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AS4.1-7 | General Anaesthesia — Assignment

Instructions

1. Read the patient vignette below carefully.

Vignette: Mr Ramesh, a 62-year-old male (weight 78 kg, height 168 cm, BMI 27.6), is listed for elective laparoscopic right hemicolectomy for a T2N0 carcinoma of the ascending colon under general anaesthesia. Past medical history: hypertension (well controlled on amlodipine 5 mg OD), type 2 diabetes (metformin 500 mg BD; HbA1c 7.2%), mild COPD (FEV1/FVC 0.68; on salbutamol PRN). No known drug allergies. Mouth opening 4 cm; neck extension full; thyromental distance 6.5 cm; on pharyngeal examination with mouth wide open and tongue protruded, soft palate, uvula, and fauces are visible but tonsillar pillars are partially obscured. He had a uneventful appendicectomy 20 years ago under general anaesthesia. He last ate a full meal 8 hours ago and drank clear fluids 3 hours ago.

1. Assign an ASA physical status classification (I–VI) with justification.

3. Perform a structured airway assessment:
a. Assign the Mallampati class with justification (remember: Mallampati grades the oropharyngeal view, NOT systemic disease — do not confuse with ASA).
b. List three other bedside predictors of difficult intubation that should be assessed and their expected values in this patient.
c. Predict the likely Cormack-Lehane grade and explain your reasoning.

4. Design an anaesthetic plan covering:
a. Pre-medication and fasting confirmation (apply the 2-4-6-8 rule explicitly).
b. Induction: name the agent and dose in mg/kg (for Ramesh's weight), type of intubation, muscle relaxant and dose.
c. Maintenance: agent(s) and delivery method; monitoring (list minimum 5 monitors with their clinical purpose).
d. Vital organ support: circulatory, respiratory, temperature, and fluid management strategy.
e. Emergence and extubation criteria.

1. Identify two potential intraoperative complications specific to laparoscopic abdominal surgery and describe how you would recognise and manage each.

1. Outline the post-operative recovery plan including pain management strategy (multimodal, opioid-sparing where possible) and criteria for safe discharge from the recovery room.

Word guidance: 700–950 words (excluding tables/diagrams if used).

Length: 700-950 words

Grading Rubric — General Anaesthesia Assignment Rubric

Criterion	Points	Full-marks descriptor
ASA Classification and Airway Assessment: Correct ASA grade with justification; correct Mallampati class with description of pharyngeal findings; three valid bedside airway predictors identified; reasoning for C-L grade prediction is anatomically sound	20 pts	ASA III correctly assigned with justification for all three comorbidities; Mallampati II correctly identified with accurate description of what is seen; three valid predictors (e.g., ULBT, thyromental distance, mouth opening) cited with expected values; C-L grade prediction logically derives from the airway assessment
Anaesthetic Plan — Agents and Doses: Induction agent named with correct mg/kg dose and actual dose for 78 kg; fasting confirmation applies 2-4-6-8 rule; muscle relaxant choice and dose correct; maintenance strategy appropriate for laparoscopic surgery	25 pts	Propofol 1.5–2.5 mg/kg cited with actual dose range (117–195 mg) correctly calculated; 2-4-6-8 rule explicitly applied and patient confirmed to meet clear-fluid criterion (3 h) and solid-food criterion (8 h); non-depolarising NMBA at correct dose; maintenance with volatile or TIVA with rationale; all doses in mg/kg
Monitoring and Vital Organ Support: Minimum five monitors named with specific clinical purpose for each; organ-support strategy covers circulation, ventilation, temperature, and fluids; monitoring plan is appropriate for laparoscopic surgery	20 pts	Five monitors named with a clinically meaningful purpose for each (e.g., capnography = confirms ETT position, detects CO₂ absorption from insufflation, estimates PaCO₂); circulatory support addresses PONV, laparoscopic haemodynamic shifts, Trendelenburg; temperature monitoring + active warming mentioned; fluid management includes goal-directed or maintenance strategy
Laparoscopic Complications and Recovery Plan: Two laparoscopic-specific complications correctly identified; recognition and management described accurately; recovery criteria and multimodal analgesia plan are clinically sound	20 pts	Two valid laparoscopic complications described (e.g., CO₂ absorption → rising ETCO₂ + hypercapnia; gas embolism; surgical emphysema; haemodynamic shifts from Trendelenburg/pneumoperitoneum); recognition criteria specific; management steps correct; recovery criteria include standard parameters (consciousness, SpO₂, pain, PONV); analgesia is multimodal and opioid-sparing
Clinical Reasoning and Integration: The plan is coherent, internally consistent, and patient-specific (calculations use 78 kg); ASA and Mallampati are not confused; evidence-based reasoning is applied throughout; writing is concise and within word guidance	15 pts	All calculations use patient weight; no conflation of ASA with Mallampati; plan is logically sequenced from pre-op through recovery; evidence-based reasoning cited for key choices; within 700–950 words