Anaesthesia & Operating Theatre Nursing

GCC Comprehensive Clinical Guide — SCFHS / DHA / DOH Aligned

OR Nursing Anaesthesia GCC Exam Prep

ASA Classification & Fasting Calculator

ASA Classification—
ASA Description—
Fasting Status—
Fasting Notes—
Anaesthetic Risk—
Recommendation—

ASA Physical Status Classification

ClassDefinitionExamples
ASA INormal healthyNo conditions, non-smoker, minimal alcohol
ASA IIMild systemic diseaseControlled HTN/DM, mild asthma, BMI 30–40, smoker, social drinker, pregnancy
ASA IIISevere systemic diseasePoorly controlled DM/HTN, COPD, morbid obesity BMI >40, active hepatitis, ESRD on dialysis, premature infant PCA<60wks, history of MI/CVA/TIA >3 months
ASA IVSevere disease — constant threat to lifeRecent MI/CVA/TIA <3 months, severe valvular disease, sepsis, DIC, ARF, severe ARDS
ASA VMoribund — not expected to survive without surgeryRuptured AAA, massive trauma, intracranial bleed with mass effect, bowel ischaemia with significant cardiac pathology
ASA VIBrain-dead — organ donationDeclared brain dead, organs being removed for donation

Add suffix E (e.g. ASA IIIE) to denote emergency surgery — increases risk.

Fasting Guidelines (ERAS / ASA)

SubstanceMinimum FastNotes
Solids / fried / fatty food8 hoursStandard safe minimum
Light meal / non-human milk6 hoursToast, crackers
Breast milk (infants)4 hoursInfants only
Clear fluids (water, black coffee, clear juice)2 hoursNo pulp, no milk
Clear carbohydrate drink (ERAS)2 hourse.g. 200 mL carbohydrate drink <2h pre-op — reduces insulin resistance
Bowel Prep: Only indicated for low rectal resection or colostomy formation — NOT routine for all colorectal surgery.

Airway Assessment

Mallampati Classification

ClassVisible structuresIntubation difficulty
Class ISoft palate, uvula, fauces, pillarsEasy
Class IISoft palate, uvula, faucesModerate
Class IIISoft palate, base of uvula onlyDifficult
Class IVHard palate only visibleVery difficult

Other Predictors of Difficult Airway

  • Thyromental distance <6 cm — difficult laryngoscopy
  • Mouth opening <3 cm (inter-incisor gap) — impedes laryngoscopy
  • Limited neck mobility — cervical spine disease, halo brace
  • Obesity (BMI >35) / OSA — redundant pharyngeal tissue
  • Beard — impairs mask seal
  • Overbite, receding mandible, macroglossia

STOP-BANG Score (OSA Screening)

  • Snoring loudly
  • Tired / fatigued during daytime
  • Observed apnoea during sleep
  • Pressure — treated for or has hypertension
  • BMI >35
  • Age >50
  • Neck circumference >40 cm
  • Gender — male

0–2: Low risk 3–4: Intermediate 5–8: High risk OSA

High STOP-BANG: consider awake fibreoptic intubation or advance planning; post-op HDU/monitoring for CPAP-dependent patients.

Pre-operative Investigations — Evidence-Based Approach

Key principle: Routine blanket pre-op testing is NOT evidence-based. Investigations should be guided by patient history, comorbidities, and surgery type.

ECG

  • Age >50 years + cardiac risk
  • Known CVD, arrhythmia
  • Major surgery with intermediate/high cardiac risk

CXR

  • Suspected cardiac/pulmonary pathology
  • Recent respiratory symptoms
  • Not routine for stable patients

Blood Tests

  • FBC — major surgery, known anaemia, anticoagulants
  • UEC — renal disease, diuretics, ACEi/ARB
  • Coagulation — anticoagulants, liver disease, haematological conditions
  • Group & screen — intermediate/major surgery

Anaemia Optimisation

Target Hb >80 g/L before elective surgery. For major cardiac/orthopaedic surgery consider >100 g/L. Treat underlying cause: iron deficiency → IV iron (ferric carboxymaltose), B12/folate deficiency → supplementation. Consider erythropoietin-stimulating agents (ESA) in selected patients. Delay elective surgery until optimised.

