Download DEPARTMENT OF

DEPARTMENT OF
CARDIOTHORACIC ANAESTHESIA
FREEMAN HOSPITAL
NEWCASTLE UPON TYNE
HANDBOOK
Revised August 2016
INTRODUCTION
The Department of Cardiothoracic Anaesthesia welcomes you to the Cardiothoracic
Centre at Freeman Hospital.
The Northern Regional Health Authority has two established cardiothoracic centres,
one at Freeman Hospital in Newcastle on Tyne and the other at South Cleveland
Hospital in Middlesbrough. Freeman Hospital is one of the most comprehensive
centres in the country with integral cardiological, thoracic and intensive care services
and a case mix that includes all types of adult and paediatric cardiac and thoracic
surgery including heart and lung transplantation, VADs and ECMO as well as
dysrhythmia surgery. The Department in association with the Directorate of
Cardiothoracic Surgery and the Directorate of Cardiology and Respiratory Medicine
provide the medical services for the Cardiothoracic Centre.
This handbook is intended as a guide to maximise your learning during the limited
period that you have with us. The Consultant staff are still learning things every day
and we do not expect you to master cardiothoracic anaesthesia during your rotation.
However, you will come in close contact with cardiovascular and pulmonary physiology
and various methods of controlling and altering pathological states. This will provide
you with a sound base applicable beyond the cardiothoracic centre. Some of you who
desire to become specialists in cardiothoracic anaesthesia may take the opportunity
of spending a year as a Fellow in the speciality at a national training centre such as
ours.
The opportunity for obtaining knowledge and “mastering” new skills depend on how
energetically you take advantage of our resources. We can guide you towards
reference articles, textbooks and meetings to support your efforts. Whatever your
level of training, we are glad to have you as a colleague and welcome you to our
training programme in cardiothoracic anaesthesia. We hope you will enjoy working in
the department.
The Department is situated in the Cardiothoracic Centre. We have a suite of 4
operating theatres and 6 radiological laboratories in close proximity to the adult and
paediatric cardiac ITU’s. The adult cardiac intensive care unit (ward 21) is sited on
level 3 of the Cardiothoracic Centre of Freeman Hospital. It has 21 ITU beds
consisting of a main bay with 15 beds and 6 cubicle. At present, there is not enough
nursing staff for all 21 beds but the staff is used flexibly to make maximum use of
these facilities. The unit is comprehensively equipped with modern haemodynamic
monitors, ventilators, blood gas apparatus etc.
The old cardiac ITU is now called 25a and is used as a level 2 step down but mainly
for post op thoracic patients. It is staffed by the same nurses as adult ITU but the
first line medical cover is the surgical team. It frequently closes at the weekend. The
Paediatric ITU has 6 beds and is staffed for 4-6 beds at present. Equipment is
similar to that in the adult ITU.
We use Th19 several times a week in the Institute of Transplantation notably for the
robot assisted cases.
The pre and postoperative cardiothoracic patients are housed in Ward 23
(paediatric), Wards 24, 24A (CCU), 25, 30 (adults) in the cardiothoracic block.
Occasionally patients may be in 29 but this is a respiratory ward.
PERSONNEL
ADULT CONSULTANT STAFF:
Dr Hazel Powell, Rota-maker
Dr Kevin Brennan, Head of Adult ITU
Dr Chandrika Roysam, TAVI lead
Dr Deirdre Timon
Dr Leena Pardeshi, Flexible Training Advisor for SHO & SpR
Dr Mahesh Prabhu, Echocardiography Lead
Dr Orathi Sanjay
Dr Abraham Samuel, Acute Pain Lead & Audit Lead
Dr Denis O’Leary ,Head of Department, VAD Lead
Dr Henning Pauli ,Deputy College Tutor
Dr Anthony George, ECMO lead
Dr Francesca Caliandro
Dr Jim Park
Dr Shabana Anwar, Consultant Intensivist
Dr Mostafa Eladawy (Locum)
PAEDIATRIC CONSULTANTS
Dr Simon Haynes, Anaesthetist and Intensivist
Dr Jon H-Smith, Anaesthetist and Intensivist, Lead for all Paediatric Intensive Care
Units in the Trust, Lead Clinician for ECMO
Dr Thesesa Chila, Anaesthetist
Dr Alan McCheyne, Anaesthetist
Departmental Secretary
TBIC - Direct Line 0191 2137488
Trainees – The department has nine Cardiothoracic Fellows and five ST Trainees
from the Northern School of Anaesthesia.
There are also two adult critical care practitioners ACCPs on the ST rota
Other Key Personnel:
Mrs Liz Bailey - Speciality Manager
Dr Simon Haynes– Clinical Director
Lorna Charlton – Matron, Adult ITU (ward 26)
Karen Mason – Anaesthetic Sister
Billy Watson – Chief Perfusionist
David Kinnersley- Theatre Matron
Cardiothoracic Module
The aim is to expand a trainee’s understanding of the peri-operative management of
patients suffering from advanced pathology of the cardiovascular and respiratory
systems. A wide spectrum of age, pathology and therapy are covered from
preoperative assessment to postoperative management. Relevance to everyday
practice comes from the fact that such patients may present for anaesthesia in nonspecialist hospitals.
Many centres will be able to undertake the training of sub specialists who wish to
become consultants in a particular field. Such training should be an extension of
training on offer to UK anaesthetic trainees. It should not be restricted to UK
trainees but also be available to candidates from other countries. National Training
Centres for Sub-specialities, particularly highly specialised facets such as
anaesthesia for paediatric cardiac surgery, intensive care and transplantation is a
concept for the future.
It is generally felt that the period of training for a consultant with a special interest
in cardiothoracic anaesthesia should be a minimum of twelve months cardiothoracic
anaesthesia in addition to the basic anaesthesia training. For overseas trainees or
fellows, a similar period is appropriate.
The training programme includes a series of guidelines and emphasis in the following
areas: Cardiac Anaesthesia; Cardiothoracic ITU; Perfusion Techniques and ECMO;
Cardiothoracic Transplantation; Thoracic Anaesthesia; Echo Cardiography; Paediatric
Cardiac Anaesthesia and Intensive Care; Presentation Skills.
Formal Teaching
1.
2.
3.
Formal Combined Anaesthetic Teaching- as per departmental programme,
Anaesthetic Seminar Room, Level 1, General Anaesthetic Department
Monthly Audit – Mandatory (Dates available from Secretary), Cardiothoracic
Lecture Theatre, Level 2
Every Thursday Evening
17:00 – 18:00 Teaching, Cardiothoracic Seminar Room Level 3 Portakabins
Alternating Journal Club and Teaching (all welcome)
ADULT CARDIAC ATTACHMENT
1.
