
anything else
sf5240: remove anything from inside the mouth
nm5231: yes okay clear the airway yes 
sf5241: i can't think of anything else
nm5231: i'm sorry
sf5241: can't think of anything else
nm5231: okay that's your no you haven't dyed your hair it's okay er right any 
other offers 
su: 
nm5231: sorry 
su: 
nm5231: well we've done a few manoeuvres to make sure it's patent we've taken 
obstructions out and we've done jaw lift chin thrust in an effort to move the 
back of the tongue off the postero aspect and clear the airway anything else 
there sorry are we going to just breathe how much oxygen's in the air twenty-
one per cent do you think that's enough if you're in trouble it can't hurt you 
can it right okay clear up plus or minus and adjunct and then look at the 
supplemental that you can give the issue of an adjunct for the airway er wh-, 
by that i mean er an oropharyngeal airway or a nasopharyngeal airway has 
anybody tried to put one of those in before yeah er you have to do an oral 
airway on a patient who's fairly subta-, er unconscious obtunded if you try it 
in an awake patient you'll get a smack because it's not very nice the nasal one 
you can do in a more conscious patient but it goes past the area on the medial 
aspect of the nose where three blood vessels come together which is called L-, 
nm5231: Little's Area excellent and that bleeds like a stuck pig if you get 
that wrong and scratch it you turn a very small airway problem into a huge 
airway problem because the blood will go back hit the chords chords spasm 
you're in trouble so these are not to be taken lightly they should be used 
appropriately how can you give the supplemental oxygen as we suggested it can 
go either orally or nasally er what do you think is my chosen method sitting at 
the end there an awake conscious i'm asked please write up some oxygen for this 
guy what method oral or nasal do you think i use
sm5242: nasal via a mask probably
nm5231: nasal excellent why do you think i use nasal
sm5242: because they're awake and they're conscious and
nm5231: okay not really sir
sm5242: because it's easy to deliver that way
nm5231: it's just it's actually more easy to put a face mask over them and walk 
away they can talk through it swear through it cough whatever putting two 
little probes under the nose is highly irritating and they do fight and throw 
them off any other offers
su: you get more air oxygen going through your nasal cavity than you do through 
your mouth
nm5231: no right let's 
sm5243: is it because physiologically you are designed to breathe through your 
nose and you can moisturise and things like that
nm5231: yes that's it heat and moisture exchange now obviously none of the 
ladies snore yeah right so er you wouldn't know what it's like to wake up with 
a really dry throat and a sore mouth because you've had gas moving across your 
mouth basically dries the upper airway out now you have er cilia all the way 
down your respiratory tract which are six microns long and beat at a hundred 
times a minute and they form a mucociliary escalator they move mucous and er 
fluid and dust particles that have become trapped in this up the respiratory 
tree during the course of the day and three or four times a day you'll go 
without knowing you're doing it and you've just coughed it up and swallowed it 
mmm if you allow the airway to dry out this mucous goes hard the cilia break 
and that's it you've got no mucociliary escalator that means all the crap sits 
at the bottom and you're at great risk of a chest infection er anybody here 
smoke of course you don't you're all medical students yeah right er that does 
exactly the same strips the cilia off okay and causes retention of secretions 
which is why after you've stopped smoking you get this terrible cough and 
people say oh i gave up smoking but i got the most disgusting cough i i went 
back on the fags it was easier the problem being that when you stopped all the 
hairs grew back in your lung and went jeez look at this lot and they're trying 
to get it up er and you had to go through a period of expectorating all of this 
rubbish so at the end of the day do no harm one of the basic tenets of medicine 
so given the choice you give them nasal oxygen sorted the last twist is if any 
of you do paediatrics very young er patients are obligate nasal breathers so 
you can put it over the mouth if you want but it's not going to do any good 
what about er Chronic Obstructive Pulmonary Disease call it waht you like can 
you give those oxygen right show of hands who would give a C-O-P-D patient 
oxygen okay alright let's give you a clinical scenario so we do it properly er 
you are in your first day in A and E and sister says in resus we've got a an 
old dear chroni bhroni er coughing blue bloated the whole nine yards sitting in 
in there and she looks grim can i give her some oxygen doctor all those who 
would raise their hands please okay all of those who wouldn't how refreshing 
good for you no the answer is yes okay when i was working at er Dudley City 
Hospital we had er a very dedicated medical team who'd read an awful lot about 
this and thought oxygen was bad for you and didn't give it and still didn't 
give it and then carried on not giving it and then the patient came to some 
serious harm so we had a meeting where they finally got an anaesthetist in to 
sort this out for them if you do give somebody oxygen like this what is the 
problem 
nm5231: the drive that's it most of us rely on C-O-two for our drive in this 