Anticoagulant / Antiplatelet Bridging

Warfarin: stop 5 days pre-op (target INR <1.5). LMWH bridging for high-risk (mechanical heart valve, recent VTE <3 months, high-risk AF). DOACs: stop 1–2 days (apixaban/rivaroxaban) or 2–4 days (dabigatran) depending on renal function and surgery risk. Aspirin: continue for high cardiac risk; stop 7 days if bleeding risk high. Clopidogrel: stop 5–7 days pre-op (liaise with cardiologist if recent stent).

Inhalational Anaesthetic Agents

AgentMAC (%)Key Notes
Isoflurane1.15Pungent odour, coronary steal debate, hepatotoxicity rare (trifluoroacetyl metabolite)
Sevoflurane2.0Non-pungent — favoured for inhalational induction; Compound A nephrotoxicity concern at low flows (>2 L/min recommended); MH trigger
Desflurane6.0Very low blood:gas coefficient — fastest emergence; pungent — not for induction; requires special vaporiser; global warming concern; MH trigger
Nitrous oxide (N₂O)104Analgesic adjunct; expands gas-filled spaces (avoid: bowel obstruction, pneumothorax, middle ear); PONV risk; occupational exposure concern
Malignant Hyperthermia (MH) Triggers: All volatile agents (halogenated) + suxamethonium. Signs: temperature rise, masseter spasm, tachycardia, metabolic acidosis, raised CK. Treatment: remove trigger, dantrolene 2.5 mg/kg IV (repeat to max 10 mg/kg), cooling, correct acidosis/hyperkalaemia.

Propofol (TIVA)

  • Induction: 1.5–2.5 mg/kg IV (reduce in elderly/haemodynamically unstable: 0.5–1 mg/kg)
  • Maintenance (TIVA): 4–12 mg/kg/hr (TCI target 3–6 mcg/mL)
  • Pain on injection: Pretreat with IV lidocaine 20–40 mg + tourniquet, or inject into antecubital fossa
  • Antiemetic properties — preferred in PONV-risk patients
  • Cardiovascular: Causes vasodilation + mild myocardial depression — hypotension common at induction
  • Contraindication: Egg/soy allergy (relative), severe haemodynamic instability
Propofol Infusion Syndrome (PRIS): Occurs with doses >4 mg/kg/hr for >48 hours. Features: metabolic acidosis + rhabdomyolysis + cardiac failure (new onset LBBB/right heart failure) + lipidaemia + renal failure. Risk factors: high dose, prolonged infusion, critically ill patients, children. Management: stop propofol, switch to alternative sedation, supportive care — PRIS can be fatal.

Neuromuscular Blocking Agents

Depolarising — Suxamethonium (Succinylcholine)

  • Dose: 1–1.5 mg/kg IV (also 4 mg/kg IM if no IV access)
  • Onset: 60 seconds — fastest NMB available
  • Duration: 10–12 minutes (pseudocholinesterase-dependent)
  • Uses: RSI, laryngospasm
HyperKalaemia Risk: Avoid 48–72 hours post burn injury, crush injury, prolonged immobilisation, denervation injury (spinal cord injury, stroke, muscular dystrophy). Reason: upregulation of extrajunctional ACh receptors → massive K⁺ release → cardiac arrest. Also: MH trigger, raised IOP, raised ICP (transient).

Pseudocholinesterase deficiency: Prolonged block (hours) — dibucaine number <30 = homozygous deficiency. Management: ventilate until block resolves, fresh frozen plasma as source of enzyme.

