ANAKAYUB's General Recipes for Op (for juniors)

General Rules

Check STOPBANG if BMI > 30
I want the CT/MRI film and scope video
Oral paracetamol for all patients unless contraindicated
Withold ACE-i/ARB’s preop (unless the ambulatory BP is > 180/110)
If you think there’s a possibility of difficult airway —> Ear to sternal position mandatory
Parecoxib/other NSAID-based drug if no RA and you think can help with opioid sparing
Dexa 8 for all GA’s
Dexa 10 for all with blocks
IV TXA 1 g for all op’s with potential significant bleeding/fluid shifts
My PONV algorithm in OT: dexa, granisetron, haloperidol (1 mg)
Extubation protocol: FiO2 0.3 for routine, low risk. FiO2 1 otherwise. NMT-guided reversal. Pressure support until extubation. If changed to spontaneous —> APL 30 during ETT removal

Personal Awake Fiberoptic Regimen

No nebulized lignocaine
Pre-procedure glycopyrrolate 200 mcg
Decide on orotracheal vs nasotracheal
Phenylephrine-lignocaine into “best” nostril
Lignocaine gargle
Some O2
Remifentanil only if it itself will be used intraop
Lignocaine spray via fiberscope x 2 (3 ml 2%) at supraglottic
Pre-procedure transtracheal block or another 3 ml at infraglottic)

Ketofol

1:4
50 mg ketamine (1 ml) in 200 mg (20 ml) propofol
Run as propofol TCI

Extubatable Midline Laparotomy

Bilateral QLB3
Alternatives: Rectus sheath/subcostal and posterior TAPs

Laparoscopic Bowel/Liver Surgery

MgSO4 10 mmol on induction
IV lignocaine 1 mg/kg stat, 1 mg/kg/h till end of op
Minimal opioid
Ketamine 10 mg every 20-30 minutes if needed

Rooftop Liver Surgery

Many options
T8 epidural/bilateral ESP
Confirmed masuk ICU → ITM

Thyroid

If goiter/tumor: obstructive/infiltrative symptoms. Postural symptoms. Breathing/voice/swallowing changes
Neck and chest xray if goiter
USG goiter extent
CT neck if there is an element of airway effect. Extent of retrosternal extension if present
Deviation, narrowest diameter

General Orthopedic

Routine TXA (1 g): spine and arthroplasty surgeries

Hip Fracture, Femoral Only Surgery

FICB single shot for postop analgesia, then oral analgesics → May be performed pre-spinal
If in doubt → 2 ml heavy bupivacaine + 15 mcg fentanyl. Turn op side down, strict lateral, 10 minutes. Set additional iv access as required. BP monitoring by the minute until confident

Hip Fracture, Pelvic and Femoral Surgery. THA’s

FICB catheter, postop
If GA —> TCI remi, aim to block preextubation 

General Femur

FICB (especially if LFCN territory is involved)

TKA’s

ACB catheter, postop

Knee Sports

ACB postop (check neurology first)

BKA’s for block

Transgluteal/subgluteal sciatic - Debatable chance of blocking the posterior cutaneous nerve of the thigh, better tourniquet tolerance. If confirmed not for tourniquet → KIV popliteal (better onset)
Femoral 

AKA’s for block

Transgluteal/subgluteal sciatic - Debatable chance of blocking the posterior cutaneous nerve of the thigh
Femoral
LFCN
Obturator

Minor hand

USG wrist block

Major hand

Axillary +/- MCN

Shoulder (x pernah ada case)

Interscalene/superior trunk

Forearm

Costoclavicular/infraclavicular

Other Upper Limb

Supraclavicular

Minor foot

Ankle (maybe USG in the future)

Pediatric Surgery

NBM time for solids-FM/BF/CF should be specific and based on the estimated op time → Minimize NBM time
If you think that the postconceptual age is < 60 weeks, please calculate. I will ask
No routine premed sedation.
CVL reference
Pediatric one lung ventilation 
Sedation with ketofol: until the peds TCI machine is back online, use a 200 mcg/kg/min dose of propofol (and lower according to response down to 100 mcg/kg/min as the floor)
Dexa 0.15 mg/kg for GA only, 0.2 mg/kg for all with blocks
Unilateral hernia → USG II block
Bilateral hernia/testicular surgery (even unilateral) → Caudal
Hypospadias/complex penile surgery (especially if CBD insertion is planned) → Caudal +/- clonidine 1 mcg/kg
Laparotomy → Caudal/QLB3 +/- clonidine 1 mcg/kg
Thoracotomy → ESP (0.3 ml/kg)

Any O&G op

How big is the gynecological mass in terms of week size
Any mass of at least 14 weeks’ size → Aspiration prophylaxis

Open Lower Transverse O&G, any op

Bilateral posterior TAP

General for LSCS

Phenylephrine infusion/granisetron/dexa as per “Dr Hamizah’s protocol”
Continue phenylephrine on delivery
NIBP every minute post delivery, oxytocin 1 u/min depending on BP
If 1 IV line → 2 3-way connectors (do not stop the phenylephrine too early)

Caesarean Delivery, Non-Standard Incision/Potentially Complicated

CSE, HTA style → Height-based dosing, epidural with lignocaine 2% + 5 mcg/ml adrenaline. Epidural 3 mg morphine at end of op, remove catheter

Plastic Upper Limb Vascular

Supraclavicular + PECS 2 (serrato-pectoral only) or “direct” ICBN

Dental/ENT in General

Dexa 8 for all

Chest Trauma needing more than medical therapy

ESP catheter

Neurosurgery

Presentation, neurology, scans (film & images)
Positioning
Extubatable?
Neuromonitoring

ICU patients, not intubated, major op, potentially extubated

KIV ITM