NATIONAL CONGRESS of the
VIETNAM SOCIETY of ANESTHESIOLOGISTS
Associate Professor Stephen Gatt OAM MOM KM KCHS JP MD LRCP DCH CHE MASCH MRACMA MRCS AFACHSEM AFRACMA FFARACS FANZCA FFICANZCA FJFICM FCICM FRCADirector of Anaesthesia Operational amp Administrative Wales AnaesthesiaSenior Staff Specialist The Royal - for Women amp Sydney Childrenrsquos HospitalsVisiting Medical Practitioner Prince of Wales Private HospitalPresident Obstetric Anaesthesia Society of Asia and OceaniaConjoint Associate Professor in Anaesthesia Discipline of Anaesthesia Critical Care and Emergency Medicine
University of New South Wales Sydney Australia
TrienniumNumber of maternities
Number of Caesarean sections
Caesarean rate as percentage of maternities
Number of direct deaths due to anaesthesia
Number of direct deaths due to anaesthesia for Caesarean section
Rate of direct deaths due to anaesthesia per 100 000 Caesarean section
1964ndash6 2 600 000 88 000 34 50 32 36
1982ndash4 1 884 000 190 000 101 19 11 6
2000ndash2 1 997 000 425 000 21 7 4 1
Acknowledgement Cooper et al 2014 BJA Online ISSN 1743-1824
ANAESTHETISTS ARE NOT
DOING TOO BADLY ON THE
MORTALITY STAKES
What did the old GA CStechnique consist of
bull optimal pre-oxygenationbull thiopentone induction bull suxamethonium (succinylcholine) depolarising neuromuscular blockbull endotracheal intubation under cricoid pressure
bull 23 MAC volatile in 50 N2O for maintenance until delivery
DELIVERY
volatile concentration reduced to 12 MAC
opiate + non-depolarising muscle relaxant syntocinonoxytocin
fraction of N2O increased to 67
The lsquoOldrsquo StandardGA CS which lasted from 1960s to
mid-noughties (~2005)
bull Taught as a standard technique for over four decades
bull Reliablebull Easily reproducible formulabull Reduced the incidence of acid aspiration
syndrome and awarenessbull Ensures optimal intubating conditions bull Lowest possible adverse impact on the newborn
Why did this sequence work for so long
Generations of anaesthetists and their anaesthetic assistants
have been trained to make this hazardous undertaking a slick
and efficient process
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
TrienniumNumber of maternities
Number of Caesarean sections
Caesarean rate as percentage of maternities
Number of direct deaths due to anaesthesia
Number of direct deaths due to anaesthesia for Caesarean section
Rate of direct deaths due to anaesthesia per 100 000 Caesarean section
1964ndash6 2 600 000 88 000 34 50 32 36
1982ndash4 1 884 000 190 000 101 19 11 6
2000ndash2 1 997 000 425 000 21 7 4 1
Acknowledgement Cooper et al 2014 BJA Online ISSN 1743-1824
ANAESTHETISTS ARE NOT
DOING TOO BADLY ON THE
MORTALITY STAKES
What did the old GA CStechnique consist of
bull optimal pre-oxygenationbull thiopentone induction bull suxamethonium (succinylcholine) depolarising neuromuscular blockbull endotracheal intubation under cricoid pressure
bull 23 MAC volatile in 50 N2O for maintenance until delivery
DELIVERY
volatile concentration reduced to 12 MAC
opiate + non-depolarising muscle relaxant syntocinonoxytocin
fraction of N2O increased to 67
The lsquoOldrsquo StandardGA CS which lasted from 1960s to
mid-noughties (~2005)
bull Taught as a standard technique for over four decades
bull Reliablebull Easily reproducible formulabull Reduced the incidence of acid aspiration
syndrome and awarenessbull Ensures optimal intubating conditions bull Lowest possible adverse impact on the newborn
Why did this sequence work for so long
Generations of anaesthetists and their anaesthetic assistants
have been trained to make this hazardous undertaking a slick
and efficient process
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
ANAESTHETISTS ARE NOT
DOING TOO BADLY ON THE
MORTALITY STAKES
What did the old GA CStechnique consist of
bull optimal pre-oxygenationbull thiopentone induction bull suxamethonium (succinylcholine) depolarising neuromuscular blockbull endotracheal intubation under cricoid pressure
bull 23 MAC volatile in 50 N2O for maintenance until delivery
DELIVERY
volatile concentration reduced to 12 MAC
opiate + non-depolarising muscle relaxant syntocinonoxytocin
fraction of N2O increased to 67
The lsquoOldrsquo StandardGA CS which lasted from 1960s to
mid-noughties (~2005)
bull Taught as a standard technique for over four decades
bull Reliablebull Easily reproducible formulabull Reduced the incidence of acid aspiration
syndrome and awarenessbull Ensures optimal intubating conditions bull Lowest possible adverse impact on the newborn
Why did this sequence work for so long
Generations of anaesthetists and their anaesthetic assistants
have been trained to make this hazardous undertaking a slick
and efficient process
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
