10. Other topics green anaesthesia DAS neck

Question 1

Green Anaesthesia

Answer 1

Summary

The detrimental health effects of climate change continue to increase.

Although health systems respond to this disease
burden, healthcare itself pollutes the atmosphere, land, and waterways.

We surveyed the ‘state of the art’ environmental
sustainability research in anaesthesia and critical care, addressing why it matters, what is known, and ideas for future
work.

Focus is placed upon the atmospheric

chemistry of the anaesthetic gases,
recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment.

Life cycle assessment (LCA; i.e. ‘cradle to
grave’ analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products,
processes, and systems.

The number of LCAs within medicine has gone from rare to an established body of knowledge in
the past decade that can inform doctors of the relative ecological merits of different techniques.

LCAs with practical outcomes are explored,
such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock.

Avoid, reduce, reuse, recycle, and reprocess are then explored.

Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare’s ecological footprint are highlighted.

Question 2

Impact

Answer 2

Effects of other increasing GHGs (mainly
CH4, N2O, O3, and halogenated compounds) have contributed
as much to global warming as increasing CO2 its

halogenated compounds (including volatile anaesthetic
agents) accounting for approximately 11%

Nitrous oxide is responsible for the
majority of ongoing ozone depletion

approximately 6% of anthropogenic global warming

CO2 equivalent (CO2e) is used to indicate the global
warming potency of GHGs relative to the reference unit of CO2

Question 3

GWP

Answer 3

m global warming potential (GWP). Carbon
dioxide has, by definition, a GWP of 1,

whereas N2O for example has a GWP of 265

Question 4

Evidence

Answer 4

Anaesthetic activity

1. Gases
   Avoid, where possible, the use of
   anaesthetic gases with high GWP and
   minimise amount used of all
   anaesthetic gases.
2. TIVA
3. Regional anaesthesia
4. ICU
5. Plastic syringes
   Avoid excessive use
6. Theatre Attire
   Avoid disposables
7. Energy Consumption
   Turn off machines

Question 5

1. Gases

Answer 5

Known:
Avoid the use of desflurane and nitrous oxide.

The GWPs of anaesthetic gases are well researched.

Encourage low flow and automated end tidal control anaesthesia.

Uncertain:

What is the worldwide use of anaesthetic gases/TIVA
and how is this evolving?

Waste anaesthetic gas reclamation research is emerging,
though currently rare clinically.

What are the environmental effects of medical use of O2/air?

Question 6

2. TIVA

Answer 6

Known: TIVA (propofol) itself has approximately 1%
the GWP of even sevoflurane volatile anaesthesia.

Uncertain:
TIVA’s other environmental effects.

Quantification of water contamination
from anaesthetic pharmaceuticals.

Balancing TIVA’s plastic waste, etc. with the GWPs of volatiles.

Question 7

3. Regional

Answer 7

Uncertain: What is the environmental footprint of regional anaesthesia?
Are there trade-offs between the carbon footprint and other environmental effects?

Question 8

4. ICU

Answer 8

Known:
The carbon footprint of machines for treating100 ICU patients and the overall ICU footprint.

ICU engineering HVAC formed the majority of the carbon footprint.

Methods to reduce the use of excessive
gowning for routine patient care whilst
avoiding cross-contamination.

Uncertain: How to safely reduce the
carbon footprint of ICU engineering energy use.

Question 9

5. Plastic syringes

Answer 9

Plastic syringes
Avoid excessive use
Draw up the minimum practicable number of syringes.
Leave emergency drugs/equipment unopened, but immediately available.

Question 10

6. Theatre attire

Answer 10

Theatre attire

Avoid disposables
Use washable, theatre-only hats and shoes.

Question 11

7. Anaesthetic Machine

Answer 11

Energy consumption
Turn off anaesthetic machine and scavenging + Suction use out of hours

Known:
Heating, ventilation and air conditioning make up a large proportion of OR carbon emissions so ‘set back’ out of hours

Anaesthetic breathing circuits Known:
Evidence from two studies96,97 that weekly circuit changes are as safe as daily changes.

Uncertain: Unclear how widespread knowledge/translation of such knowledge is.

Question 12

8. Reusable

Answer 12

Surgical gowns Known: Review of five LCAs comparing reusable to single-use showed reusable surgical
gowns consistently have a lower environmental footprint (energy, water, waste).

Anaesthetic drug trays Known: One LCA of anaesthetic drug trays71 showed reusable trays have lower financial
and environmental footprints.

