2025 Lab 1 Exam 2/Final Flashcards
Need 2025 Lab 1 Exam1/Midterm Deck to Complete Material
Nasal Cannula
For every 1L/min of O2 = 4% Increase in O2%
FiO2 of 24-44%
Anesthesia (Monitored Anesthesia Care)
Need a gas sampling line to monitor for spontaneous respirations
2 Variations Essentially
Nasal Cannula without CO2 monitoring
Nasal Cannula sampling line (CO2 monitoring)
Used when patient under anesthesia is asleep, common would be during MAC, make sure they are breathing
A lot of providers will just jump to mask if have to go more than 4 L/min in fear of drying out patients nose
Face Masks
Simple
FiO2 35-60% (6-10L/min)
Partial rebreathing
FiO2 60-90% (6-10L/min)
Non rebreathing
FiO2 Almost 100% (10-15L/min)
Venturi Mask
24-50% (Variable)
Simple Mask
FiO2 35-60% (6-10L/min)
Some providers prefer to use a simple mask post surgery when delivering patient to PACU… can see the fog to know they are breathing
Partial Rebreathing Mask
FiO2 60-90% (6-10L/min)
Nonrebreathing Mask
FiO2 Almost 100% (10-15L/min)
Rebreather Mask Function
Rebreather Mask Diagram
High Flow Devices
Have flow rates and reservoirs large enough to provide the total inspired gases reliably
Flows in excess of 30-40 L/min (or 4x minute volume)
Venturi masks, aerosol masks, and T-pieces powered by air-entrainment nebulizers or air oxygen blenders
Ability to deliver predictable, consistent, and measurably high and low FiO2s despite ventilatory pattern
Venturi Mask
24-50% (Variable)
Provides predictable and reliable FIO2 values of 24-50% (independent of patient’s respiratory pattern)
Air entrainment based on Bernoulli principle
Rapid velocity of gas moving through a restricted orifice
Fixed FiO2 model (color coded)
OR
Variable FiO2 model (graded adjustment)
Venturi Effect
Nasal Airways
Nasal airways
Nasal trumpet
Oral Airways
Oral airways
Berman
Side channels to facilitate air passage
Guedel
Tubular center channel allows air to pass
LMA Description
Specially designed airway that seats over the larynx to allow ventilation in normal patients. The LMA may be a useful adjunct in patients who are inadequately ventilated by mask.
The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support
It consists of an inflatable silicone mask and rubber connecting tube
It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation
All parts are latex-free
Construction
Silicone
30o between airway tube
and body of mask
Basic components
15 mm connector
Airway tube
Cuff
Inflation system
Valve
Pilot balloon
Pilot tube
When to Use LMA
The Laryngeal Mask Airway is an appropriate airway choice when:
Mask ventilation can be used
(except in the Difficult Airway Algorithm) … can take the place of Mask Ventilation
Endotracheal intubation is not necessary (when they do not have to be paralyzed is a big indicator)
MAC procedures are good with LMA
LMA Function
Establishes airway
with supraglottic seal
(above the vocal cords)
LMA Indications
Indications
Administration of general anesthesia
Establish unsecured airway emergently
Facilitate endotracheal intubation
Adjunct to FOB airway management
Decadron is a drug to be used to help with swelling and bleeding in the airway
LMA Advantages
Advantages:
Allows rapid access
Does not require laryngoscope
Does not require neuromuscular blockade for placement or maintenance
(just need Propofol, and some lidocaine for the sting of the Propofol)
Provides airway for spontaneous or controlled ventilation (can be used PPV, but not a first choice)
Tolerated at lighter anesthetic planes
Advantages (compared to):
Less stimulating during use (ETT)
Less ↑ in intrathoracic and intraabdominal pressures during emergence (ETT)
Less cardiovascular response (ETT)
Less ↑ in IOP (ETT)
Frees practitioner’s hands (mask)
Provides seal for PPV (OAW or NAW)
LMA Disadvantages
Does not protect against aspiration in the non-fasted patient
Standard LMA not recommended for use with ventilator… though it is used all the time
Requires re-sterilization if Original LMA
Learning curve for insertion
Over-estimated ease of use
(can be harder to correctly insert and seat compared to an ETT)
Not a Secure Airway
LMA Contraindications
Non-fasted patients
(the only true absolute contraindications)
Risks of aspiration (GERD, not NPO, hiatal hernia, obesity, pregnancy, bowel obstruction, acute pancreatitis, ….)