What did the old GA CStechnique consist of
bull optimal pre-oxygenationbull thiopentone induction bull suxamethonium (succinylcholine) depolarising neuromuscular blockbull endotracheal intubation under cricoid pressure
bull 23 MAC volatile in 50 N2O for maintenance until delivery
DELIVERY
volatile concentration reduced to 12 MAC
opiate + non-depolarising muscle relaxant syntocinonoxytocin
fraction of N2O increased to 67
The lsquoOldrsquo StandardGA CS which lasted from 1960s to
mid-noughties (~2005)
bull Taught as a standard technique for over four decades
bull Reliablebull Easily reproducible formulabull Reduced the incidence of acid aspiration
syndrome and awarenessbull Ensures optimal intubating conditions bull Lowest possible adverse impact on the newborn
Why did this sequence work for so long
Generations of anaesthetists and their anaesthetic assistants
have been trained to make this hazardous undertaking a slick
and efficient process
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
The lsquoOldrsquo StandardGA CS which lasted from 1960s to
mid-noughties (~2005)
bull Taught as a standard technique for over four decades
bull Reliablebull Easily reproducible formulabull Reduced the incidence of acid aspiration
syndrome and awarenessbull Ensures optimal intubating conditions bull Lowest possible adverse impact on the newborn
Why did this sequence work for so long
Generations of anaesthetists and their anaesthetic assistants
have been trained to make this hazardous undertaking a slick
and efficient process
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Why did this sequence work for so long
Generations of anaesthetists and their anaesthetic assistants
have been trained to make this hazardous undertaking a slick
and efficient process
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
What has changed over the last three decades
VIRTUALLYEVERYTHING
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
lsquoStandardrsquo GA CS What has changed
bull Preoperative Resuscitationbull Pre-oxygenationbull Induction sequencebull Notion of lsquoUrgencyrsquobull Rapid Sequence and Difficult Airway Algorithm
bull Maintenance sequence bull Philosophy eg techniques modified to suit
ndash local conditions
ndash tailor-made for to individual patient
bull Postop pain management
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
lsquoFetal Distressrsquo and NRFHRT
NRFHRT
FD
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
In Utero Fetal Resuscitation Prior to Declaring Cat 12 GA CS
bull Turn oxytocic (syntocinon) infusion off
bull Turn mother into left lateral position
bull O2 from Midogas mouthpiece or a facemask
bull 1 lit crystalloid ndash Plasmalyte 148 Rep or Hartmannrsquos LR or N Saline
bull IV vasopressor if MAP low 100mcg phenylephrine or 9mg ephedrine first dose
bull Tocolysis GTN 400mcg sublingual aerosol or terbutaline 250mcg SC
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Retrospective Study 1 amp 5 min Apgars following CS for FD
2007 Indonesia Dr Soetomo Hospital Surabaya Malays J Med Sci Jul14(2)41-6 2007
SAB gt Ketamine GA gt thiopental GA for fetal distress
Evaluation of anaesthesia methods in caesarean section for foetal distress Wahjoeningsih S Witjaksono W
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Choice of Neuromuscular Blocker in RSI for CS GA
bull withdraw the short-acting low potency depolarising muscle relaxants
eg suxamethonium
bull replace them with lsquocleanerrsquo non-depolarisers with fewer side-effects
eg rocuronium
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
ldquoSo many modifications to the GA CS have been put in place that when the
modern GA CS is reviewed in its entirety it would seem that the time has
come to question if the lsquostandardrsquo GA CS is still valid and whether it is due
for a major revamprdquo
Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt 2006
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Succinylcholine Suxamethoniumin Obstetrics
bullmaternal hyperkalaemia (eg in Guillain Barre)bullinteracts with Mg++ (eg in pre-eclampsia )bullmuscle lsquoafter-painrsquo
(75 for CS vs 30 in the non-pregnant group)bullileus () bullsuxamethonium apnoea bullproblems with storage -
bullinactivation at high temperaturebullfreezing from cold storagebullleakage from pre-filled syringes
bullhigh incidence of complications ndash very low potency drug
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Change in philosophy on the safety of suxamethonium for GA CS
bull Pre-oxygenation + suxamethonium may not offer a great degree of protection against the albeit rare scenario of inability to intubate and inability to ventilate
bull Increased emphasis on the timing of the
individual components of the RSIndash variation in the timing and application of cricoid