Adult ITU (WARD 21)
If you are rostered for Ward 21 during the day (0800-2000), you are
expected to take a hand over from the on-call anaesthetic trainee of the
previous night, with the ITU consultant at 0800. You are also one of the
designated bleep holders for cardiac arrests in the cardiothoracic centre.
Only the top of the ‘green sheet’ need be done for this. The transplant VAD
and ECMO patients will be done by the tx fellow. Subsequently full patient
reviews are organised with the team on ITU, examining all systems of the
patient in depth. In this time, the previous day’s patients are reviewed and
either discharged or the decision made to retain in ITU – these are usually
done by the ITU2 consultant. After coffee (!), a formal ward round with
trainees presenting the findings occurs at 11.00 and then clinical plans are
formulated. Progress notes and plans are documented in the patient’s notes
and the “Daily Instructions” sheets completed.
All chest X-rays must be reviewed daily either during or immediately after the
morning round. Following the ward round, the trainees complete the various
tasks allocated to them during the round.
At the end of your shift, you are expected to hand over to the incoming
anaesthetic trainees who are on-call for the night.
The trainees accept patients as they come from the operating theatre. An admission
note needs to be completed (yellow form). Of particular importance are any problems
preoperatively, any specific management instructions from the theatre anaesthetic
or surgical teams especially in relation to cardiovascular support, ventilation and
sedation. First Day Patients are looked after overnight by the Anaesthetic ST.
Cardio-anaesthetic fellow and the anaesthetic ST needs to be familiar with all
patients..
The 730pm handover round will be done together with the fellows
Trainees should frequently review patients to ensure optimal progress over the
course of the day. If you have any uncertainties about the management of a
patient, discuss this with the duty consultant anaesthetist. The consultants are used
to having a close patient involvement and like to be aware of any concerns about a
patient’s progress
Any early post op problems that may be surgical must involve the surgical team on
call. Vad and TX are often complex and may need MDT discussion.
Educational Aims of Cardiothoracic ITU Experience
1.
To become familiar with pharmacological control of the cardiovascular
system and comfortable with managing the failing heart using all modes
of pharmacological support. To see the roll of mechanical support of the
failing heart.
2.
To gain experience of the ITU management of patients with multi-organ
failure with the background of an impaired heart.
IT IS CUSTOMARY FOR THE DUTY CONSULTANT TO INFORM YOU WHEN
HE/SHE IS LEAVING THE HOSPITAL.
IF YOU ARE UNABLE TO CONTACT THE DUTY CONSULTANT, PLEASE CONTACT
ONE OF THE OTHER ADULT ANAESTHETIC CONSULTANTS.
THE ON CALL CONSULTANT WILL USUALLY DO A WARD ROUND AT 10pm OR
SO.
SUMMARY OF OVERNIGHT WARD 26 RESPONSIBILITIES
Anaesthetic SpR - Care of First day cardiac surgical patients.
Share the management of all long term (>24hr) patients with the cardio-anaesthetic
fellow
Cardio-Anaesthetic Fellow – Care of Transplant patients, support for and supervision
of Anaesthetic SpRs ITU.
Surgical SpRs – Available on the ward for “surgical issues” on CITU such as bleeding
problems, chest re-opening and IABP insertion.
A guide for managing emergencies in Cardiac Surgical Patients
Bleeding
Coagulation problems in cardiac surgical patients can differ from the other surgical
patients. Pre-op risk factors for bleeding can be compounded by post-CPB
coagulopathy and surgical bleeding. Fluid replacement is dictated by the patient’s
hemodynamic state, urine output, haematocrit and ongoing blood losses. Consider
extra Protamine, TEG. If mediastinal and chest tube drainage suddenly stops, the
tubes should be examined for clots with concern for impending tamponade. If
bleeding exceeds 150mls/hour, please repeat coagulation profile and correct as
necessary. (2mls/kg in a small stature patient).If bleeding exceeds 200mls/hr with
hemodynamic compromise, involve the cardiac surgical registrar as re-exploration may
be necessary. Please inform the consultant anaesthetist on call. The cardiac surgical
registrar should inform the consultant surgeon about any re-exploration.
Cardiac tamponade
Accumulation of fluid around the heart can produce a severe restriction of atrial and
ventricular filling with drop in stroke volume. The classic signs of cardiac tamponade
in a post-op ventilated cardiac patient might not be obvious. The clinical suspicion
should be raised in patients with hypotension, acidosis, oliguria and elevated CVP
(consider the rate of rise of CVP rather than an absolute number).This is a clinical
diagnosis and may not be clear cut. Echocardiography should be considered.
Remembering Transthoracic echo can diagnose but cannot 100% exclude. TOE is
better.
Please inform the consultant anaesthetist on call, the cardiac surgical registrar and
the cardiac anaesthetic fellow. The treatment is re-exploration, occasionally to
exclude it as a treatable cause. Depending on the patient’s haemodynamic status, this
is usually done in the cardiac theatre. The cardiac surgical registrar will organise
getting the theatre team in. Rarely the pt may be reopened in ITU.
If general anaesthesia is required in an extubated patient with cardiac tamponade, be
aware induction can precicipate acute CVS collapse. Continue administering IV fluids/
inotropes until the team arrives. Higher Heart rate must be maintained to preserve
cardiac output. Consider turning the pacing rate up. The primary problem is reduced
ventricular pre-load and not failure of myocardium.
Give 100% O2 via face mask. Allow spontaneous breathing as long as possible. If
spontaneous breathing is not possible, use low tidal volumes with a higher respiratory
rate. Be cautious with PEEP. Be cautious with anaesthetic induction doses. Avoid
drugs that can depress the myocardium.
Antibiotic prophylaxis for chest re-exploration is 2g Aztreonam.
CARDIAC ARREST
The guidelines for CPR after cardiac surgery were reviewed by the Clinical
Guideline Committee of the European Association
for Cardio-Thoracic Surgery (EACTS).
These guidelines will be followed in the event of cardiac arrest.
Infection control issues
The Newcastle Upon Tyne Hospitals NHS Trust’s policy on Infection Prevention and
Control is the responsibility of all staff within their own sphere of work.
The Newcastle Upon Tyne Hospitals NHS Trust has adopted the WHO guidelines on hand hygiene
and will carry out regular audits to ensure that all staff comply with these guidelines.