Morbidly obese patients
Obstructive or abnormal lesions of the oropharynx
Maxillofacial Trauma
Respiratory disease with low compliance and/or high resistance
Patient position or surgery limiting airway access
Upper airway pathology (infection, hematoma, cyst, ….)
LMA Insertion Problems
Jam into vallecula (pull out start over)
Push epiglottis down over glottic opening (pull out start over)
Get caught on glottic opening (adjust with little pull back, might have to pull out and start over)
LMA: ProSeal
Special Features:
Suction gastric contents
Basic components
Cuff
Drainage system
External drain tube with connector
Internal drain tube
Drain tube orifice
Integral bite block
Introducer strap
LMA: Fast-trach LMA
Special Features:
May be used as a rescue airway and fiberoptic conduit when intubation is difficult, hazardous or unsuccessful
It can be used for bronchoscopy in the awake or asleep patient
LMA Head Positioning
LMA Insertion 1
LMA Insertion 2
LMA Insertion 3
LMA Insertion 4
Verify LMA Placement
Connect to ventilator and verify
Chest Rise
Bilateral Breath Sounds
Absence of Gastric Sounds
EtCO2
Condensation in tube
Acts as a Bite Block
Secure LMA
Preoperative Assessment Importance
Our pre-operative interview is where we establish the initial level of trust and communication with our patient
The information obtained in this interview can play a significant role in how we cater our anesthetic plan for each individual
Depending on what questions you ask and how you ask them, the patient may reveal more pertinent history that allows for us to treat them as safely and efficiently as possible
Making the patient feel comfortable/at ease before surgery will ensure the best possible outcome
WE are the most powerful “drug” we can give our patients before heading back to surgery
PreOp Assessment - Before Entering Patient’s Room
Find out exactly what the patient is getting done and which surgeon is performing the procedure (each surgeon will have their own preferences – after working with them several times, we learn them and are able to more efficiently plan our anesthetic)
If you are unfamiliar with the procedure, do your research! Look it up and find out any pertinent information that can help you establish your anesthetic plan
Based on this information, you can have a baseline idea of your anesthetic plan (ie: GETA, TIVA, LMA, ETT, monitoring techniques required, etc)
Review the patient’s chart for any relevant medical history
Looking at their medication list ahead of time can give you an idea of what conditions they have
If the patient has had previous surgeries, we can generally see how induction/intubation went, any issues that arose, etc
Review lab results and determine if any more need to be ordered
ALWAYS be sure to get a pregnancy test for woman of childbearing age
Think of any pertinent questions you may need to ask them based on their medical history
PreOp - Entering Room
Knock first! Ask for permission to enter
Although this sounds simple, small things like this help to develop a level of respect with the patient (and may be easily forgotten if it is a busy day)
Introduce yourself upon entering
“Hi, I’m _____________, the student Anesthesiologist Assistant working together with Dr. ___________ (attending anesthesiologist) and ______________ (preceptor).”
“Can I ask you some medical questions related to today’s procedure?”
If there are people in the room with them, this gives them the opportunity to tell you if they would like privacy when discussing medical information
Identify the Patient
Be sure you have the correct patient in front of you! There is nothing worse than getting into an interview and realizing later that you have the wrong chart (and therefore reviewed the incorrect information ahead of time) or are in the wrong room entirely
The most common identifying factors are patient’s name and DOB
It is a good idea to check their wrist band if they have one on to double check their name is correct everywhere.
Human errors happen all the time! Be sure to not only check your work, but the work of others in order to provide the safest possible care for each patient. Something as serious as incorrect administration of medications could start with something as simple as a registration error when the patient was admitted to the hospital!