Non-Depolarising NMBs

DrugDose (intubation)DurationReversal
Rocuronium0.6 mg/kg (RSI: 1.2 mg/kg)30–60 minSugammadex ✓
Vecuronium0.1 mg/kg25–40 minSugammadex ✓ / Neostigmine
Atracurium0.5 mg/kg20–35 minNeostigmine
Cisatracurium0.15 mg/kg40–75 minNeostigmine
Pancuronium0.1 mg/kg60–90 minNeostigmine

Reversal Agents

  • Neostigmine 50 mcg/kg (max 5 mg) + glycopyrrolate 10 mcg/kg (to prevent bradycardia) — for all non-depolarising NMBs. Not effective for deep block.
  • Sugammadex 2 mg/kg (moderate block) or 4 mg/kg (deep block) or 16 mg/kg (immediate reversal of rocuronium 1.2 mg/kg in RSI) — selective rocuronium/vecuronium reversal only.

Local Anaesthetics & LAST (Local Anaesthetic Systemic Toxicity)

DrugMax dose (plain)Max dose (+ adrenaline)Duration
Lidocaine3 mg/kg7 mg/kg1–2 h
Bupivacaine2 mg/kg2 mg/kg4–8 h
Ropivacaine3 mg/kg—4–6 h
Prilocaine6 mg/kg8 mg/kg1–2 h

LAST — Signs & Symptoms

CNS (early): Circumoral numbness, metallic taste, tinnitus, agitation, seizures

CNS (late): Loss of consciousness, coma

CVS: Arrhythmia, bradycardia, hypotension, cardiac arrest (bupivacaine most cardiotoxic)

LAST Management — Lipid Emulsion Protocol (20%)▼
  1. Stop LA injection immediately
  2. Call for help — activate emergency response
  3. Airway: 100% O₂, ventilate if needed
  4. Seizures: Benzodiazepine preferred (avoid propofol — cardiovascular depression)
  5. Lipid Emulsion 20%:
    • Bolus: 1.5 mL/kg IV over 1 minute
    • Infusion: 0.25 mL/kg/min — continue for at least 10 minutes after cardiovascular stability
    • If no response: repeat bolus ×2 at 5-min intervals
    • Maximum total dose: 12 mL/kg
  6. Cardiac arrest: CPR per ALS algorithm. Avoid lidocaine as anti-arrhythmic. Amiodarone preferred for arrhythmia.
  7. Consider early ECMO notification for refractory cardiac arrest
  8. Report all LAST events to AAGBI / local authority
Propofol is NOT a substitute for lipid emulsion in LAST — it worsens haemodynamics.

Basic Airway Manoeuvres & BVM

  • Head tilt–chin lift: First-line in non-trauma
  • Jaw thrust: Preferred in suspected C-spine injury
  • Oropharyngeal airway (OPA/Guedel): Size = corner of mouth to earlobe. Contraindicated in conscious patients (gag reflex)
  • Nasopharyngeal airway (NPA): Better tolerated in semi-conscious; contraindicated in base of skull fracture

Bag-Valve-Mask (BVM) Ventilation

  • E-C grip technique: Thumb + index finger (C) on mask, remaining three fingers (E) on mandible
  • Two-person technique: One provider maintains mask seal bilaterally, second squeezes bag — preferred for difficult airway/obesity
  • Tidal volume: 6–8 mL/kg (avoid gastric insufflation)
  • Rate: 10–12 breaths/min in adults

Supraglottic Airways (SGA)

