4 - Critical Care within Surgery Flashcards
What are the indications and contraindications for bag valve mask ventilation?
Indications:
- Hypercapnic respiratory failure
- Hypoxic respiratory failure
- Apnea
- Altered mental status with inability to protect airway
- Patients undergoing anesthesia for elective surgical procedures
Contraindications
- Total upper airway obstruction
- Increased risk of aspiration after paralysis and induction
How do you do ventilation with a BVM?
- Decide if need airway adjunct (OP or NP)
- Head-tilt Chin-lift or jaw thrust if cervical spine injury suspected
- E and C grip with good seal
- 15L oxygen attach to BVM
- Squeeze bag until chest rises
What are the risks with BVM ventilation?
- Barotrauma to lungs from too much inflation
- Gastric insufflation which can lead to vomiting and aspiration
How do you insert a laryngeal mask?
MAKE SURE PT FULLY OXYGENATED BEFORE STARTING
- Lubricate LM
- Head-tilt-Chin-lift and face LM away from you, black line facing you and advance down until reaches natural stop
- Inflate cuff (no inflation if I-Gel) and attach ventilation bag
- Listen to axillas and check CO2 is being detected so ventilation is successful
- Secure in place with tape and continue ventilating
What are the main differences with an endotracheal tube and a laryngeal mask?
Endotracheal tube can be used long term but paralysis is required unlike LM
Higher ventilation pressures can be used in endotracheal tube
What are the contraindications of endotracheal tube insertion?
- Conscious or semi-conscious pt
- Inexperienced operator
- Upper airway obstruction
- Suspected cervical fracture
What equipment do you need ready for endotracheal intubation?
- 2x IV access with medication
- Endotracheal tube
- 10ml synringe
- Water based lubricant
- Laryngoscope
- Bougie
- Magill forceps
- Stethoscope
- Guedel and NP airway
- Laryngeal masks
- Bag and mask with oxygen source
- Tape
- Yankauer suction
- CO2 monitor
What position does a pt need to be in for endotracheal intubation?
Laying flat with single pillow under neck
(Sniffing morning air)
What are the steps for endotracheal intubation? (WATCH VIDEO)
https://www.youtube.com/watch?v=-M3OlfmKjO8
ASSISTANT NEEDED FOR CRICOID PRESSURE
- IV induction agent and muscle relaxant
- Lubricate ETT
- Pre-oxygenate pt with 3 mins of 15L O2
- Holding laryngoscope in left hand, insert it looking down its length, slide down right side of mouth until the tonsils are seen, now move it to the left to push the tongue centrally until the uvula is seen
- Advance over base of the tongue until epiglottis seen
- Apply traction to the long axis of the laryngoscope handle to visualise the vocal cords
- Insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords
- Inflate the cuff of the tube when gets to 20cm in with 15ml air from a 20ml syringe. Remove laryngoscope
- Attach ventilation bag/machine and ventilate (~10 breaths/min) with high concentration oxygen and observe chest expansion and auscultate to confirm correct positioning
- Applying CO2 detector or end-tidal CO2 monitor to confirm placement
- Secure the endotracheal tube with tape
- If it takes more than 30 seconds, remove all equipment and ventilate patient with bag and mask until ready to retry intubation
What monitoring does a patient being intubated need?
- Cardiac monitoring
- Sats probe
How can you confirm the ET tube is in place?
- Chest rises and falls
- ETT mists up
- CO2 monitor detects CO2
- CXR to check not gone past carina into right main bronchus
What are the complications of endotracheal intubation?
- Oesophageal intubation
- Endobronchial intubation (one lung intubated)
- Desaturation
- Aspiration
- Laryngeal spasm
- Dental damage
- Vocal cord injury
- Hypotension
- Cardiac arrest
What are some triggers that a patient may be septic?
What is the sepsis 6 and what are the indications for escalating to critical care?
What do the colors of cannulas mean?
Use big ones for resuscitation
How do you prepare IV antibiotics for administration?
https://em3.org.uk/foamed/19/2/2016/antibiotic-preparation-administration-using-antt
What are the short term and long term complications of critically ill patients?
Short
- VTE (PE/DVT)
- Wound infection
- Pneumonia
- Catheter UTI
- Central line infection
- Sarcopenia
- Pressure sores
- AKI
**
Long**
- Barotrauma
- PTSD
- Depression
- Cognitive impairment
- Impaired pulmonary function
- Polyneuropathy
- Fatigue
How do inotropes and vasopressors work and give some examples of each?
Many drugs can have effects of both
Inotropes: Increase contractility of the heart
Vasopressors: vasoconstrict to raise mean arterial pressure
How are inotropes and vasopressors given?
Central line (cannot go through peripheral veins)
What are the types of organ support on intensive care?
- Mechanical ventilation
- Renal replacement therapy
- TPN/PEG feeds
- Neurological support to decrease ICP or stop seizures
- Cardiovascular support with inotropes/vasopressors or ECMO
What new advanced organ support technology is currently being developed?
ADVOS
Combined multi-organ support of liver, lung, kidney, and acid-base balance.
Based on the principle of albumin dialysis, ADVOS allows extracorporeal fluid-based elimination of CO2, hepatic toxins, water-soluble and protein-bound nephrotoxins, as well as the correction of metabolic and respiratory acidosis
What information is important to gather about a patient before considering referring them to intensive care for treatment?
- Details of current illness and response to treatment so far
- Any co-morbidities?
- Any frailty?
- Baseline of functioning?
- Physiological reserve?
- What would the patient want? - Reversibility of illness?
How should you alter a warfarin prescription in the following situations?