Check that the patient understands what they are having done and why (in simple terms), who their surgeon is, which side the procedure is on (if applicable), and that all of this information matches that provided on their chart/other preoperative documents such as consent forms
The Big Four
The things you want to get no matter what, get before a patient might go unconscious if emergency situation:
Anesthetic History
Family History with MH
Allergies - Anaphylaxis or Side Effect?
NPO Status
PreOp Assessment - Anesthetic History
“Have you had any previous surgeries/anesthesia?
If they have, be sure to find out if it was general or regional
An easy way to do this is ask if they were knocked out for the procedure or awake
Were there any issues with the anesthesia?
Red flags you are looking for: high fever (possible MH), staying intubated for extended time (possible pseudocholinesterase deficiency), or nausea vomiting (PONV)
“Are you aware of any family history of issues with anesthesia?”
This is especially significant if the patient has never had anesthesia before, as it could be indicative of a genetic condition (ie: MH)
PreOp Assessment - Allergies
“Do you have any allergies to medications or otherwise?”
Some people say they are allergic to something just because they don’t like the way they feel from it (ie: “Epinephrine makes my heart race” or “Augmentin makes me nauseous”
Check for TRUE anaphylactic reactions
If they are allergic to exotic fruits think possible latex allergy
If they are allergic to shellfish think possible iodine allergy
If they are allergic to Penicillin no Ancef!
If they are allergic to tape, be sure to use proper tape for eyes/tube/etc during procedure (paper tape or “pink tape”)
NPO Status
“When was the last time you had anything to eat or drink?”
Sometimes patients don’t tell the whole truth or forget…
Consider asking “what did you have for breakfast this morning?”
This information helps us to determine their fluid deficit
(hourly requirement in mL/hr) = (weight in kg) + 40
Fluid deficit = (hourly requirement) x (number of hours NPO)
PreOp Assessment - Medications
If the patient is on beta blockers, they should take those the morning of surgery
As a general rule, herbal supplements should be stopped two weeks prior to surgery… can google what ones (should be about 10)
ACE/ARB/Diabetics/Diuretics should be avoided for 24 hours before surgery!!
… The GLP-1 agonists (ozempics, etc.) guidelines are constantly changing due to their newness
Anticoagulants need to be stopped before surgery
Xarelto 24 hours before
Eliquis 48 hours before
Coumadin (Warfarin) 5-7 days before (there is an INR test for therapeutic levels that could postpone the surgery)
Aspirin and/or Plavix 7-10 days before
PreOp Assessment - Social History
“Do you drink alcohol?”
How much, how often, what kind?
“Do you smoke cigarettes?”
How many packs/cigarettes per day and for how long?
“Any elicit drug use?”
Assure them that this is a judgement free zone, but we need to know so we can properly care for them before, during, and after the procedure
The patient may be hesitant to answer this or lie if there are others in the room
The best time to ask may be when you are rolling back into the operating room or have privacy
PreOp Assessment - Measuring Physical Activity
It is important that we establish the patient’s overall physical activity level
To do this, we determine their METS, or metabolic equivalent, which is the energy spent when the patient is sitting at rest
One MET is approximately 3.5 mL of O2 consumed per kg of body weight per minute
METS
“Can you climb a flight or stairs without feeling shortness of breath?”
“Do you do your own grocery shopping?”
“Are you able to clean your house on your own?”
However, each of these things could vary so much by individual
A more standard question to ask would be something like…
“If we were to take a walk to the entrance of the hospital together right now, could you do that with no issues?”
Of course, this is all dependent on the issue patient is presenting for
For example, if they have a broken leg, they may have issues walking)
PreOp Assessment - Review of Systems
PreOp - ROS: Neurological
Any deficits pre anesthesia… so know if there is a deficit post anesthesia due to procedure or not
PreOp - ROS: Endocrine
Past Diabetes and Thyroid function only ask about them if see it in record
PreOp - ROS: Respiratory
PreOp - ROS: Cardiovascular
PreOp - ROS: Gastrointestinal
PreOp - ROS: Urinary, Reproductive, Hepatic, Renal
PreOp - ROS: Musculoskeletal
PreOp - Physical Exam
Heart
Lungs
Mouth/Airway
PreOp - Physical Exam: Heart Sounds
Listen to the different valve sounds on YouTube
PreOp - Physical Exam: Lung Sounds
Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales).