LMA / i-gel Sizing

SizePatient weight
1<5 kg (neonate)
1.55–10 kg
210–20 kg
2.520–30 kg
330–50 kg (small adult)
450–70 kg (average adult)
570–100 kg (large adult)
Contraindications to SGA: Full stomach / not fasted, known GORD, oropharyngeal pathology, airway pressures >20 cmH₂O required, morbid obesity (relative), prolonged prone position (relative).
Rapid Sequence Induction (RSI) — Step-by-Step Protocol▼
  1. Pre-oxygenation: 100% O₂ via tight-fitting mask for 3–5 minutes (or 8 vital capacity breaths). Target EtO₂ >90%.
  2. Positioning: Ramped position (obese patients) or 20° head-up; sniffing position.
  3. Preparation: IV access confirmed, drugs drawn up, suction on and working, difficult airway trolley available, assistant trained in cricoid pressure.
  4. Pre-medication: Fentanyl 1–2 mcg/kg (attenuates intubation response); IV lidocaine 1.5 mg/kg for head injury (blunts ICP rise).
  5. Cricoid pressure: Applied at loss of consciousness — 10 N awake, 30 N at induction (Sellick manoeuvre). Release if causes laryngeal difficulty or active vomiting.
  1. Induction agent: Propofol 1.5–2.5 mg/kg OR ketamine 1–2 mg/kg (haemodynamically unstable/asthma) OR thiopentone 3–5 mg/kg (historical, head injury).
  2. NMB: Suxamethonium 1.5 mg/kg IV OR rocuronium 1.2 mg/kg IV (if sux contraindicated — reversible with sugammadex 16 mg/kg).
  3. Intubation: Direct laryngoscopy or videolaryngoscopy — do NOT bag-mask ventilate between induction and intubation (no ventilation phase).
  4. Confirm: Waveform capnography (gold standard) + bilateral breath sounds + chest rise. Secure ETT at 21 cm (female) or 23 cm (male) at teeth.
  5. Release cricoid pressure after ETT cuff inflated and position confirmed.
Modified RSI allows gentle BVM ventilation (low pressure <10 cmH₂O) in patients with desaturation risk (obesity, paediatrics, critically ill) while maintaining cricoid pressure.

Endotracheal Tube (ETT) — Key Parameters

Tube Sizes (Internal Diameter)

  • Males: 7.0–8.0 mm ID
  • Females: 6.5–7.5 mm ID
  • Children: (Age/4) + 4 mm (uncuffed); (Age/4) + 3.5 mm (cuffed)

Insertion Depth at Teeth

  • Males: 23 cm
  • Females: 21 cm
  • Confirm: Bilateral breath sounds, symmetric chest rise, no gastric gurgling

Cuff Pressure

  • Target: 20–30 cmH₂O
  • <20 cmH₂O: aspiration/leak risk
  • >30 cmH₂O: tracheal mucosal ischaemia
  • Use cuff manometer — not finger-feel
Waveform capnography is the gold standard for ETT confirmation and continuous monitoring. Loss of CO₂ waveform = oesophageal intubation or cardiac arrest until proven otherwise.

Difficult Airway Algorithm — Can't Intubate Can't Oxygenate (CICO)

StepAction
1. OptimiseRepositioning, external laryngeal manipulation (BURP), 2nd laryngoscopist, different blade
2. SupraglotticInsert LMA/i-gel — if oxygenation achieved, wake patient, plan awake FOI
3. BVMTwo-person technique, OPA/NPA, attempt oxygenation
4. CICO declaredCall for additional help, declare CICO emergency
5. Surgical airway (FONA)Scalpel–Bougie–Tube technique: Horizontal stab incision through cricothyroid membrane, insert bougie, railroad 6.0 mm ETT or dedicated tracheostomy tube, inflate cuff, confirm CO₂, ventilate
Time is critical in CICO: Do not delay surgical airway — irreversible brain damage in 4–6 minutes. Needle cricothyrotomy provides temporary oxygenation but is NOT definitive — must proceed to surgical airway.
WHO Surgical Safety Checklist — Sign In / Time Out / Sign Out▼

Sign In (before induction)

  • Patient identity confirmed (2 identifiers)
  • Consent form signed and correct
  • Site marked (if applicable)
  • Anaesthetic machine & medication check complete
  • Pulse oximeter on and functioning
  • Known allergies identified
  • Difficult airway / aspiration risk?
  • Blood loss risk >500 mL? IV access / blood available?

