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

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

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

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

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

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

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

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

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

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

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

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