CHF
Rhonchi. Sounds that resemble snoring.
Bronchitis/COPD
Stridor. Wheeze-like sound heard when a person breathes.
Laryngospasm/inflammation of cords
Wheezing. High-pitched sounds produced by narrowed airways.
Brochospasm/asthma
Listen to on YouTube and what is causing each one inspiration, expiration, etc.???
PreOp - Physical Exam: Dental/Mallampati
“Open your mouth and stick out your tongue, without saying ‘ahh’ please”
Assign Mallampati score (see next slide) and document
“Anything loose, chipped, cracked, or removeable?”
Implants, caps, crowns, dentures, etc
If they have dentures or anything removeable, it will be taken out prior to rolling back to OR
Let them know they will be placed with their belongings and available for them in the recovery room
Dentures are commonly lost between pre-op and PACU! Be sure to put them in the appropriate place to avoid this
Document everything you see and are told in the dental exam
Remember teeth numbering system (shown on next slide)
It is very important to make note of all of this in case anything gets damaged or knocked out during intubation
PreOp - Physical Exam: Range of Motion
PreOp - Explain What Will Happen Next
PreOp - Others…
“Is there anything we haven’t discussed that you think is important for me to know so I can take excellent care of you?”
This is a way to cover everything you may have missed and give the patient an opportunity to bring up any issues or concerns they may have regarding their medical history
Anesthetic Plan
Select an Anesthetic Technique
General Anesthesia
Regional Anesthesia… Local Anesthesia
Monitored Anesthesia Care
A lot of times the surgeon will dictate this to you , and you then formulate the particulars of that plan for the technique based on the individual.
Formulate an appropriate anesthetic plan based on
the preoperative interview and the proposed surgical procedure
Communicate this plan efficiently and effectively
General Anesthesia: Preoperative Preparation
Diagnostic/Laboratory Studies
* CBC, BMP, Coagulation, ECG, Chest Xray,
CT, Echo
* Type and Screen Crossmatch
* Allowable Blood Loss
IV access
Premedication
* Anxiolysis, analgesia
* Aspiration prophylaxis
Increase gastric pH
Reduce gastric volume
* Antiemetics
Positioning
General Anesthesia: Monitoring and Equipment
Standard ASA Monitors
Ventilation
EtCO2- capnography
Circulation
ECG, NIBPM/IBPM
Oxygenation
SpO2
Temperature
ADDITIONAL MONITORS BASED ON CIRCUMSTANCES OF THE OPERATION
Special Monitors- ICP, PAP, CVP
Warming Devices- Bair Hugger
Infusion Devices
Bladder Catheter
OGT/NGT to suction
General Anesthesia: Induction
Intravenous/Inhalational
Inhalational Induction- used in pediatric anesthesiology for patients who will not be able to tolerate putting in an IV preoperatively.