Time Out (before skin incision)

  • All team members introduced by name and role
  • Confirm: patient, procedure, site, position
  • Antibiotic prophylaxis given in last 60 minutes?
  • Anticipated critical events:
    • Surgeon: steps, duration, blood loss
    • Anaesthetist: patient concerns
    • Nurse: equipment sterility confirmed, any concerns
  • Imaging displayed if required

Sign Out (before patient leaves OR)

  • Procedure performed confirmed with surgeon
  • Instrument, sponge, needle count — correct?
  • Specimen labelled correctly?
  • Equipment problems to address?
  • Recovery/post-op plan communicated
  • Key concerns for recovery noted
WHO Surgical Safety Checklist reduces surgical mortality by 47% and complication rates by 36% (Haynes et al., 2009).

Patient Positioning & Nerve Injury Prevention

PositionNerve at RiskPrevention
Supine — arm abducted >90°Brachial plexusArm abduction <90°, neutral head position, avoid prolonged extension
Supine — elbow flexed against hard surfaceUlnar nerve (cubital tunnel)Pad elbow, avoid pressure at medial epicondyle
LithotomyCommon peroneal nerve (fibular head), femoral nerve, sciatic nervePad lateral knee (fibular head), avoid hip flexion >90°, simultaneous leg lowering
Lateral decubitusBrachial plexus (lower arm), peroneal nerveAxillary roll, pad fibular head, check ear not folded
ProneEyes (central retinal artery occlusion), brachial plexusGel head ring or Mayfield, eyes free of pressure, arms <90° abduction
Lithotomy Compartment Syndrome: Prolonged lithotomy >2 hours → calf ischaemia → compartment syndrome. Signs on reversal: severe calf pain, tense compartment, elevated CK. Fasiciotomy may be required. Limit lithotomy time; consider sequential compression devices.

Diathermy (Electrosurgery) Safety

Monopolar Diathermy

  • Patient plate (dispersive electrode): Apply to dry, clean, non-bony area closest to surgical site; good contact essential to prevent burns
  • Check plate site before and after procedure
  • Avoid over bony prominences, scar tissue, metal implants

Cardiac Device Interference

  • Pacemakers: diathermy may inhibit pacing or cause reprogramming
  • ICDs: suspend tachytherapy intraoperatively
  • Liaise with cardiology pre-op; have magnet available; cardiac monitor continuously
  • Use bipolar or ultrasonic device where possible

Fire Risk

  • Fire triangle in OR: oxygen source + fuel (drapes, alcohol prep) + ignition (diathermy)
  • Allow alcohol skin prep to fully dry before draping
  • Minimise O₂ concentration near surgical field (face/head/neck surgery)

Temperature Management (Normothermia)

NICE Standard: Maintain core temperature 36.5–37.5°C perioperatively. Hypothermia defined as core temperature <36°C.

Normothermia Interventions

  • Forced air warming blanket (e.g. Bair Hugger) — most effective active warming
  • IV fluid warmer (all fluids >500 mL warmed to 37–40°C)
  • Humidified anaesthetic gases — HME (heat-moisture exchanger)
  • Warm theatre environment for paediatric patients (>21°C)
  • Warm skin prep solutions

Consequences of Hypothermia

  • Increased surgical blood loss (platelet dysfunction, coagulopathy)
  • Increased surgical site infection (impaired neutrophil function)
  • Prolonged drug metabolism (delayed emergence)
  • Increased PACU stay and cardiovascular events
  • Shivering — increases O₂ demand ×3–5

Tourniquet Safety

Pressure Guidelines

  • Upper limb: SBP + 75 mmHg (minimum 100 mmHg above SBP) — typically 200–250 mmHg
  • Lower limb: SBP + 150 mmHg — typically 250–350 mmHg
  • Check cuff integrity and calibration before use

Maximum Application Time

  • Upper limb: 2 hours (120 min)
  • Lower limb: 1.5 hours (90 min)
  • If extension needed: deflate ≥15 min before re-inflation

Esmarch Bandage (Exsanguination)

Used before tourniquet inflation to exsanguinate limb and maximise bloodless field.