situation you've reversed it and you're relying on hypoxia for the drive now if 
you give them oxygen you take away the hypoxic drive big deal you're in a 
hospital if it hits the fan who're you going to call Ghostbusters the 
anaesthetist no you're right you're right you'll you'll find out don't you 
worry when it when it hits the fan who are you going to call it's one of us 
basically obviously we don't appear on Holby City and A and E and all the not 
that i'm bitter but there you go er at the end of the day if they lose their 
drive but they are oxygenated they are safe you can take other measu-, other 
measures or methods to actually deliver the oxygen to them such as face mask 
ventilation or endotracheal tube and external ventilation so rather be safe and 
deal with the consequences later and in a place of safety like a hospital 
you've got no excuse not to give it if they stop breathing it doesn't matter we 
can sort it right secretions mm lovely er why do you think i'm interested in 
that yes oh sorry were you just doing your hair i do apologise er if you have 
somebody er going off to sleep and waking up from awake to asleep is usually 
fairly quick the stages of anaesthesia are plainly seen with a gaseous 
induction but that's not very commonly done now an intravenous you go straight 
through bang gone as you wake up you sometimes come through the awake bit 
slower the secretions can cause terrible chord spasm if you are not awake 
enough to coordinate a cough and clear things then you could be in trouble so 
it's worth assessing secretions in some patients so maybe give them a drying 
agent pre-operatively like and go back and review them right breathing th-, the 
rate rhythm and the air entry again it doesn't matter what the question was 
this is the answer when it comes to exam time er what do i mean by ronchi or 
ronchi extra sounds now you could do a whole lecture on the other things you 
might hear er leading onto a description of other pathologies and i thought 
rather than bore you we'd just touch base with those which do you think i feel 
is the most important of those 
nm5231: sorry there was a clue earlier in the discussion 
nm5231: rate yes absolutely it's a very good clinical sign it is incredibly 
difficult to breathe fast unless you've got a reason to do it okay and it's 
exhausting it really is so when assessing somebody or treating them the rate is 
a good end point to see how your resuscitation is going if you have somebody in 
pain you get sympathetic outflow and that also causes if you have somebody 
who's shocked we touched on it you have an area of hypoperfusion so you are not 
going to undergo aerobic respiration in that area you will undergo anaerobic 
respiration and build up a peripheral lactic acidosis your acidosis needs to be 
sorted out out somehow your peripheral vascular acidosis is usually cleared by 
causing a respiratory alkalosis so you'll find them trying to blow off the C-O-
two in an effort to get rid of the peripheral vascular acidosis right 
circulation aspect heart rate maximum heart rate two twenty minus age why do 
you think that figure exists any offers any offers any offers sir you look like 
a bright chap what er why do you think there is a figure 
sm5243: 
nm5231: i was looking at another chap but that's yeah okay am i sorry am i a 
bit cross-eyed this afternoon er there are lots of studies er who does studies 
researchers who looks after patients physicians so enough said right er why do 
you think that sorry i was picking on you sorry mate why do you think that 
figure exists
sm5243: er it's an it's an indicator of a of a heart rate above which you can't 
get an effective cardiac output
nm5231: nearly there nice one well that's good effort thank you basically if 
you take a little baby what's the heart rate of a a brand new baby 
nm5231: sorry a hundred and forty sometimes depending whether they've had a 
feed a pee or you've just whalloped them heart rate of an old dear sitting 
there reading the Daily Telegraph or something sixty seventy what do you think 
the most important part of the cardiac cycle for these patients is sorry it's 
diastole let's go back to the physiology i don't know what your course is 
structured like and i'm not entirely sure where the i'm sure you know all of 
this but where you've touched base with this coronary artery blood flow only 
occurs during diastole during systole the pressures are so high in the actual 
myocardium there is no pressure gradient okay as the heart rate is increased 
the period that is shortened is diastole so the period available for coronary 
artery perfusion is also shortened hence there's a maximum above which you are 
unable to perfuse your myocardium at that age so if you've got a sixty year old 
you don't really want to put them up over about a hundred and sixty really do 
you but if you've got a twenty year old i i'm sure some of you have had heart 
rates in excess of that if you've been whatever so it's worth knowing if you 
are therefore looking at a patient in recovery and they say the heart rate's a 
hundred and twenty doctor if you've got two next to each other you've got a 
twenty year old and an eighty year old totally different ball game you're a bit 
worried about the eighty year old because you're thinking mm mm mm touching 
base you are looking at slowing that patient down but you're also aware that at 
that age they are rate dependent what are you going to do call Gho-, Gho-, 