Lack of hand hygiene was highlighted in the resent Department of Health visit. We scored very low
on cleanliness!!
The following points will be closely monitored and audited.
Hand hygiene. Wash your hands or use alcohol gel for decontamination
 Before patient contact,
 Before an aseptic procedure,
 After patient contact,
 After body fluid exposure
 After contact with patient surroundings. The last point means that we have to clean our
hand after touching any object or furniture in the patient’s immediate surroundings even if
the patient is not touched (such as trolley, beds etc.) We don’t do well on that score.
All wrist watches and jewellery (particularly stoned rings) should be removed before hand
decontamination. Cuts and abrasions must be covered with waterproof dressings. Please refer to the
WHO guidelines attached.
Gloves are single-use items and should be removed and discarded immediately afterwards.
Patients with MRSA and C Diff:
On entering the infected area, all staff should
 Wash their hands with soap and water (not alcohol gel)
 Put on disposable apron and clean gloves for protection.
 When leaving the infected area, discard the apron and gloves in a yellow or orange bag.
 Wash hands with soap and water (not alcohol gel).
Peripheral venous cannula insertion:
 Wash hand and use gloves for protection.
 Clean the insertion site with 2% Chlorhexidine Gluconate spray and allow to dry.
 Complete the peripheral venous cannula record.
 This applies to all lines inserted in the wards, theater and ITU. The only patients exempted
are those having day case procedures.
 All cannula ports must be cleaned with 2% chlorhexidine before and after giving iv fluids or
injections.
All giving sets should be changed
 Immediately after giving blood and blood products
 24hrs after giving TPN (if it contains lipids)
 After 72hrs for all infusions.
Ventilated patients:

Equipment should be visibly clean with filters in the proper places.

Tubing should be free from excessive condensation and fluid.

Staff should wear gloves and decontaminate hands before and after airway suctioning.
Goggles should be used when suctioning infected patients.

Head of bed should be elevated to 30-450 unless contraindicated.
Theatre :
Gowns should not be worn from Theatre to theatre or from ITU to Theatre.
Gowns should be bare below the elbow unless they are sterile
Caps and masks are a prerequisite in the operating theatre.
PRE-OPERATIVE ASSESSMENT
Each patient coming for cardiothoracic surgery will be seen pre-operatively, in most
cases, one to two weeks prior to surgery in the pre-assessment clinic. A COPY OF
EVERY PREASSESSMENT FORM WILL BE AVAILABLE IN THE SECRETARIES
OFFICE IN THE WEEK BEFORE THE OPERATION. The first cardiac patient will be
on the ward, the evening before the operation. The second patient might arrive from
home on the day of operation at 07:30 AM. Some unstable patients will be
transferred from other hospitals or may be admitted on the coronary care unit
(ward24A) or cardiology wards (usually ward 24). It is customary for the Consultant
to perform the pre-operative visit but the trainee should also see all patients on his
list pre-operatively even if already assessed by the Consultant.
The aim is to identify high risk patients such as
Emergencies especially following failed angiographic procedures
Severe left main stem stenosis
Severe aortic stenosis
Preoperative left ventricular decompensation
Cardiac disease in combination with other systemic disease
The following should be noted:
1.
Present and past history
2.
Type of medications used and allergies. Sensitivities. Be familiar with each
drug and dosage that the patient uses.
3.
Cath. Lab data, angiographic, echo and radionucleide studies if performed.
4.
Haematological and microbiological data.
5.
ASA and NYHA classification should be made.
6.
Anaesthetic considerations
a.
Airway – intubation difficulty
Teeth – poor repair, are extractions required prior to surgery.
b.
Neck – mobility, dizziness on extreme flexion, carotid bruits, jugular
venous access.
c.
Pulses – equal bilaterally, evidence of vascular disease, previous shunts
or dissecting aortic aneurysm.
d.
Heart – Can the patient tolerate lying flat? Can PA catheter be inserted
safely? Danger of air embolism from a R to L shunt.
e.
Lungs – Bronchospasm, preop pulmonary hypertension, pneumonia.
f.
Neurological – There is a high incidence of neurological sequelae
following cardiopulmonary bypass, hence a brief evaluation of carotid and
cerebrovascular disease must be made. Previous stroke, TIA, muscle
weakness, blurred vision and dizziness should be noted.
7.
Pre-medication for adults individual consultants have preferences please liaise
with them.
Antibiotics
Flucloxacillin 1 gram or Clindamycin 300 mg (for patients
allergic to penicillin) is given orally with the pre-medication.
If MRSA+ve, teicoplanin is used as antibiotic prophylaxis
Other drugs
Familiarity with cardiac drugs and their dose regimes should
be undertaken at an early stage. Warfarin should be
discontinued at the earliest opportunity – check INR on
morning of surgery if patient is on warfarin.
Ace inhibitors
For the most part ACE inhibitors should be withheld from
the evening before surgery until postoperatively
Aspirin and anti platelet agents
They should be usually discontinued before surgery. Routine
patients approx 7 days preop, sometimes they are continued
in ‘unstable’ patients or if stents have been placed.
ALL OPEN HEART AND OTHER COMPLEX CASES MUST BE DISCUSSED
WITH YOUR SUPERVISING CONSULTANT PRIOR TO ANAESTHESIA
Intra-operative Care
Physiological Monitoring Technicians (PMT) They are highly trained in this
field and are good trouble-shooters when necessary. They are there to
support you if you wish to use monitoring equipment, pacemakers,
defibrillators, insert a pulmonary artery catheter or an intra-aortic balloon
catheter in the cardiac theatres and ITU’s.
Defibrillators
A.
External defibrillator (unsterile) is always connected at start of the
case.
B.
Connect internal defibrillator (sterile) when chest opened.
C.
External pads if patient is having separate cardiac surgery or a “redo” or
is a major risk of arrest prior to sternotomy.
Trained Anaesthetic Nurses/Operating Department Assistants will help the
anaesthetist(s) during the operation. An on-call nurse/ODA will assist you
during out of hour’s operations. They are responsible for:
Checking and connecting the anaesthetic machines and suction apparatus
in the theatre and anaesthetic rooms. This includes pulse oximeters and
capnographs.
Checking that there is an adequate supply of syringe pumps in working
order.
Preparing the airway equipment and intravascular trays.
Drawing and checking the anaesthetic drugs required by the
anaesthetist.
Making sure that the patient’s blood is available in the theatre blood
fridge. Providing help during the operation in obtaining various
medications, blood or other types of fluid.