pressurendash alteration in choice and dose of RSI drugs used and
the timing of their administration
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
AT CAESAREANSECTION HOW
FAST CAN YOUINTUBATE
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Solutions
ndash vecuroniumbull vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
ndash atracurium ndash rapacuronium (withdrawn from the market)ndash rocuronium
bull rocuronium RSI in which the rocuronium precedes the ketamine and propofol
ndash suxamethonium bull pretreated with vecuronium or d-tubocurarine bull augmented with Tacrine (tetrahydroaminacrine)
ndash sugammadex + rocuronium
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
NDMR REVERSALNDMR REVERSAL
cyclodextrin reversal agent for rocuronium
Org-25969
Sugammadex Na
Octasulfanyl-γ-cyclodextrin
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Sugammadex
C72H104Na8O48S8
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Chemical Encapsulation of NDMR Rocuronium by Cyclodextrin Sugammadex
True inclusion complex
Association constant
107 M-1
Selective reversal
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
IV Induction CSIV Induction CS
Propofol =gt Propofol =gt validated for use in GA CS (and neonates)validated for use in GA CS (and neonates)
thiopentone =gt thiopentone =gt now intermittently unavailable in Australianow intermittently unavailable in Australia
etomidateetomidatemidazolammidazolamdiazepamdiazepampropanididpropanididmethohexital methohexital ketamine =gt ketamine =gt best neurobehavioural score in infants but CI in PEbest neurobehavioural score in infants but CI in PE
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
IV Maintenance AdjunctsIV Maintenance Adjuncts
midazolammidazolamalfentanilalfentanilmorphinemorphine fentanylfentanylpropofol TCIpropofol TCI thiamylal thiamylal butarphanolbutarphanol remifentanil TCIremifentanil TCI
intraoperative adjunct to intraoperative adjunct to analgesia and analgesia and
maintenancemaintenance
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Inhalational AgentsInhalational Agents trichlorethylenetrichlorethylenehalothanehalothane isofluraneisofluraneenfluraneenfluranesevofluranesevofluranedesflurane in 67 Ndesflurane in 67 N22O O
NN22O alone without inhalational agent O alone without inhalational agent
(awareness)(awareness)Sevoflurane in O2 AirO2 + Ketamine + opioidSevoflurane in O2 AirO2 + Ketamine + opioid
5050 N20 O2+sevo 2
7030 N20 O2+opioid+sevo 05
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Vented LMA (Proseal) Intubating LMA (Fastrach)
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Keep the Meeting
On Track
amp
On Time
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Pulmonary Acid Aspiration
bullproton pump inhibitorsbullsodium citrate (and other antacids) bullH2-blockers
prophylaxis
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 13 Molar
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
My belt amp braces recipe ndash ALL CSs
bull Night before CSEsomeprazole (Nexium)
bull Morning of surgeryRanitidine (Zantac)
bull On call to OR (standing order)Na citrate
PPI
+
H2 blocker
+
antacid
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
1
2
lsquoOLDrsquo Thio-Sux-Halo
RSI for GA CS
lsquoNEWrsquo Gatt Rule of 100s RSI for GA
CS
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
The Gatt Rule of 100s GA CS NDMR RSI Induction Sequence
Cricoid PressureIntubate
Secure AirwayDeliver infant
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Why lsquo100srsquo
After delivery
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Immediate Reversal for
Rocuroniumhellip
within 1-2 minutes
sugammadex
Rocuronium + Sugammadex
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Time Sequence lsquo35secsrsquo for ROCURONIUM SUGAMMADEX
35 35 35
PREOXYGENATE CRICOID PRESSURE - SELLICK
SUGAMMADEX RESCUE
70 seconds
135 seconds
lt35 sec after roc
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Attention to detail is paramount
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
Success with these sequences
bull EXPERIENCE WITH KETAMINE ndash PROPOFOL gt15 years
bull and with KETAMINE ndash THIOPENTONE since 1984
bull EXPERIENCE WITH THE ROCURONIUM ndash SUGAMMADEX SEQUENCE
gt7 years
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
WHAT DO THE DODO AND THE
ldquoOLDrdquo GA CS
SEQUENCES HAVE IN COMMON
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
SugammadexSugammadexPhase III Trial Results 2006Phase III Trial Results 2006
THE LAST NAIL THE LAST NAIL IN THE COFFIN OF IN THE COFFIN OF THE GA CS AS WE THE GA CS AS WE
HAVE ALWAYS HAVE ALWAYS TAUGHT IThellipTAUGHT IThellip
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