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PRE-OPERATIVE ORDERS POST-OP ORDERS (GA)

 Patient seen and evaluated.


 History reviewed. PE done. Chart entries and lab results noted. s/p _________ under _____________.
 Anesthesia plans explained to patient and watcher.  To PACU now.
 Risk understood and accepted.  Monitor vital signs every 15 minutes until stable then q hourly
 Secure consent for anesthesia. thereafter.
 Maintain on NPO for at least 6 hours prior to OR or NPO post  Oxygen inhalation via face mask/nasal cannula at 5 LPM until fully
midnight. awake.
 IVF: D5NR 1 L x 8 hours.  NPO until further orders.
 Anesthesia medications:  IVF: D5NR 1 L x 8 hours
a. Promethazine 25-50 mg IM  Medications:
b. Nalbuphine 10 mg IM, defer if SBP < 90 mmHg a. Ketorolac 30 mg IV q 8
c. Atropine sulfate 0.4-0.5 mg IV b. Nalbuphine 10 mg IV q8
 Monitor vita lsigns before and 15 mins after giving meds and c. Antibiotics
please record.  Moderate to high backrest.
 Lab if any  Suctions secretions as needed.
 Blood if any  Encourage deep breathing.
 Please weigh the patient. ___ Kg  WOF: Dyspnea, bleeding, hypotension.
 Refer accordingly.  Please facilitate the following labs
a. CBC
Comorbidities b. 12 L ECG
1. Hypertension- let the patient take early morning dose of anti-  Refer accordingly
hypertensive medications with small sips of water.  Thank you!
2. DM- do CBG q4 and 1 hour prior to OR once on NPO
3. Hyperthyroidism- may take anti-thyroid medications with small
sips of water to keep patient euthyroid.

POST-OP MEDICATIONS
POST-OP ORDERS (SPINAL)
1. Ketoprofen 100 mg IV q 12
s/p 2. Ketorolac 30 mg IV q8
 To PACU now. 3. Tramadol 50 mg IV q8 (RD: 3mg/kg)
 Monitor vital signs every 15 minutes until stable then q hourly 4. Nalbuphine 10 mg SIV q6 (RD: 0.2mg/kg)
thereafter. 5. Mefenamic Acid 500 mg/tab TID
 Oxygen inhalation via face mask/nasal cannula at 5 LPM until fully 6. Ibuprofen 200/400/600 mg/tab TID
awake. 7. Diclofenac 50 mg/tab BID
 NPO/ Resume diet when fully awake. 8. Tenoxicam 40 mg/tab BID
 IVF: D5NR 1 L x 8 hours 10. Paracetamol RD: 15 mg/kg (300mg/2ml)
 Medications: 11. Meperidine 25 mg IV for shivering
a. Ketoprofen 100 mg IM q12 x 2 days then shift to 12. Dolcet Tramadol 37.5 mg + PCM 325 mg q4-6 daily
Ketoprofen 100 mg/tab BID 13. Ranitidine 50 mg IV q8 or 150 mg/tab BID
b. Nalbuphine 10 mg slow IV PRN for severe pain. Defer if
SBP <90 mmHg
 Flat on bed until 6 hours after lumbar puncture.
 Refer accordingly
 Thank you!
OTHER ADJUNCTS TO ANESTHESIA

DRUG DOSE DURATION


 If Morphine sulfate given, tramadol 50 mg IV q8 PRN
 Ketorolac 30 mg IV q8. (First dose= _____). Next dose at
1. Metoclopramide 10 mg IV 1-2 hrs
_________. (10 mg/2ml) 10-15 mg PO 30-60 min

2. Ketorolac LD: 30-60 mg IM


(30 mg/ml) MD: 14-30 mg q8
LD: 15-30 mg IV
MD: 15 mg q8

3. Doxapram IV bolus 0.5-1 mg/kg


Cont infuse 1-3 mg/min
Max dose 4 mg/kg

4. Naloxone 0.4 mg/dl dilute to 0.04 mg/ml


IV dose 0.5-1 ug/kg q3-5 min
Neonatal RDS: 10 ug/kg q 2min

5. Flumazenil IV bolus 0.2 mg/min up to 1 mg


Continue infusion 0.5 mg/hr
X IN THE ANESTHESIA RECORD FLUID MANAGEMENT

SPINAL Pre-loading Adult: 12-20 cc/kg


X- LLDP, SAAS, LP done at L3-L4 using SNG 25 Elderly: 300-400 cc
(+) CSF, clear and free-flowing, (-) blood OB: 1-2L
Bupivacaine/Tetracaine __ mg given intrathecally Fluid Deficit 2ml/lg x hrs of NPO
Morphine Maintenance x hrs of NPO
Give ½ 1st hour
EPIDURAL Give ½ 2nd-3rd hour
X- LLDP, SAAS, EP done at L3-L4 using TNG 18, Epidural space Maintenance 1st 10 kg x 4cc/kg
identified by LORTA/hanging drop 2nd 10 kg x 2 cc/kg
(-) CSF, (-) Blood Remaining kg x 1 cc/kg
EC threaded up to level (___+5 cm). Test dose of Epinephrine ___ Shortcut: Wt +40
and Lidocaine ___ given. Replacement Procedure dependent
Head 2-4cc/kg
GETA Extremities 4-6cc/kg
X- Write in order of the drugs given. Thoracic 6-8cc/kg
Concentrate dose and meds of administration. Abdomen 8-10cc/kg