Helping in the safe transport of the patient to the ITU following
surgery.
Anaesthetic Record
These are important medicolegal documents and care must be taken to ensure
accuracy. The open-heart surgery record is comprehensive and well laid out. It
comes in duplicate, the first copy is attached to the patient’s notes by the
anaesthetist if required. If you are unsure about its use, discuss it with your
consultant. The anaesthetic record for non-open heart surgery is a two-page
document, which is also comprehensive and is used across Freeman Hospital. There is
only one copy, which must be attached to the patient’s notes.
Pre-Induction
The anaesthetic nurse is there to help you and has checked the equipment and
prepared the medication needed for your anaesthetic. Please double check.
When patient arrives in the anaesthetic room:
1.
14G Intravenous cannula inserted into a large vein on hand/forearm under local
anaesthesia (LA).
2.
20G cannula inserted into radial artery under LA. Connect to transducer
system. Record baseline haemodynamic parameters. Obtain room air blood gas
sample. For thoracic patients discuss plan with the consultant.
3.
Oxygen administered via a face mask and pulse oximeter attached. ECG leads
attached. In redo cases, external defibrillator pads are attached.
PLEASE NOTE THAT SMALLER GAUGE CANNULAE ARE USED FOR
PAEDIATRIC PATIENTS.
Induction
1.
Appropriate anaesthetic and antibiotic drugs.
2.
Intubate and connect to the ventilator using O2/air/volatile if using. CVP line
is generally inserted into right internal jugular vein usually after induction (left
side if heart transplant). The CVP line should be stitched into the skin in two
places and then covered with a sterile dressing. Three way taps are attached
to each limb of the CVP catheter and capped. If PA catheter is to be used,
insert sheath and catheter at the same time.
3.
Oesophageal or nasal temperature probe is sited.
4.
Foley catheter inserted into the bladder by the surgical trainee and connected
to a urometer.
Post-Induction
1.
Transfer patient to the operating room and connect to ventilator using 02/air
and volatile agent mixture if using. Connect to pulse oximeter and Capnograph.
2.
PMT will connect the haemodynamic monitoring.
3.
Confirm that all the monitors are connected and working properly before
allowing the scrub nurse to prepare the patient for surgery.
4.
After chest is opened, the scrub nurse will pass the defibrillator cables over.
Connect them to the defibrillator.
Pre-bypass Management
1.
Deflate lungs if requested and inform surgeon that the “lungs are down” prior
to sternotomy. 2 units of concentrated donor blood are available in the
theatre transfusion store for routine bypass operations, 4 units for ‘urgent’
procedures and 4-6 units for redo procedures. For redo procedures ensure
that at least 2 units of blood are available in the theatre before reordering.
Be aware of sudden, massive haemorrhage during sternotomy or subsequent
2.
dissection. Loss of functioning graft during this procedure may result in
ischaemia.
Follow anticoagulation protocol. The surgeon usually requests Heparin to be
administered prior to cannulation . Give heparin slowly via the CVP line and
inform surgeon and perfusionist that heparin has been given.
ACT is
performed 2-3 minutes later. Patients on pre-op heparin may be resistant and
require further doses. ACT > 300 can use the pump suction but Please ensure
that the ACT is > 400 secs prior to commencing bypass.
Cardiopulmonary Bypass Management
Cardiopulmonary bypass is managed mainly by the perfusionist. The anaesthetist is
responsible for the composition of the prime and any additions during the procedure,
the administration of volatile, other anaesthetic drugs and vasoactive agents into the
bypass apparatus. The anaesthetist must prescribe and sign for pump ingredients and
parameters for CPB such as pressure and HCT.
1.
2.
3.
4.
5.
6.
7.
The perfusionist goes onto bypass slowly. Watch blood pressure carefully for
any unusual rise or fall in systemic, central or cpb line pressure. It may indicate
improper cannulation. Inform the surgeon immediately.
It is important to make sure that SVC drainage is good and the CVP is low.
Check eyes for pupillary size and conjunctival oedema, face for development of
plethora during bypass and differential cooling of the two sides of the face
(Watson’s sign). Check carotid arteries for thrills. These features act as a
further screen of improper cannulation.
Stop ventilation when full bypass is established. Turn off unneeded infusions;
administer additional anaesthetic agents if required. Withdraw PA catheter 57 cms (if used).
Maintain mean arterial pressure between 50-70mm Hg using a volatile
anaesthetic agent or a vasoconstricter agent as required.
An infusion of a vasodilator may be administrated during cooling and rewarming.
Measure ACT when working temperature has been reached and repeat every
half-hour. Maintain ACT above 400 seconds (600 seconds when Trasylol is
used)
To wean off bypass, the following conditions should be met:
a.
Nasal temperature > 36.5 degrees
b.
Blood gas, potassium and ionised calcium within normal limits.
c.
Normal sinus rhythm is preferable with a rate 70-100 depending on the
case. Use atrial pacing or AV sequential pacing if necessary. Maintain
perfusion pressure around 70 mm Hg.
d.
Start ventilation, initially by hand to expand noncompliant, atelectatic
areas, which have developed during bypass.
Switch over to the
ventilator and check that the correct tidal volume, gas concentration and
volatile agent are being delivered. Avoid stretching the IMA graft
during initial expansion of the lungs. Restart the pulse oximeter and
capnograph if disabled.
8.
The surgeon, perfusionist and anaesthetist will wean the patient off bypass
together. Check that the heart does not overfill. Observe the monitors and
the heart directly.
Post Bypass Management
1.
The anaesthetist takes over the management of cardiovascular haemodynamics
and circulation blood volume. The use of vasodilator and inotropic therapy
should be considered. Pump blood should be returned in aliquots of 50 - 100mls
at a time based on filling pressure and condition of the heart.
2.
Following removal of venous lines and discussion with the surgeon, protamine
is administered slowly. Inform surgeon and perfusionist when protamine
commences so they can discontinue suction and when all the protamine has been
given.
3.
Non-heparinised blood sample taken for estimation of ACT and a heparinised
sample taken for blood gas 5-10 minutes after protamine administration. If
ACT is not within 10-15 seconds of control, an additional 50 mg of protamine
should be given and ACT checked again. If ACT still abnormal, check
coagulation screen. Condsider heparinase TEG. (ACT is affected by
temperature and hct as well as heparin)
4.
It is desirable to keep the MAP between 70-80 mm Hg, recognising the
patients pressure range may be higher. Hypertension is treated with additional
opiates, volatile agents or a vasodilator either as a bolus or infusion.