Ghostbusters get one of us down and we'll increase the the preload increase the 
ventricular output er BP when you're assessing the blood pressure i put down 
the mean arterial pressure why do you think i've made a point of that it's 
because looking at the physics that is responsible for the majority of the 
pressure the mean okay two thirds of it when you look at the actual pulse wave 
the shape of it can be controlled by the pliable nature or not pliable 
depending on age of the vascular tree if you've got an incredibly i-, 
uncompliant vascular tree in the old patient due to atherosclerosis it's very 
hard and that just makes the spikes very high and sometimes the troughs very 
low but the mean is still the same so that is a true reflection of what the 
blood pressure is so when somebody says to you oh but the systolic's a hundred 
and sixty doctor you say well yeah how old's the patient okay be sensible look 
at the real points we touched upon capillary refill er if you have hypovolaemia 
your capillary refill times erupt because you're periphery veins are 
constricted stands to reason really all of these er first three are very quick 
to assess they're indirect measures of how you are achieving perfusion end 
organ perfusion is something like urine output are you actually getting enough 
blood at the right pressure to the to produce urine that is a true end point 
but there is a lag in seeing that so we rely on the top three in the first 
instance hoping to god that the end organ backs us up on our management of the 
top three so what are you going to give they open the cupboard and they go well 
there you go er what do you want to give you've decided you're hypovolaemic and 
you've said oh we need to give some fluids any offers 
nm5231: normal saline anything else 
nm5231: gelatines anything else
nm5231: right basically there are several classes there is no right or wrong 
answer each class you can make an argument for okay some of the arguments are 
very tenuous to say the best let's just have a look at how most junior doctors 
make their decision okay when asked how to give er the fluids let's go back one 
i think this is the end you can split them into crystalloid colloid blood 
products the crystalloids it's five per cent dextrose normal saline or dextrose 
saline the colloids you've got starches you've got gelatines you've got albumen 
and on the blood side you've got blood blood products like F-F-P platelets and 
those sort of things this is a mine field i spent two hours this morning trying 
to educate er some anaesthetists to be sensible in their choice i'm not 
expecting you to be experts at this at all what i'm going to say to you is that 
er any fluid is better than no fluid i'll put it in context if you're dealing 
with shock a as a junior you shouldn't be on your own with that patient and B 
er you're looking for quick volume expansion aren't you if you remember the 
fact that for every er unit of blood in inverted commas volume of blood you 
want to replace if you use crystalloids you've got to give three times the 
volume you will then understand that you are going to cause three times the 
side effects of crystalloids and take three times as long which is why in hypo 
er volaemic states most people give a volume expander of the colloid or er 
blood product variety now we can go in for hours into the colloids and say 
they're split into the starches and the gelatines most people end up giving er 
gelafusin have you all heard of gelafusin a standard colloid now i put up er a 
lecture this morning about the gelatines and basically gelafusin and haemaccel 
are the two common ones gelafusin is a boiled cow basically that's where they 
get it from they break down the carcass of of cows and the same for haemaccel 
now the gelafusin begins with a G and therefore is good and is succinilated 
it's link with er entity the haemaccel starts with h and is horrible and is 
therefore urea linked so the haemaccel is a boiled cow that someone has pissed 
up i don't want that in my veins i don't know about you the other aspect is 
that it has calcium in it and if you are in the process of replacing blood for 
these patients the calcium has a nasty habit of clotting everything off because 
you've got citrate in the blood products to stop them clotting and you can be 
in real trouble this is a separate lecture the administration of fluids what 
i'm trying to get across to you are the basics of hypovolaemia and the other 
types of shock any questions not one so you're all entirely happy with what 
shock is and how to deal with it 
sf5244: can you just put up the last slide the previous slide please
nm5231: yeah yeah yeah right i would like to thank the medical students who 
presented you did two excellent presentations thank you very much and as i say 
what i've told these guys is that you are all very welcome to approach any 
member of the anaesthetic department and come and spend some time in the 
theatres and see what it's all about the two reasons for that are one any 
critical care you get from an anaesthetist will be useful in whatever 
speciality you go into two sixty per cent of the hospital's activity er 
involves an anaesthetist but you don't know about it until you're postgraduate 
in most cases we are trying to raise the profile of the anaesthetic department 
just to let you know who we are basically so if you want to come and play ring 
the anaesthetic department tell them who you are and you can come and spend 
time with any of us thank you very much