LMAs Known: One LCA of reusable and single-use LMAs72 showed reusables have a lower
environmental footprint than single-use.

Face masks, circuits and laryngoscope
blades.
Known: Using reusable anaesthetic equipment estimated to save AUD$5000/OR/
annum91; however, in Australia, using reusable equipment can have a slightly higher
carbon footprint than single-use. Conversely in Europe/UK/USA the carbon footprint is
much lower for reusable equipment (more renewable electricity).

Reusable laryngoscopes are less expensive and have a lower environmental footprint
than single-use laryngoscopes.84

Reusable anaesthetic equipment can
require greater use of water
Known: Washing reusable equipment uses more water than required for manufacturing
single-use equipment.

Donate equipment to less developed
nations.
Donation of useful anaesthetic equipment can have social, financial and environmental
benefits but these must be balanced against risks and problems such as access to
appropriate training, consumables, and waste disposal management.1

Question 13

AAGBI suggestion

Answer 13

The greatest impact for many will come from reducing their use of anaesthetic gases with significant global warming potential – in particular desflurane and nitrous oxide.

We suggest:

1. Avoid nitrous oxide whenever possible,
   and use oxygen/air as the carrier gas;
   the effect of the increased use of volatile agent
   to achieve an adequate depth of anaesthesia
   is more than offset by the benefit of eliminating nitrous oxide
2. Avoid use of desflurane except for rare occasions
   when its use is really necessary
3. Use low flow anaesthesia (max 1.5 l/min) during maintenance in all cases
4. Consider swapping volatile agent-based anaesthesia for a TIVA technique
5. Consider use of central neuraxial block or regional anaesthesia

Question 14

BMJ article suggestions

Answer 14

Inform yourself about the basic science of climate change, the health benefits of taking action, and the urgency of doing so

Advise your patients. Better diet and more walking and cycling will improve their health and reduce their carbon emissions

Save energy and money through house insulation, turning off appliances and lights and reductions in use of goods and services

Drive and fly less, walk or cycle more, teleconference/webcast

Eat local food, less meat, and less processed food - a low carbon diet is a healthy diet. Drink tap water

Advocate locally

Agitate for personal carbon entitlements and financial incentives to reduce carbon costs

Advocate population stabilisation, by promoting literacy and promoting women’s access to birth control, via the International

Planned Parenthood Federation or Marie Stopes International.

Advocate a climate change agenda at all meetings

Ally yourself with other health professionals

Question 15

Nitrous oxide project

Answer 15

The NHS has committed to achieving net-zero direct emissions by 2040, this specifically includes anaesthetic gases. Nitrous oxide confers the largest carbon footprint of the anaesthetic gases within the acute sector, accounting for at least 80% of the total anaesthetic gas footprint in 2019/20.

Flattening anaesthetic nitrous oxide emissions by: minimising system waste; educating and promoting green practice; and assessing and applying nitrous oxide catalytic cracking technologies where appropriate.

Piped Nitrous Oxide Waste Reduction Strategy
Recent efforts within NHS Lothian to reduce the total contribution of theatre nitrous oxide has revealed that wastage from piped manifold systems is a far more significant problem than that of persistent clinical usage. NHS Lothian’s lean approach can be adopted to address piped nitrous wastage oxide at any acute site. The project lead for NHS Lothian advises that once a nitrous oxide mitigation project team is established at an acute site, they should first discuss their investigative approach and draw on the Lothian methodology as an exemplar and not an absolute standard. An audit and analytics sheet has been included at the end of this document to facilitate investigation

Question 16

BJA article conclusions

Answer 16

Conclusions
Healthcare itself pollutes.

Anaesthesia and critical care are
the cause for a considerable contribution to such healthcare
pollution. We recognise that there can be accord and conflict
between individual patient health and public health commitments, particularly in the field of infection prevention,
although one can protect the patient and the planet.