Hypotension is usually treated with colloid replacement if under filled or
inotropic agent if heart is full and sluggish.
5.
There may be “pump blood” that is bagged after weaning off bypass. Remember
this is heparinised and consider further protamine. Routine use of cell salvage
is now in practice and this pump blood may be washed.
6.
Complete ICU short order form in full.
7.
Transfer patient to the ICU with a nurse and a monitoring technician. If
inotropic or vasodilator infusions are being used in theatre, they should be
continued during transfer. The patient is hand ventilated and connected to a
monitor, which displays ECG, heart rate, BP and pulse oximetry during transfer.
8.
Arrival at the ITU bed space, connect your patient to the ventilator with
appropriate settings and switch on the disconnect alarm. Hand over your
patient to the ITU resident and nurse. They will be interested in any
surgical or anaesthetic problems, haemodynamics, inotropic and vasodilator
therapy, blood gas exchange, fluid balance and critical incidents in theatre if
any.
INOTROPIC AGENTS
Intravenous infusion dose guide
In Freeman Hospital, concentration of inotropic agents is based on the “0.3 x kg
body wt in 50mls” formula. A “Standard” solution is adjusted to economise on the
amount of drug used by diluting to 60mls instead of 50mls, and by avoiding the use of
a second ampoule by diluting to a smaller volume, e.g. by using 200 mg in 48 mls of
solution (200/48) of dopamine instead of 210/50. A standard solution contains 1
mcg/kg/minute in 1 ml of solution of Dopamine/Dobutamine and 0.01 mcg/kg/minute
of adrenaline, isoprenaline or noradrenaline in 1 ml of solution.
WEIGHT
(kg)
DOPAMINE
DOBUTAMINE
30
32
34
36
38
40
42
44
46
48
50
52
54
56
58
60
62
64
66
68
70
72
74
76
78
80
82
84
86
88
90
110/60
115/60
120/60
130/60
140/60
140/60
150/60
160/60
170/60
170/60
180/60
190/60
190/60
200/60
200/57
200/56
200/54
200/52
200/51
200/49
200/48
200/46
200/45
200/44
200/43
200/42
200/41
200/40
200/39
200/38
200/37
110/60
120/60
120/60
130/60
140/60
140/60
150/60
160/60
170/60
170/60
180/60
190/60
190/60
200/60
210/60
220/60
550/60
230/60
240/60
250/60
250/58
250/56
250/55
250/53
250/52
250/52
250/51
250/50
250/48
250/47
250/46
ADRENALINE/
ISOPRENALINE
NORADRENALINE
1.1/60
1.2/60
1.2/60
1.3/60
1.4/60
1.4/60
1.5/60
1.6/60
1.7/60
1.7/60
1.8/60
1.9/60
1.9/60
2.0/60
2.0/57
2.0/56
2.0/54
2.0/52
2.0/51
2.0/49
2.0/48
2.0/46
2.0/45
2.0/44
2.0/43
2.0/42
2.0/41
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GENERAL DEPARTMENTAL INFORMATION
1.
On-call Rooms – on Ward 21
2.
Catering -> sandwich trolley with food in Cardio Theatres at Lunchtime 11301330. When on call if you place your order with the kitchen it will be delivered
to Ward 25 on their dinner trolley - Various vending machines
3.
Registrar Room Level 3 -> Mail boxes – computer – (very slow and virus-laden!!)
4.
Anaesthetics Department Secretary Level 3 Portakabins – Diane Robson Annual Leave Forms, Rota Requests etc.
LOG BOOK
There is a departmental logbook for you to use during your stay. It has been designed
with Cardiothoracic experience in mind. Feel free to use it, any comments are
welcome. This is on the hard drive of the computer in the Trainees Room.
ACUTE PAIN SERVICE
This handout is intended to give you some background information on the role of our
Acute Pain Service and more specific information about the analgesic techniques you
are likely to encounter in this hospital. If you feel that the information could be
usefully amended or expanded, please pass on your suggestions to any of the Pain
Team.
Acute Pain Service staff
The Pain Team at Freeman Hospital consists of Consultant Anaesthetists and Nursing
Sisters:
Consultant Anaesthetists:
Sameena Ahmed (Lead Consultant), Abraham Samuel and Leena Pardeshi.
Pain Nurses:
Angela Knight, Stewart Keenan, Jenny Houston and Susan Breen.
The Acute Pain Service conducts daily pain rounds commencing at 9am in Recovery.
A weekly pain round is carried out in conjunction with an Anaesthetist (Thursday)
All Consultants are available for teaching advice and help.
Acute Pain Service information
All up to date Acute Pain Service Guidelines can be found on the trusts intranet site.
Please refer to them if you are unsure about any aspect of pain management.
Acute Pain Service routine
We review all patients using Epidural infusion analgesia (EIA) twice a day and see
patients with nerve catheters and PCA’s once a day. The majority of patients will be
postoperative, but we also take referrals from ward staff for patients with acute
non-operative pain. You will be allocated pain round sessions.
The official hours for the APS Nursing staff are 08.00 - 17.30 Monday to Friday.
There is no nursing cover from Friday evening until Monday morning.
As 1st on call you will be expected to review any patients with EIA on Saturday
morning and evening and Sunday morning and evening, you will also be required to
cover bank holidays. If you are busy in theatre you must contact the 2nd on call or
Consultant to cover you while you review the EIA patients. When reviewing the
patients you must document on the prescription chart that you have seen the patient
and on the Saturday, Sunday and Bank Holiday morning you must carry out and
document a full set of epidural observations. Ward staff are instructed to contact 1 st
call for acute pain problems out of hours.
Epidural infusion analgesia (EIA)
Please ensure that you reserve EIA for patients undergoing significant upper
abdominal/chest surgery, major pelvic surgery, or in whom medical conditions warrant
regional rather than opiate analgesia e.g. severe COAD. You should discuss any such
patients with one of the Consultant staff pre-operatively.
The following wards will accept patients with EIA 23, 25, 25a, 26, 38 and PICU but
you should always check in advance with the nurse in charge to ensure the ward is
adequately staffed to cope with the additional monitoring.
Our routine mixture for adult EIA is 0.1% bupivacaine with 5-40 mg Diamorphine
per 500ml. Paediatric patients usually do not require Diamorphine. The EIA is
delivered via dedicated Hospira Gemstar pumps, which are used only for Epidurals,
Intrathecals and occasionally Nerve Catheters. Analgesia should be maintained with
0.1% bupivacaine and routine top ups of stronger concentrations are not
recommended. EIA must be prescribed on the dedicated yellow prescription forms.