Contraindications to Esmarch:
  • Malignancy (risk of tumour cell emboli)
  • Active DVT / PE risk (thrombus dislodgement)
  • Local infection / open fracture
  • Severe peripheral vascular disease

Tourniquet Pain

Deep aching pain despite regional anaesthesia after 30–45 min — caused by ischaemic C-fibre activation. Managed with IV opioids or deepening general anaesthesia.

Aldrete Score (PACU Discharge Criteria)

Score each parameter 0–2. Total score ≥9/10 required for PACU discharge.

ParameterScore 2Score 1Score 0
ActivityMoves all 4 limbs voluntarilyMoves 2 limbsUnable to move
RespirationBreathes deeply, coughs freelyDyspnoea / limited breathingApnoeic
CirculationBP ±20% of pre-op baselineBP ±20–49%BP ±≥50%
ConsciousnessFully awakeArousable on callingNot responding
Colour / O₂ SaturationSpO₂ >92% on room airNeeds O₂ to maintain >90%SpO₂ <90% on O₂

PONV — Apfel Score & Management

Apfel Score (1 point each)

  • Female gender
  • Non-smoker
  • History of PONV / motion sickness
  • Postoperative opioid use

0–1: Low (10–20%) 2: Moderate (40%) 3–4: High (60–80%)

Prophylaxis (based on risk)

  • Low risk: no prophylaxis or single agent
  • Moderate: 2 agents (ondansetron 4 mg + dexamethasone 4–8 mg at induction)
  • High risk: 3 agents — ondansetron + dexamethasone + droperidol 0.625 mg or NK1 antagonist (aprepitant)
  • TIVA with propofol reduces PONV vs volatile agents
  • Avoid N₂O (increases PONV risk)

Treatment of Established PONV

  • Use a different class than prophylaxis agent given
  • Ondansetron 4 mg, prochlorperazine 12.5 mg IM, metoclopramide 10 mg, cyclizine 50 mg
  • Ensure adequate hydration

Common PACU Complications

Emergence Delirium / Agitation

  • Common in children post-sevoflurane anaesthesia
  • Assess: pain (FLACC scale), hypoxia, urinary retention, emergence delirium
  • Treatment: Propofol 0.5–1 mg/kg (rescue for sevoflurane-related), fentanyl for pain, dexmedetomidine (preventive)
  • In adults: exclude hypoxia, hypercapnia, pain, full bladder first

Post-Dural Puncture Headache (PDPH)

  • Onset 24–48h post spinal/epidural
  • Positional: worse upright, better lying flat
  • Frontal/occipital location, may have neck stiffness, diplopia, tinnitus
  • Conservative: bed rest, oral fluids, caffeine, paracetamol/NSAIDs
  • Epidural blood patch: Gold standard — 15–20 mL autologous blood injected epidurally at same/adjacent space. Success rate 70–98%.

Shivering

  • Increases O₂ consumption ×3–5 times
  • Treat underlying hypothermia (active warming)
  • Drug treatment: Meperidine (pethidine) 25 mg IV — most effective; clonidine, tramadol, dexmedetomidine

Pain Management — Multimodal

  • Paracetamol (acetaminophen): 1 g IV/oral q6h — baseline analgesic
  • NSAIDs: Ketorolac 15–30 mg IV, ibuprofen — reduce opioid requirements 30–40%
  • Opioids: Morphine PCA or IV PRN; titrate carefully, monitor respiratory rate
  • Regional anaesthesia: Epidural, peripheral nerve blocks (TAP, femoral, sciatic) — superior analgesia + opioid-sparing
  • Adjuncts: Ketamine (sub-anaesthetic), dexamethasone, gabapentinoids

Reversal Agents Summary

  • Sugammadex: 2 mg/kg (moderate block TOF count 2) or 4 mg/kg (deep block)
  • Neostigmine: 50 mcg/kg + glycopyrrolate 10 mcg/kg
  • Flumazenil: 0.2 mg IV (benzodiazepine reversal) — short acting, may need repeat
  • Naloxone: 0.4 mg IV (opioid reversal) — titrate to effect; use diluted 40 mcg aliquots for respiratory depression post-op