Over the past decade considerable progress has been made in
improving the research foundation of environmentally sustainable healthcare, a summary of evidence pertaining to
anaesthesia and critical care

Such considerations do not usurp patient-centred nor fiscally prudent care, but rather complement such goals by protecting
patients, our healthcare system, and the environment

Question 17

BJA 2015 articles

Answer 17

Key points
*
The inhalational anaesthetic agents sevoflurane isoflurane and desflurane have global warming potentials 2-3 orders of magnitude higher than CO2.
*
Nitrous oxide contributes significantly to global warming and ozone depletion.
*
5% of the carbon footprint (CO2e) of the NHS is attributable to exhaled anaesthetic agents.
*
Most medical nitrous oxide liberation originates from Entonox use, including maternity use.
*
Reducing the environmental impact of anaesthesia, can be achieved through behaviour change

Question 18

Nitrous oxide

Answer 18

global warming effect, the atmospheric lifetime is sufficiently long to ensure that it reaches the stratosphere where it is capable of ozone destruction

Photolytically generated oxygen atoms react with ozone to produce two oxygen molecules. Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers

Question 19

GWP100

Answer 19

Isoflurane 510

Sevo 130

Desflurane 2540

N2O 310

Question 19

How big an issue is the global warming effect of inhalation anaesthetics?

Answer 19

How big an issue is the global warming effect of inhalation anaesthetics?
It has been estimated that the annual warming effect of all the inhalation agents is the equivalent to that of one coal fired power station, and 0.01% of that of the CO2 released from current global fossil fuel combustion

further, 90% is due to nitrous oxide and two-thirds of this is from Entonox use, most of which is used in the delivery suite.

Question 20

Top tips for green anaesthesia modified from the Greenhouse Gas Protocol

Answer 20

Reduce direct liberation of GHGs into the atmosphere (Scope 1)

 Avoid car driving either commuting or on business

 Minimize the use of nitrous oxide

  Wider use of epidural analgesia or PCA for labouring mothers

 Low flow anaesthesia where ever possible

 Minimize desflurane usage

Minimize (fossil fuel generated) electrical energy use (Scope 2)

 Switch to conductive warming devices from convective

 Turn off AGSS out of hours

 Turn off (or low power standby) equipment lighting and ventilation when not in use

Purchase electrically powered devices in accordance with guidance on Green Public Procurement for Electrical and Electronic Equipment23

Minimize the indirect liberation of CO2 into the atmosphere (Scope 3)

 Reduce the amount of drugs, disposables and gases used to deliver anaesthesia

 Purchase disposable devices made with less material

 Reuse as much material as possible

 Minimize waste, including drugs.

 Maximize recycling possibilities

Avoid contamination of the environment with drugs that persist, accumulate or are toxic

Question 21

Advances in airway assessment

Answer 21

The sensitivity and positive predictive value of traditional airway assessment tools are poor at predicting the difficult airway.
*
Advanced airway assessment techniques exist, which are more informative and relatively easy to learn and interpret.
*
Nasoendoscopy can be used in both the elective and emergency setting to assess supraglottic and glottic pathology.
*
Virtual endoscopy uses pre-existing CT or MRI images to simulate the views seen during flexible nasoendoscopy.
*
The use of ultrasound in airway assessment is increasing; it offers additional real-time information and aids decision making.

-Preoperative airway assessment
-Tracheal tube size
- Cricothyroid membrane
-Fasting status
-Assessment of tracheal intubation
- Vocal cord assessment

Conclusions
A range of techniques are available to anaesthetists to aid with assessment of the potential difficult airway. There is an increasing body of evidence to suggest they should be considered in order to aid planning and maximise patient safety.
Nasoendoscopy can be safely and easily performed before anaesthesia and surgery; although it does not guarantee an ability to successfully intubate the trachea it is a useful adjunct to the anaesthetist’s armamentarium. Upper airway POCUS aids airway management because of its ease, accessibility and lack of invasiveness. The addition of VE to the assessment may aid the development of a safer airway management plan in high-risk patients. By providing a virtual fly-through of the best route for intubation with a flexible bronchoscope, VE potentially reduces the failure rate of the technique.

Question 22

Anaesthesia for the obese patient

Answer 22

Obesity only increases perioperative risk significantly when BMI is ≥40 kg m−2, or when associated with significant comorbidities.
*
Day-case surgery is usually appropriate if BMI is <50 kg m−2 and comorbidities are optimised.
*
Obstructive sleep apnoea and obesity hypoventilation syndrome are common high-risk conditions that influence management of anaesthesia.
*
Rapid sequence induction should not be routine in the absence of specific indications.
*
Previous bariatric surgery has important implications for subsequent anaesthesia.

Question 23

PICC Lines

Answer 23

Large numbers of patients undergoing anaesthesia and critical care have long-term vascular access devices in situ.

Anaesthetists increasingly insert such devices.

Particular long-term complications include thrombosis, occlusion, fracture, fibrin sheaths, and bacterial colonization.