Nursing staff on the ward are not authorised to programme epidurals or change bags,
it is the responsibility of the on-call Anaesthetist to do this.
EIA should be continued until the patients’ use has declined and he/she can convert
to oral analgesia. The exit site must be inspected daily for signs of infection and to
ensure that the IV3000 dressing remains intact; if any disconnection occurs in the
epidural line between patient and filter then the epidural must be removed as
contamination of the catheter is inevitable. Ward staff do not routinely discontinue
EIA without reference to the Pain Service or 1st on-call Anaesthetist.
Patient Controlled Analgesia
We use Morphine PCAs (50 mgs/50 ml – pre-filled syringes). If Morphine is contraindicated then Fentanyl (neat 50mcg per ml) may be used. We have a large supply of
Graseby 3300 PCA pumps. PCA information leaflets are available on all surgical
wards.
PCA is usually started in the Recovery Room, and the nursing staff will load and
programme the pump for you, provided that you have completed the dedicated
prescription chart (available in all Theatres / Recovery / Wards). Please ensure that a
Codan non-return valve is included in the IV line whenever you set up a PCA - this is
particularly likely to be missed when you are setting one up on the wards.
All patients with PCA are only nursed on surgical wards, where the nursing staff are
familiar with the pumps and can change the syringes. The Nurses are not qualified to
programme pumps or administer loading doses. Most ward staff are sufficiently
familiar with PCA management that they are able to decide when the patient can
reasonably be weaned from the technique. Mild opiates are prescribed for any
patients whose PCA is discontinued (please see PCA discontinuation guidelines).
Setting up PCAs /Epidurals
Before removing a PCA / Epidural pump from the theatre equipment store the pump
log must be completed (situated in recovery). Also please inform the Pain Service if
you set up a PCA / Epidural out of hours (leave a message on their office answer
phone – ext 27379).
PCA and EIA equipment is not routinely stocked on all the wards, so take everything
with you from Theatre for ease.
Ketamine
Ketamine is occasionally used for chronic pain / palliative care patients; please refer
to separate guidelines (intranet).
Paravertebral catheters in cardio-thoracic patients
Paravertebral infusions are routinely used post-operatively on any patient undergoing
Thoracotomy (including single lung transplants). The standard prescription used is
500ml bag of Bupivercaine 0.1% running continuously at 10-15mls per hour via the
grey Hospira Gemstar pumps. Patients must be nursed on Wards 23, 25, 25a, 26, 38,
PICU or 30; Nursing staff cannot change the bags of local anaesthetic agents. The 1st
on call is expected to change the local anaesthetic infusion bags as required. The
Acute pain sisters usually change the bags during the day to avoid disturbing the 1st
on call at night. However, you may be called over to replace the bags during the day at
weekends and Bank Holidays.
PAEDIATRICS
Orthopaedic patients admitted to PICU (Freeman ward 28)
Patients are admitted to ward 28 from theatres with a prescription for a morphine
infusion. This will be prescribed on a ward 28 drug chart, together with any
additional analgesics, antibiotics etc that may be needed. The nursing staff can
prepare this infusion prior to the patient’s arrival on the ward.
Typical prescription will be (patient’s weight in mg of morphine) made up to 50 mls
with 0,9% saline. This should run at up to 2 mls/hr with 1ml boluses of the solution as
required. Maximum amount of morphine 50 mg in 50 mls.
The following morning, assuming the patient has been extubated (ie in the majority of
cases), they will be converted to a PCA (with additional enteral/rectal analgesia as
needed).
This will be a ‘standard’ PCA in most cases, commonly with boluses but almost
invariably with no background infusion. The prescription will be written on a
standard PCA chart in theatres the preceding day, and the solution will be prepared
and the pump programmed by (band 6) PICU nursing staff prior to discharge.
If there is no prescription available, it will be completed by a consultant (JC/YT/MG
or JHS/SH/MR/TM) and NOT a trainee. The solution will however be made up, and
the pump programmed, by (band 6) PICU nursing staff.
The APS have kindly offered to facilitate any necessary training and help
troubleshoot while this system becomes established.
Once the patient is ‘established’ on ward 17 ongoing troubleshooting and pain
management issues will be dealt with by anaesthetists on the ‘general’ side together
with the APS.
Paediatric/congenital cardiac patients requiring PCAs on discharge from ward 28
If a patient is to be discharged from Ward 28 but requires a morphine PCA this
should be prescribed by a consultant (JC/YT/MG or JHS/SH/MR/TM) and the
solution will be prepared and the pump programmed by (band 6) PICU nursing staff
prior to discharge. It will almost invariably be a bolus/lockout programme with no
background infusion.
Management and troubleshooting of epidurals (plus paravertebrals and PCAs) on
wards 23 and 28
Initial troubleshooting should be referred to the cardiac anaesthetic registrar who is
first on call (or occasionally the trainee on the ward). Simple problems can be dealt
with by that person. On PICU, particularly at night, the resident doctor on the unit
will troubleshoot pain problems.
If there are to be any significant changes to a prescription, or if problems are
complex or difficult to resolve, a consultant paediatric cardiothoracic anaesthetist
should be contacted by telephone for advice at an early opportunity. They may either
give telephone advice or come to see the patient. Changes to PCA or
epidural/paravertebral prescriptions should not be made without the knowledge and
approval of a consultant paediatric cardiothoracic anaesthetist.
In reasonable daytime hours, the APS will kindly continue to provide input and help
with ongoing acute pain management for all patients within the cardiothoracic
directorate and those patients cared for on ward 28.
Chronic pain patients
You will also encounter occasional chronic pain patients with a long history of opiate
use and / or abuse. If you are planning PCA or EIA in a patient with a history of
chronic opiate use, please discuss the management with a member of the Pain Service
prior to commencing the infusion.
Entonox
Entonox analgesia is available for patient use on Wards under the supervision of the
Acute Pain Service. Some Ward staff have been trained to administer entonox. You
can gain access to extonox via the Acute Pain Service.
Protocols for Peri-operative Care
The following aspects of peri-operative care will be applied to all patients under the care of
all Consultants. Unless specific, clear and documented instructions are given to the
contrary by senior medical staff (Registrar/Consultant level), the following should occur:
Thromboembolism
Prophylaxis
THORACIC major cases - All patients to receive Tinzaparin 3500u
SC OD evening before surgery and continuing until discharge.
TED stockings to be placed at same time and prescribed alongside
the Tinzaparin. Continue until discharge only.