Older children may prefer intravenous induction
Deciding on what agents you want to use:
* NPO status questionable, uncontrolled acid reflux
(GERD), trauma, obesity, diabetes, difficult airway→ RSI with cricoid pressure and succinylcholine
- When patient has taken ACEIs or ARBs, or when
hypotension upon induction of anesthesia is expected and not desired:
Use etomidate instead of propofol
Use lower dose of propofol
Use increased narcotics, benzodiazepines, and
inhalational agents
General Anesthesia: Airway Management
Mask
* Inhalational induction
OETT
* Mechanical ventilation
NETT
* Maxillofacial surgery, dental
operations, when orotracheal is not
feasible
LMA
* Spontaneous ventilation
General Anesthesia: Maintenance
Checklist prior to incision/procedure
start:
* Patient is anesthetized
* Narcotized
* Paralyzed (if needed)
* Antibiotic is circulating
Volatiles
Fresh gas
Muscle Relaxants
Fluids
* If pt > 20 kg, # kg + 40= hourly rate of
fluid replacement
* If pt < 20 kg use 4-2-1 rule (as get more into this, will learn this isn’t/doesn’t have to be applied based on the patient)
* Hourly rate * # hours NPO= preop
deficit
* 1st hour: half of preop deficit is given
along with hourly maintenance
* 2nd and 3rd hour: 1⁄4 of preop deficit is
given along with hourly maintenance
General Anesthesia: Emergence
Check TOF, administer antiemetic(s)
Call attending
Give reversal agent (glycopyrrolate first, neostigmine second if not mixed… giving glyco first hopefully blocks bradycardic effects of neo)
Begin to turn gas down slightly and decrease RR to build ETCO2
Suction
Decrease VA/turn off
THIS IS THE ART OF HOW YOU DID REALLY… HOW WELL THEY COME OUT IS A BIG INDICATOR OF THE INDUCTION, MAINTENCE, AND EMERGENCE
Is patient ready for extubation?
* Check TOF for 4/4 twitches and sustained tetany
* Check to see if patient can follow commands
* Adequate tidal volumes
* Extubation (NEED TO BE SPONTANOUSLY BREATHING)
Confirm patient stable for transport to PACU
Common Patient Presentations: GERD
RSI with cricoid pressure and succinylcholine is
the induction plan
30 ml of 0.3 molar Bicitra, sodium citrate increase
gastric pH
Pepcid/Famotidine, 30 mg PO/IV- decreases
gastric H+ ion secretion
Ranitidine/Zantac, 20 mg IV- H2 receptor
antagonism
Omeprazole-PPI, controls the production of
gastric acid
Common Patient Presentations: History of PONV
Risk factors: female gender, young age, history
of PONV, non-smoker, laparoscopic or gyn cases
Transdermal scopolamine patch
Decadron, given post induction-avoid in
diabetics
Metoclopramide/Reglan- accelerates gastric
emptying
Zofran
Phenergan/Promethazine- H1 antagonist
Benadryl/Diphenhydramine-H1 antagonist
Neuraxial Anesthesia
Spinal/Epidural Anesthesia and analgesia
* Spinal effects may only last 4 hours; w/
epidurals you can keep redosing if the
catheter is left in
Considerations: is the patient a good
candidate for the technique? Safe platelet
count, no bleeding disorders, not on
anticoagulants
Complications: hypotension, nausea/vomiting
MAC / Local
Patient is spontaneously breathing
Administer propofol, benzodiazepines, and
narcotics as necessary throughout the case
Continuously assess/monitor the patient
MAC CAN BE THE HARDEST TO DO BECAUSE:
Airway not controlled
Not Paralyzed… so have to control their movement
Making an Anesthesia Plan
Step 1: Consider the procedure
* Comes with experience/varies by hospital
Step 2: What will actually change your anesthesia plan?
* The details are in the preop
* NPO
* If not RSI
* Were there problems with anesthesia/MH?
* Allergies
* Airway assessment
* ROM/glidescope?
* LMA vs ETT
Step 3: Refine the plan
* Now that you have a general idea of the type of anesthesia, look at the history and refine
your plan
* Examine every problem the patient has and consider how to optimize the anesthetic
Step 1: Safely move patient onto OR bed attach monitors and preoxygenate
Induction of Anesthesia
Step 2: Push Induction Drugs
Step 3: Check eyelash reflex & bag mask ventilation
Step 4: Push the muscle relaxant & bag mask ventilate
Step 5: Perform intubation
Step 6: Verify correct ETT placement
Step 7: “1-2-3” Ventilator, flows, gas
Step 8: Continue preparing patient for incision
Tape the ETT
Patient Positioning
Put on warming device
Insert OG tube (if you need to suction out stomach)
Put in Temp probe
Surgeon enters room
* Check which antibiotic and administer (Usually 1-2 g Ancef)
Immediately before incision
* Ask yourself, “Is the patient anesthetized, paralyzed, and narcotized?”