Anaesthetists require a basic knowledge of insertion, care, and removal of such catheters

Question 24

Indications for long term venous access

Answer 24

for long-term venous access include cancer chemotherapy, long-term antibiotics, total parenteral nutrition (TPN), and haemodialysis

Rx duration,
aftercare capabilities, and
individual patient factors will
guide the catheter choice

Question 25

Principles of catheter design

Answer 25

1. Short-term central venous access devices

polyurethane, making them stiff enough to insert
over a guidewire.

They soften at body temperature to reduce vessel damage.

The high-tensile strength allows multiple
thin-walled lumens within one narrow catheter

Long-term venous access devices

are predominantly made from more flexible silicone
to reduce vessel damage and thrombosis

require insertion via a splitting sheath
and can be single, double, or triple lumen.

Catheter tips can be preformed, for example, with tapered tips or staggered holes or open/straight ended

pen-ended catheters can be cut to length but are easily blocked by blood backflow, especially with increasing gauge.2,3 Preformed tips can incorporate a valve (e.g. Groshong devices) to avoid backflow unless negative pressure is applied and may reduce occlusive and infective complications

Question 26

Types of catheter

Answer 26

1. Peripherally inserted central catheters (PICCs) are

small bore and typically inserted with ultrasound guidance via
the basilic or brachial vein in the upper arm

to end in the lower part of the superior vena cava (SVC).

Many centres perform such procedures
on wards without X-ray screening.

_______________

2. Tunnelled cuffed catheters
   exit the skin distant to the site of venepuncture
   (typically internal jugular or subclavian)

Subcutaneous Dacron anchoring cuff, for example,
Hickman and Broviac types
Tissue growth into the cuff anchors it after about 3 weeks, and is a barrier to the tracking of skin micro-organisms along the catheter

_________________________

3. Port catheters
   have a thick self-sealing silicone diaphragm
   over a titanium or plastic reservoir at the proximal end

They are sutured into a subcutaneous pocket necessitating a larger incision. Once healed, the intact skin barrier means that they carry the lowest infection risk and allow bathing and swimming

________________

4. Dialysis catheters
   are large bore, relatively stiff catheters
   designed to withstand both positive and negative pump pressures.

two separate catheters or a dual-lumen catheter with staggered tip positions to prevent blood recirculation.

lotted blood easily occludes the large lumens when not in use so heparin (1000 units ml−1) is usually used to fill the dead space

Other considerations
Coagulopathy, poor limb or vein condition, musculoskeletal abnormalities, and cosmetic aspects should be considered when choosing an insertion site. Blocked central veins from previous catheters may be evident from the presence of chest wall collaterals that are visible externally or on ultrasound, or an unusually engorged vein at the site of intended puncture.

Question 27

Practicalities of line insertion

Answer 27

Catheters are typically passed through a splitting (peel away) sheath, with an image intensifier or ECG guidance to verify central guidewire/catheter position.

For tunnelled catheters and ports, wide infiltration is used with 0.5–1% lidocaine with 1/200 000 epinephrine across the vein entry site, tunnelling tract, and skin exit site using a 22 gauge spinal needle

∼30–60 ml in total is necessary. Epinephrine-containing solutions cause vasospasm and should be avoided when inserting PICCs. Midazolam (2–5 mg) and fentanyl (50–100 µg) sedation with supplemental oxygen is useful for anxious patients.

Choice of access site

The arm veins (brachial, cephalic, basilic),
internal jugular, and subclavian/axillary veins.

The internal jugular is easily accessible and has a direct line to the central veins, but tunnelling the catheter can be difficult and leaves a visible protuberance under the skin.

PICCs are less invasive to insert, but achieving an optimal central position can be problematic2 if screening is not used. Misplaced PICCs will sometimes relocate with time, a change in position, or after forceful flushing with saline

Question 28

Tunnelling techniques

Catheter position

Securing catheters

Answer 28

Small incisions are made at the skin exit and venepuncture sites and deepened with blunt dissection. A curved tunnelling rod attached to the catheter is advanced from the exit site to the venepuncture site

The optimal catheter tip position is in the long axis of the lower SVC or upper RA ideally outside the pericardial reflection.

Securing catheters
External anchorage is with adhesive ‘Statlock’ devices or sutured wings. PICC lines require permanent fixation, but tunnelled lines are secure once the cuff has sufficient tissue ingrowth (around 3 weeks).