GCC Anaesthesia Nursing — Regulatory Framework

DHA (Dubai Health Authority)

  • Anaesthesia nursing scope defined under DHA licensing framework
  • Competencies: pre-op assessment, intraoperative monitoring, PACU care, drug management
  • Continuing Professional Development (CPD) required for licence renewal
  • DOH (Abu Dhabi) mirrors scope with Jawda quality framework alignment

SCFHS (Saudi Arabia)

  • Operating Theatre Nursing classified as specialty — separate certification pathway
  • Saudi OTN certification: competency-based assessment + examination
  • Anaesthesia technologist role distinct from anaesthesia nurse in Saudi context
  • CBAHI accreditation standards mandate checklist compliance and competency documentation

GCC Surgical Volumes Context

Rapid growth in surgical capacity across GCC — Vision 2030 (KSA), Dubai Health Strategy, Abu Dhabi Health Strategy driving significant investment in OR nursing workforce. High demand for certified perioperative nurses. International recruitment (Philippines, India, UK, Ireland) alongside local nationalisation programmes (Saudisation, Emiratisation).

Malignant Hyperthermia (MH) in GCC

MH is a rare but potentially fatal pharmacogenetic disorder. All GCC ORs must have dantrolene available and staff trained in recognition and management.

Diagnosis

  • Unexplained rise in EtCO₂ (earliest sign)
  • Tachycardia, muscle rigidity, masseter spasm
  • Rising temperature (late sign — >38.8°C core)
  • Metabolic & respiratory acidosis
  • Raised CK, myoglobinuria, hyperkalaemia

Dantrolene Protocol

  • Initial dose: 2.5 mg/kg IV bolus (repeat every 5 min to max 10 mg/kg)
  • Each 20 mg vial requires 60 mL sterile water — team effort for preparation
  • Continue dantrolene 1 mg/kg q6h for 24–48h post-episode
  • Minimum 36 vials dantrolene recommended per OR department

GCC MH Hotline

Contact the North American MH Registry (MHAUS) hotline: +1-800-644-9737 (international calls accepted 24/7). Maintain local hospital MH protocol in OR emergency manual.

Trigger-Free Anaesthesia

For known or suspected MH-susceptible patients: TIVA only (propofol + remifentanil), avoid all volatile agents and suxamethonium. Flush anaesthetic machine for 10–20 minutes at high flow with activated charcoal filters.

Obese Patient Anaesthesia — GCC Context

GCC has one of the highest global obesity prevalences — Saudi Arabia, Kuwait, UAE consistently rank among top 10 worldwide. BMI >40 common in OR population.

Key Considerations

  • Drug dosing: Use Ideal Body Weight (IBW) for most drugs; Total Body Weight (TBW) for suxamethonium, propofol induction loading dose; Lean Body Weight (LBW) for propofol maintenance, opioids
  • Airway: High OSA prevalence (STOP-BANG ≥3 common) — plan difficult airway; ramped positioning; videolaryngoscopy first-line; post-op CPAP
  • Positioning: Ramped position (ear-to-sternal notch horizontal) improves laryngoscopy view and FRC; beach chair for awake FOI
  • Respiratory: Reduced FRC, rapid desaturation — thorough pre-oxygenation in ramped position; PEEP 5–10 cmH₂O intraoperatively; lung recruitment manoeuvres
  • Cardiovascular: OSA-related pulmonary hypertension, LVH, increased cardiac output — careful fluid management
  • VTE prophylaxis: Weight-adjusted LMWH, early mobilisation, intermittent pneumatic compression

Ramadan Fasting Patients

Ramadan occurs annually (Islamic lunar calendar). A significant proportion of the GCC patient population will be fasting during Ramadan. Elective surgery planning must account for this.