* Increase volatile agent
* Check train of four (aka “twitches”)
* Give another 50-100 mcg fentanyl
THIS IS ALL REALLY THE BEGINNING OF THE MAINTENANCE PHASE
Typical Emergence
Passive process with gradual return of consciousness, after
discontinuation of anesthetics and adjuvants
Most patients transition from surgical anesthetic state to awake state with intact protective reflexes (coughing, swallowing)
Patients do not experience REM sleep even though “asleep”
Preparation of Emergence
Depending on type of anesthetic used (inhaled vs IV), specific timing for discontinuation must be planned BEFORE surgical procedure end, not AT END of procedure (surgeon speed, what you hear being talked about, knowledge of drugs/gases)
If volatile anesthetics used, differences in blood solubility may prolong emergence (Isoflurane > Sevoflurane > Desflurane)
If IV anesthetics used, bolus vs infusion affects speed of recovery (bolus relatively shorter than infusion, which also depends on how long infusion is on)
Factors affecting speed of emergence for volatile agents:
Inhaled concentration
Fresh gas flow in breathing circuit (turning up just O2, always waking up a pt with 100% FiO2)
Duration of administration (depends on solubility of agent)
Minute ventilation
RR x TV
TV with controlled pain = normal breathing
TV with over anesthetized = 3-5 breaths with normal TV
6-8 ml/kg
TV with uncontrolled pain = minimal TV per Respiration
Cardiac output
Dependent on agent… but overall:
Slow = Slow emergence
High = Fast emergence
Factors affecting speed of emergence for IV medications:
Liver and/or Kidney function of patient
Duration of action of IV med
Combination of IV meds
Duration of any IV med infusions
Preparation of Emergence: NMBS and Neuro
Assess and reverse effects of neuromuscular blocking agents (non-depolarizing)
* Assess degree of muscle relaxation
* Administer reversal agents
(Suggamadex and Neostigmine and Glycopyrrolate)
Observe electroencephalographic evidence of consciousness return
* BIS monitor
* Neuromonitoring, if surgery requires it
Evaluate physiologic signs of return of consciousness
* Spontaneous respiration (THE BIG ONE)
* Swallowing and gagging reflexes
* Tearing and grimacing
* Return of muscle tone:
*Volitional movements
*Response to verbal commands
Emergence with Endotracheal tube
Performing awake extubation
* Pre-oxygenate with 100% oxygen (It’s essentially just flipping to 100% Fi02)
* Suction as appropriate
* Bite block (rolled gauze, OPA)
* Establish regular breathing (ETCO2 and TV consistent and smooth, SPO2 is adequate)
* Ensure adequate minute ventilation
* Wait until awake (eye opening/obeying commands)
* Apply positive pressure (APL Valve 5-10), deflate cuff and remove tube
* Check airway patency and continue to provide 100% oxygen
* Transfer with oxygen
Problems During Emergence: Bronchospasm
Bronchospasm due to coughing and bucking on airway
Treatment
* Administer opioid to minimize coughing response
* Allow spontaneous respiration; less fighting with the ventilator
Problems during Emergence: Airway Obstruction
Airway obstruction
* Macroglossia
* Laryngeal edema
* Vocal cord paralysis
* Laryngeal or tracheal obstruction
Treatment
* If known obstructive breathing history (eg. OSA), prepare with OPA and ensure reversal of all anesthetics and narcotics
* If anticipated surgically-induced obstruction (eg. Edema), may need to consider keeping patient intubated until edema resolves
Problems during Emergence: Inadequate resolution of NMBA and Opioids
Inadequate spontaneous ventilation and/or respiratory distress with residual NMBA, before or after extubation
Treatments
* Ensure NMBA have been appropriately antagonized
* Old school: Neostigmine + glycopyrrolate
* New school: Sugammadex
* Ensure opioids are not suppressing respiratory drive
* May need naloxone antagonization
Problems during Emergence: Apnea after Extubation