Aftercare
All patients should receive education and information about catheter care.8 Many trusts provide such information, but there are also some excellent web-based information resources, for example, Macmillan Cancer Support

Question 29

Complications particular to long-term venous access

Answer 29

1. Catheter tip malposition
2. Phlebitis
3. Thrombosis
   It can surround the catheter, occlude the tip or the entire vessel, and lead to pulmonary embolus.
4. Infection
   Catheter-related bloodstream infections (CRBSIs) and catheter microbial colonization are thought to occur in three ways; by ‘tracking’ from the skin exit site (most common in short-term catheters), by intraluminal/hub contamination (most common in catheters in situ >30 days), and by seeding from haematogenous spread (in immunocompromised patients)

Catheters with an antimicrobial coating or bonding are available and may reduce CRBSIs, but further research is awaited.

5. Catheter occlusion
   Impaired catheter patency can be due to mechanical obstruction by a kink or ‘pinch-off’ (between the clavicle and first rib), clotted blood, TPN or drug precipitation, fibrin sheaths, catheter malposition, or venous thrombosis.
6. Fibrin sheaths
7. Catheter fracture

Question 30

Complications particular to long-term venous access

Answer 30

1. Catheter tip malposition
2. Phlebitis
3. Thrombosis
   It can surround the catheter, occlude the tip or the entire vessel, and lead to pulmonary embolus.
4. Infection
   Catheter-related bloodstream infections (CRBSIs) and catheter microbial colonization are thought to occur in three ways; by ‘tracking’ from the skin exit site (most common in short-term catheters), by intraluminal/hub contamination (most common in catheters in situ >30 days), and by seeding from haematogenous spread (in immunocompromised patients)

Catheters with an antimicrobial coating or bonding are available and may reduce CRBSIs, but further research is awaited.

5. Catheter occlusion
   Impaired catheter patency can be due to mechanical obstruction by a kink or ‘pinch-off’ (between the clavicle and first rib), clotted blood, TPN or drug precipitation, fibrin sheaths, catheter malposition, or venous thrombosis.
6. Fibrin sheaths
7. Catheter fracture

Question 31

Using such devices (including perioperatively)

Answer 31

Handling should be with gloves and an aseptic/no-touch technique. The hub should be cleaned and the patency of the catheter checked by aspiration and flushing with at least twice its internal volume or 5–10 ml of saline

To ensure that blood does not enter the catheter tip when the syringe is removed, the catheter should be clamped under positive pressure (i.e. during flushing).

Ports are accessed aseptically via non-coring/‘Huber’ needles after skin cleaning with 2% chlorhexidine.5 The port is palpated with two fingers and the needle inserted through the thick resilient membrane until its tip hits the back wall of the chamber. Aspirating blood and flushing with saline verifies needle position

Question 32

DAS Neck Haematoma GL

Answer 32

Haematoma after thyroid surgery can
lead to airway obstruction and death.

We therefore developed guidelines to improve the safety of peri-operative care of patients undergoing thyroid surgery.

We highlight the importance of multidisciplinary team management and make recommendations in key areas including:

monitoring;
recognition;
post-thyroid surgery emergency box;
management of suspected haematoma
following thyroid surgery; cognitive aids;
post-haematoma evacuation care;
day-case thyroid surgery;
training; consent and pre-operative communication;

postoperative communication;
and institutional policies.

The guidelines support a multidisciplinary approach
to the management of suspected haematoma
following thyroid surgery through oxygenation and evaluation;

haematoma evacuation; and tracheal intubation.

They have been produced with materials to support implementation.

Question 33

Recommendations Neck Haematoma Guideline

Answer 33

1. All staff potentially interacting with patients
   undergoing thyroid surgery should be trained
   to recognise haematoma following thyroid surgery.

This includes ward staff where patients are nursed
and doctors of all grades and speciality.

2. Minimum monitoring includes
   wound inspection,
   early warning and pain scoring,
   as well as awareness for more subtle signs
   agitation; anxiety; difficulty in breathing; discomfort).
3. A post-thyroid surgery emergency box should
   be available at the bed-side of patients who have undergone thyroid surgery during the postoperative period,
   including during transfers.
4. Emergency front-of-neck airway equipment (scalpel; bougie; tracheal tube) must be readily available on wards caring for patients after thyroid surgery.
5. If concerned about potential haematoma
   following thyroid surgery,
   immediate senior surgical review
   (e.g. registrar or consultant) must be arranged.

If senior surgical review is not immediately available, or if there are signs of airway compromise,
a senior anaesthetist should be informed immediately.