CARDIAC – All patients to receive Tinzaparin 3500u SC OD post
operatively until discharge. TED stockings until discharge only –
remember to prescribe these alongside the Tinzaparin. Not to be
continued after leaving hospital.
Antimicrobial
Chemoprophylaxis
WEIGHT
NOT ALLERGIC
TO PENICILLIN
PENICILLIN
ALLERGY
< 80Kg
1g Flucloxacillin at
induction*
500mg x 3 doses 6
hourly
600mg
Clindamycin*
300 x 3 doses 6
hourly
MRSA
POSITIVE
OR STATUS
UNKNOWN
400mg
Teicoplanin*
400mg 12 hours
later
>80Kg
<120Kg
2g Flucloxacillin at
induction*
1g x 3 doses 6
hourly
900mg
Clindamycin*
600mg x 3 doses 6
hourly
600mg
Teicoplanin*
400mg 12 hours
later
>120Kg
3g Flucloxacillin at
induction*
1.5g x 3 doses 6
hourly
1.2g
Clindamycin*
900mg x 3 doses 6
hourly
800mg
Teicoplanin*
400mg 12 hours
later
*Consider repeating dose if blood loss >4L
Endocarditis patients : treat according to microbiologist
recommendations
Aztreonam usually used for patients returning to theatre for
reopening. Seek Microbiology advice if patient returning to theatre
due to an infected wound.
THORACIC Patients –

No antibiotics with pre-medication unless specifically for a
preoperative infection as per microbiology advice.
-
Prophylactic antibiotics are given as one single dose at
induction unless specified by Microbiology Team.
No need to give postoperative doses
All other postoperative infections and sepsis related
diseases (lung infections or other systemic infections)
should be treated as per Microbiology advice.

At induction


No antibiotics for bronchoscopies
For mediastinoscopies/open thoracotomies/lobectomies/
pneumonectomy/thoracoplastys and for all VAT’s
Only one dose at induction
-
Single dose of Flucloxacillin at induction
Flucloxacillin 1 Gm IV if weight < 80Kg
Flucloxacillin 2 Gm IV if weight > 80Kg
-
If patient is allergic to Penicillin:
-
Clindamycin 300 mg IV if weight < 80Kg
Clindamycin 600 mg IV if weight > 80Kg

For Empyema/rib resection or other thoracic sepsis, please
discuss with the surgeon or the Microbiology team if necessary
If patient has received penicillin-related antibiotics in the recent
past, please use Clindamycin at Induction.

Routine Investigations
Cardiac Patients
No immediate post-op CXR or blood tests
Day 1 and Day 4
Day 4
Thoracic Patients
Day 1 and day 4
FBC, U&E, Creatinine, CXR (or post-drain), ECG
ECG
FBC & U&E
CXR daily while chest drain in situ. After drains removed only CXR
when indicated if post drain removal CXR satisfactory.
Immediate
Postoperative fluids
All patients 1ml/kg/hour crystalloid until drinking normally
except pneumonectomy 0.5ml/kg/hr
If urine output less than 0.5ml/kg/hr for 2 hours notify on call
doctor or nurse practitioner.
Haemoglobin
Transfuse only if Hb < 8.0
Blood transfusions or blood products to be discussed with, and
sanctioned by, Consultant Surgeon
Consider Ferrous Sulphate if anaemic on Day 3 onwards
Radial Artery Grafts
No anti-spasmodics need be prescribed routinely. Nitrates (ISMN,
GTN) or Calcium channel blockers (Diltiazem) may be requested by
the Consultant Surgeon however.
GI prophylaxis
All CARDIAC patients to receive Lansoprazole 30mg OD PO. This
should be stopped on discharge unless prescribed before admission.
Recommence patients on usual medication if documented dyspeptic
history.
Anticoagulation
Valve Patients
Mechanical valves – commence full dose (175u/kg) SC Tinzaparin
on first post operative day until INR >2. Start Warfarin as per protocol
Mr Nair uses IV heparin Act 200-220
INR Targets :
Mechanical Aortic Valves 2-3
Mechanical Mitral Valves 2.5 to 3.5
Biological Aortic Valves – No Warfarin – use Aspirin 150mg OD
Biological Mitral Valves & Mitral Valve Repairs in sinus rhythm – No
Warfarin - use Aspirin 150mg OD. If in AF use Warfarin with target
INR of 2.5-3.5.
Atrial Fibrillation (de novo): No anticoagulation within 48 hours. If
still in AF after 48 hours start full dose (175u/kg) Tinzaparin and
Warfarin. Aim for an INR of 2-3. Stop Tinzaparin when therapeutic
INR.
Antiplatelet therapy
All CABG patients to receive 150mg Aspirin at 6 hours post op if
chest drainage less than 100mls in previous hour
Continue 150mg daily for one year unless demonstrated intolerance
of aspirin. Reduce then to 75mg for life. Consider 75mg Clopidogrel
if on this preoperatively.
Clopidogrel may be needed if the patient has coronary stents in situ.
Drug eluting stents should have Aspirin and Clopidogrel for one year
after implantation while bare metal stents receive the combination for
one month only before continuing on Aspirin alone.
Urgent (post NSTEMI) patients to be treated with Aspirin ONLY ie if
Clopidogrel started by cardiology only for NSTEMI treatment, then
DO NOT restart. Discuss with consultant surgeon.
CABG patients who are warfarinised
(valve/AF/thrombus/endarterectomy) to receive 75mg Aspirin only.
Cardiac patients
Atrial Fibrillation
Confirm AF with 12-lead ECG..
Sinus tachycardia (>100bpm) may indicate a clinical problem and
this should be sought rather than treating this an as an arrhythmia.
What appears to be a sinus tachycardia >150bpm may well be atrial
flutter and will need control as for AF.
Check potassium
If potassium and hydration satisfactory, and patient not hypoxic:
Give 8mmol Magnesium Sulphate IV.
Options:
SEEK SENIOR ADVICE IF UNCERTAIN
1. If significantly compromised consider cardioversion.
2. Metoprolol 50-100mg TDS orally. If contraindicated use Diltiazem
180mg BD. Exercise care in patients with poor LV function.
3. 5-15mg Metoprolol can be used as an IV loading dose followed by
5mg QDS. Aim for a heart rate below 100bpm.
4. Amiodarone 300mg IV over an hour followed by 900mg over 23
hours if central line present and/or compromised (hypotensive/rate
>150). If compromised and no central line, insert line. Move to 25A.