Apnea
Treatment
* May need brief support with mask ventilation
* Ensure all drug-related causes are addressed
* If all addressed, may be neurological (eg. Stroke) or other (eg. Hypothermia, hypercapnia)
Problems during Emergence: Laryngospasm
Laryngospasm
Treatment
* Remove noxious stimuli (eg removal of blood or secretions with suction)
* Positive pressure ventilation
* Jaw thrust with notch pressure (aka Larson’s maneuver)
* If patient desaturates despite all maneuvers
* IV succinylcholine 0.1mg/kg to relax cords
* If still unsuccessful, emergency reintubation may be necessary
Problems during Emergence: Negative Pressure Pulmonary Edema
Negative pressure pulmonary edema, due to airway obstruction and simultaneous forceful inspiration (biting down on endotracheal tube, or breathing in while in laryngospasm)
Treatment
* Ounce of prevention worth a pound of cure: ensure bite block in place before extubation
* Mechanism: intense negative intrathoracic pressure with inspiration against closed glottis creates fluid shift across alveolus, leading to fluid accumulation
* Supportive treatment:
* Oxygen
* Diuretics
* May need reintubation
Problems during Emergence: Agitation
Agitation
Treatment
* Anxiety and disinhibition
* Ensure residual effects of anesthetic meds are reversed
* Inadequately treated pain
* Control pain
* Panic caused by dyspnea and respiratory distress
* Inadequate NMBA reversal
* Can look like general agitation, but generally weaker looking, esp with respiratory effort
* Hypoxemia or hypercarbia
* Oxygenate
* Ensure no obstructive breathing causing CO2 retention
Problems during Emergence: Aspiration
Inability to protect the airway resulting in gastric content
aspiration
Treatment
Turn the patient on their side, if possible
Suction the pharynx
Place the bed in Trendelenburg position
Suction the endotracheal tube
Administer 100% oxygen
Treat bronchospasm with bronchodilators
Consider bronchoscopy
Consider intubation
Laryngospasm Notch Pressure
Post-Anesthesia Care Unit (PACU) Transfer
Ensure some sort of O2 supplementation is present (NC, face mask)
If possibility of obstructive breathing, ensure OPA or NPA is present
Possibility of all problems during emergence is still possible in
PACU
Always be vigilant
Reversal of Paralysis From NMBs
Twitch Monitors: New verse Old ones
Different Ways to Utilize it:
Tetany—a sustained stimulus of 50 to 100 Hz, usually lasting 5 s
Single twitch—a single pulse 0.2 ms in duration
Train-of-four—a series of four twitches in 2 s (2-Hz frequency), each 0.2 ms long
Double-burst stimulation (DBS)—three short (0.2 ms) high-frequency stimulations separated by a 20-ms interval (50 Hz) and followed 750 ms later by two (DBS3,2) or three (DBS3,3) additional impulses
TRAIN of 4 Main Way:
Train of Four (TOF) Interpretation: A presence of 4th twitch = 0-5% paralysis (but could be higher up to that 65%-75%), 3rd twitch = 65-75% paralysis, 2nd twitch = 85% paralysis (80%), 1st twitch = 95% (90%) paralysis, 0 twitch = 100% paralysis
Someone with Fade is more paralyzed than someone without Fade.
Extubation Criteria
Spontaneous Ventilation
Vitals on monitor are stable
Deep vs Awake Extubation
Deep
Comes with more risks
Can be LMA or ETT
Typically Done If: Surgeon asks for it
Procedure requires it (ENT, groin/hernia/abdominal surgeries)
Contraindications:
Absolute -
Pts considered full stomach
Uncontrolled GERD
Tube was difficult to place
Relative -
Obesity
OSA
*** Positioning
Airway Edema
Criteria:
Have to be breathing spontaneous
Pt must truly be deep
* Assessment
The absence of coughing when you deflate the ETT cuff
Did they hold their breath on ETCO2 after deflate the ETT cuff?
Jaw Thrust reflex - Grimace or hold their breath
Pt must be thoroughly suctioned to prevent laryngospasm
Acronym
No one is home (Deep)
Dry as a bone (Suction)
Breathing on their own
Make sure have OPA in while you mask