6. If the patient shows signs of airway compromise
   due to haematoma, a systematic approach should be taken to open the wound at the bed-side.
   For this we recommend using the SCOOP approach
   skin exposure;
   cut sutures;
   open skin;
   open muscles (superficial and deep layers);
   pack wound).
7. When emergency haematoma evacuation has taken place, it is important for the surgical team, usually the consultant, to communicate with the patient, including after discharge.
   This should include offering referral for clinical psychology support or similar.
8. All organisations offering thyroid surgery should support members of the multidisciplinary team, including but not exclusive to anaesthetists, nursing staff, members of the cardiac arrest team and surgeons, to attain and maintain competency and skills required to manage complications.

Question 34

Close monitoring Thyroid

Answer 34

DESATS

Difficulty swallowing / discomfort

EWS / NEWS

Swelling

Anxiety

Tachypnoea / Difficulty breath

Stridor

Question 35

Immed actions for DESATS

Answer 35

1. O2 - 15 l/min
2. 45’ head up
3. Management of haematoma
4. Immed senior surg review
   if not available - anaesthetist
5. Evacuate if signs of compromise

Question 36

Management algorithm

Answer 36

1. Initial management - 02 head up call for ENT
2. Signs of compromise?
   Striodor
   SOB
   Desat
3. Call for help and evacuate

|
|
\/
No Improvement:

4. Intubate

Using DAS Guidelines

Consider:
1. VL
2. Most experienced - 1st attempt
3. 3+1

5. Unsuccessful
   Proceed to FONA

If improvement with evacuation
Stop and think
oxygenate

Question 37

Mx algorithm extras

Answer 37

1. Consider
   Dexamethasone
   TXA
   Flex endoscopic laryngeal assessment
   - experienced operator
2. Sx compromise
3. Important
   ensure both superficial and deep layers are opened
4. Consider
   Patient LOC - ability to maintain
   Obs trends
   Skill availability
   Request more senior / extra help
   Equipment availability
   Theatre?

Question 38

SCOOP

Answer 38

1. Skin Exposure
2. Cut subcuticular
3. Open wound
   Push fingers into wound
4. Open skin to expose strap muscles
   Open strap muscles to expose trachea
5. Pack wound
   cover with pack

Question 39

Contents of post thyroid surgery emergency box

Answer 39

Artery clip

Guidelines

Mx haematoma
SCOOP

Scalpel
Scissors

Sterile gauze / wound pack

Gloves
Staple remover

Question 40

DAS Guidelines

Answer 40

A Facemask ETT + Tracheal intubation

1. Laryngoscopy

B Maintain O2
SAD —————–> stop and think 1. Wake up / 2. Intubate via SAD/ 3. Proceed without intubation 4. Trachy / Cric

C Final attempt at FMV ————-> wake up

D FONA - CICO
Cricothyroidotomy

Question 41

Plan A

Answer 41

FM Ventilation and Tracheal Intubation

Optimise head and neck position

PreO2

Adequate NMB

D/ VL - 3+1
External manipulation

Bougie

Remove Criocoid

Maintain O2 and anesthesia

Question 42

plan B

Answer 42

Maintain oxygenation

SAD Insertion
2nd gen device

Change device or size - max 3 attempts

O2 and venilation

Stop and think

?wake up

?intubate via SAD

?proceed without intubating

Trach + cricothyroidotomy

Question 43

Plan C

Answer 43

FM ventilation

Impossible - Paralysis

FInal attempt

2 person technique and adjuncts

• wake up

Question 44

Plan D

Answer 44

Emg FONA

Scalpel cricothyroidotomy

Question 45

Post op care

Answer 45

Formulate immediate airway management plan

Monitor complications

AIrway alert form

explain in person and writing

letter to GP and database

Question 46

Plan D

Answer 46

Scalpel Cricothyroidotomy

1. Scalpel 10 blade
2. Bougie
3. Tube - Cuffed 6

Laryngeal Handshake

Palpate Cricothyroid membrane

Transverse stab through cricothyroid membrane

Turn blade 90*

Slide coude tip of bougie along blade into trach

Railroad lubricated 6.0mm cuffed tube

Ventilate inflate cuff and confirm position with capnography

Secure Tube

Question 47

Impalpable membrane

Answer 47

8-10cm vertical inscion head to toe

Blunt dissection with fingers to seperate

ID and stabilise larynx

Proceed with technique for palpable

Post op care

postpone unless life threatning
Surgical review
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