Oral Amiodarone 400mg tds loading dose followed by 200mg tds has
often been used previously but it takes days to work and is less
effective than rate control with beta blockers.
Note that Simvastatin should be reduced to 20mg daily when on
Amiodarone.
Beware potentiation of Warfarin by Amiodarone.
Consider and correct surgical complications / other acute precipitants
(pain, infection, hypoxia, embolism). These cause sympathetic
stimulation which makes HR control difficult and will restart AF after
cardioversion.
See ANTICOAGULATION SECTION - Start Tinzaparin full dose &
Warfarin if still in AF after 48 hours
THORACIC PATIENTS – Avoid Amiodarone – seek senior advice.
Pacing Wires
Remove on Day 3. Check INR is <2.5 if applicable. Patient needs to
be 24 hours free of pacing
Statins
Recommence on the statin on the first post operative day and dose
originally taken by patient
Diuretics
CABG and AVR patients with good ventricles should not routinely
be discharged on diuretics.
Hypertensive patients on thiazides should remain on them.
Prescribe according to clinical status. Use daily weight to guide
therapy.
Frusemide is the diuretic of choice.
Patients taking diuretics pre-op should be discharged on a (reduced)
dose of same diuretic.
Poor left ventricles should remain on diuretic irrespective of weight.
Discuss with consultant if unsure.
Chest drains
Cardiac – remove if no air leak and drainage less than 25ml/hr for 4
hours.
Thoracic – X ray 2 hours post op. Drains to be on suction at 5kPa
for the first post operative night, then free drainage pending review of
the chest X ray. Drains to be removed only on the instructions of a
registrar or consultant.
Pneumonectomy – drain clamped and released for 5 minutes on
the hour every hour. Drain removed the following morning after
review.
Beta Blockers
Continue any previously prescribed beta blockers at full dose where
tolerated. Half dose where indicated.
ACE Inhibitors
ACE inhibitors should be recommenced at low (half) dose post
operatively – check U & E’s.
ACE inhibitors should be started if LV dysfunction noted for first time
on this admission.
Lisinopril is the ACE inhibitor of choice if starting new
prescription on this admission. Continue any previously
prescribed ACE inhibitor.
S.C. Clark March 2010
NEWCASTLE UPON TYNE HOSPITALS NHS TRUST
FREEMAN HOSPITAL
ACUTE PAIN SERVICE (APS)
THE APS QUICK GUIDE FOR TRAINEES –
PCA AND EPIDURAL MANAGEMENT AT FREEMAN




All patients are routinely prescribed Paracetamol 1g QDS and PRN antiemetics
(follow anti-emetic guideline). If not contra-indicated NSAID's should be
prescribed.
On call Anaesthetist: to cover the Acute Pain Service during out of hour’s periods
– weekends and bank holidays.
Anti-depressants and sedatives should not routinely be given with PCA'S and
epidurals, unless the patient has been taking the drug long term.
No other Opioids: patients on PCA or Epidural opioids cannot have any other form
of opioids orally, IM, IV, Sub-cut etc. Please cross off opioids on the drug chart
or mark "Not with PCA/Epidural" this includes mild opiates – e.g. Co-codamol,
Codeine or Tramadol.
EPIDURALS
 Filters: one filter should be used and secured between 2 dressings
 Only IV3000 Epidural dressing to be used over exit site
 Diamorphine: the only opioid to be used in the 0.1% bags of Bupivicaine
 Bolus top-ups of 0.25% or 0.5% Bupivicaine should not routinely be given in ward
areas.
 Epidurals can be used on the following wards:23, 25, 25a, 26,27a and PICU.
 Anaesthetic responsibilities: patients with an Epidural remain the ultimate
responsibility of the initiating Anaesthetist
 Approximate guide for programme rates:
Lumbar
Mid thoracic
Thoracic
L3/4-L1/T12
T12 - T10
T9 - T 7/6
bolus - 6mls
bolus - 5mls
bolus - 4mls
background - 6mls
background - 5mls
background - 4mls
PCA'S
 Background infusions are only used if the patient is on long term strong opioids or
in exceptional circumstances - discuss with Consultant Anaesthetist / Acute Pain
Sister
 Anti-emetics: follow guidelines
 Respiratory depression: follow protocol (see back of PCA chart). Consider adding
oral/rectal NSAID’S, increasing lockout time and/or reducing PCA bolus
 PCA'S can be used on the following wards: - 23, 25, 25a, 26, 27a, 30 and PICU.
HOSPIRA GEMSTAR EPIDURAL PUMP TRAINING AID
On completion of this self-assessment training aid the participant will be able to demonstrate the safe and
correct use of the Hospira Gemstar epidural pump.
Name:
Position:
ATTAINED
DATE
1. State the clinical indication for use for the Gemstar pump.
2. Identify all the equipment required to operate the Gemstar pump.
3. Identify the power source for the Gemstar pump.
4. Load the cassette into the Gemstar pump.
5. Turn on of the Gemstar pump.
6. Clear programme and history from previous patient.
7. Programme the pump for continuous infusion /PCA bolus delivery.
8. Purge the giving set.
9. Start the infusion.
10. Review the programme for epidural observations.
11. Review the patient history for epidural observations.
12. Unlock the keypad.
13. Alter the programme.
14. Deliver a clinician activated loading dose.
15. Change the bag.
16. Stop the infusion.
17. Remove cassette and dispose of correctly.
18. Respond appropriately to alarms.
19. General care, cleaning and storage of the pump.
20. State where programming instructions can be located.
GRASEBY 3300 PCA PUMP TRAINING AID
On completion of this self-assessment, training aid the participant will be able to
demonstrate the safe and correct use of the Graseby PCA pump.
Name:
Position:
ATTAINED
1. State the clinical indication for use for the Graseby 3300 PCA pump.
2. Identify all the equipment required to operate the Graseby 3300 PCA pump.
3. Identify the power source for the Graseby 3300 PCA pump.
4. Load the syringe into the Graseby 3300 PCA pump.
5. Turn on of the Graseby 3300 PCA pump.
6. Clear programme and history from previous patient.
7. Programme the pump for continuous infusion /PCA bolus delivery.
8. Purge the giving set.
9. Start the infusion.
10. Review the programme for PCA observations.
11. Review the patient history for PCA observations.
12. Alter the programme.
13. Deliver a clinician activated loading dose.
14. Change the syringe.
15. Stop the infusion.
16. Remove syringe and dispose of correctly.
17. Respond appropriately to alarms.
18. General care, cleaning and storage of the pump.
DATE