Fasting Compliance

  • Preferred scheduling: Morning list — patient fasted from Suhoor (pre-dawn meal), last solid food 2–4 AM
  • By standard morning surgery time (8–9 AM), fasting duration is typically 6–8 hours for solids
  • Confirm last meal time and type — Suhoor content varies
  • Clear fluids (water) allowed until 2 hours pre-op per ERAS guidelines
  • Some observant patients may refuse clear fluids — document clearly; assess aspiration risk

Clinical Considerations

  • Diabetic patients on insulin/oral agents — monitor BGLs; hypoglycaemia risk; insulin adjustment usually required
  • Dehydration — common, particularly in hot GCC climate; IV fluid requirement may be higher
  • Cultural sensitivity: discuss fasting status respectfully; involve patient in decision-making
  • Emergency surgery: standard emergency protocol regardless of fasting status

GCC Exam Preparation — 5 MCQs

Q1. A 68-year-old male with poorly controlled diabetes, ESRD on dialysis, and morbid obesity (BMI 44) presents for elective hip replacement. His last ECG showed LVH. What is his ASA classification?
Correct Answer: B — ASA III
Poorly controlled DM, ESRD on dialysis, and morbid obesity (BMI >40) each individually qualify for ASA III. Multiple ASA III conditions together do not automatically elevate to ASA IV — ASA IV requires a condition that is a constant threat to life (e.g., recent MI <3 months, severe decompensated heart failure, severe ARDS). LVH alone is not sufficient for ASA IV.
Q2. During induction of anaesthesia, a patient develops rapidly rising EtCO₂ to 68 mmHg, tachycardia 140 bpm, and masseter rigidity following suxamethonium. What is the FIRST treatment priority?
Correct Answer: C — Stop all volatile anaesthetic agents and call for help
MH management: FIRST remove the triggering agent (stop all volatile/halogenated agents and suxamethonium). Switch to TIVA. Simultaneously call for help and begin dantrolene preparation. Dantrolene administration follows trigger removal — it is not the very first step because removal of the trigger is paramount and takes only seconds.
Q3. A 54-year-old female (non-smoker, previous PONV history, requiring morphine PCA post-op) is scheduled for laparoscopic cholecystectomy. Her Apfel score is 3. Which PONV prophylaxis strategy is most appropriate?
Correct Answer: C — Triple therapy + consider TIVA
Apfel score 3 = high risk PONV (approximately 60–80% incidence). Guidelines recommend multimodal prophylaxis with ≥3 antiemetic agents from different classes. Ondansetron (5-HT3 antagonist) + dexamethasone (corticosteroid) + droperidol (D2 antagonist). Additionally, propofol TIVA instead of volatile agents significantly reduces PONV risk. Laparoscopic surgery further increases PONV risk.
Q4. During RSI, Mallampati Class IV, thyromental distance 4.5 cm, mouth opening 2 cm are documented. After three failed intubation attempts, SpO₂ drops to 72% despite 2-person BVM ventilation and LMA insertion. What is the next appropriate action?
Correct Answer: C — Declare CICO and perform emergency FONA (scalpel–bougie–tube)
This is a CICO scenario — cannot intubate, cannot oxygenate (SpO₂ 72% despite all attempts including SGA). The Difficult Airway Society algorithm mandates immediate surgical airway (Front Of Neck Airway — FONA) at this point. Scalpel–bougie–tube via cricothyroid membrane is the recommended technique. Further intubation attempts are contraindicated. Option D is reasonable if suxamethonium was used for RSI and waking is achievable, but with SpO₂ 72%, emergency FONA is the priority.
Q5. A patient receives rocuronium 1.2 mg/kg for RSI. At end of surgery (45 min later), Train-of-Four monitoring shows 0 twitches (deep block). Which reversal agent and dose is correct?
Correct Answer: C — Sugammadex 4 mg/kg
Sugammadex dosing is depth-dependent: 2 mg/kg for moderate block (TOF count ≥2), 4 mg/kg for deep block (TOF count 0, post-tetanic count 1–2). 16 mg/kg is reserved for immediate emergency reversal of rocuronium RSI dose. Neostigmine is ineffective at deep block (TOF count 0) — it requires at least TOF count 2 for adequate reversal. Sugammadex is the only effective agent for deep rocuronium/vecuronium blockade.