Convert to Macrodrops MF + RF/ 4 (gtts/hr)


Estimated Blood Volume Wt x factor
REGULAR SEQUENCE INTUBATION  Female 65
 Male 75
1. Pre-oxygenation/ Denitrogenation (Regular TV 5 min/ 4 VC 30 sec/ 8  Full term 85
VC 1 min)  Premature 95
2. Opioids: Fentanyl 2 ug/kg
3. Sedatives: Allowable Blood Loss Actual Hct- Desired x EBV
a. Propofol 2-3 mg/kg Actual
b. Thiopental 507 mg/kg RBC Vol PreOp EBV x Hct Preparation
c. Midazolam 0.05-2 mg/kg RBC Vol 30% EBV x 20%
d. Ketamine Red cell Loss RBC PreOp- RBC 30%
e. Diazepam
f. Etoidate *1 PRBC increased Hgb by 1 g/dl and Hct by 2-3%.
4. Check for eyelash reflex.
5. Ventilate with bag. Check for chest rise.
6. Turn on volatile
7. Muscle relaxant: FRESH GAS FLOW
8. Intubation: Cuff, stylet out, ventilate, tape, ventilate
9. Volatile anesthetics FGF MV x 3
Minute ventilation (MV) TV x RR
DRUGS DOSE PREP Oxygen consumption Wt (lbs) x 2
1. Fentanyl 1-2 ug/kg 50 mcg/ml Tidal Volume Wt (lbs) x 3
2. Propofol 2-3 mg/kg 10 mg/ml 6-8 ml/kg
3. Atracurium 0.5 mg/kg 10 mg/ml FGF TV x RR x 3
4. Rocuronium Wt (lbs) x 3 x RR x 3
Urine output 0.5 cc/kg/hr (Adult)
ET tube size= Age/4 +4 1 cc/kg/hr (Pedia)
ET tube level = Age/2 + 12

RAPID SEQUENCE INTUBATION


CRITERIA FOR EXTUBATION
1. Pre-oxygenation/ Denitrogenation (4 VC 30 sec/ 8 VC 1 min) SUBJECTIVE:
2. Opioids: Fentanyl 2 ug/kg 1. Follows command.
3. Pretreatment with non-depolarizing NMB(Atracurium) 2. Clears oro/nasopharynx.
 Priming dose: 10-15% of usual intubating dose 5 mins before 3. Intact gag reflex.
induction. 4. Sustained head lift > 5 sec.
4. Best is Rocuronium at 0.1 mg/kg. 5. Adequate pain control.
5. Sedatives: (Thiopental) 6. Minimal end expiratory concentration of inhaled anesthetics.
 Induction dose given as bolus OBJECTIVE:
 Substitutes: Propofol, Etomidate, Ketamin 1. Vital Capacity >10 ml/kg
6. Mask over patient. 2. Peak voluntary negative inspiratory pressure > 200 cm H20
7. Apply Sellick’s maneuver to prevent aspiration. (B-U-R) 3. TV >6 ml/kg
8. Muscle relaxant. (Succinylcholine) 4. Sustained tetanic contraction T1/T4 >0.9
 1.5 mg/kg immediately after thiopental or Rocuronium 0.8-1.2 5. Alveolar-arterial O2 gradient (PA-Pa 02) < 350 mmHg 100% Fi)2
mg/kg 6. Dead space to TV ratio <0.6
9. Patient is rapidly intubated once spontaneous efforts have ceases (30-
60 sec). Maintain cricoid pressure until ET cuff is inflated. Open *Extubation is best performed when a patient is either deeply sedated (III) or
volatile. awake (I); recovery from NM Blockers should be established prior extubation.
10. Muscle relaxant 10 min after Succinylcholine. Maintain Volatile * Increased risk for laryngospasm when extubation is done during a light
plane of anesthesia (II).
*Sellick’s Maneuver-
GA NEEDS

1. Nalbuphine 10 mg/amp
2. Promethazone 50 mg/amp
3. Atropine sulfate 1mg/amo
4. ETT size 7 ,7.5,8
5. Suction catheter fr 14
6. Succinylcholine
7. Atracurium 10 mg/amp
8. Propofol 10 mg/ml vial
9. Midazolam 5 mg/amp
10. Ketorolac 30 mg/amp
11. Epinephrine 1 mg/ml
12. Ephedrine 50 mg/ml
13. Neostigmine 0.5mg/ml
14. Oral airway
15. Leukoplast
16. ECG pads
17. Omeprazole 40 mg/amp
18. Metoclopramide 10 mg/vial
19. IV Cannula g18,20
20. Macroset
21. K50 extension tubing
22. Syringe 10cc, 5cc, 3cc, 1cc
23. NGT tube F