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Anesthesia > Anesthesia Induction, Airway Intubation, and Initial Management > Flashcards

Anesthesia Induction, Airway Intubation, and Initial Management Flashcards

1
Q

What is induction? What is it commonly followed by?

A

delivering major injectable anesthesia agent that produces profound cerebral and cardiopulmonary depression

intubation and maintenance of anesthesia by inhalant agents

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2
Q

What is the primary time period for anesthesia-related morbidity and mortality?

A

induction

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3
Q

What 3 things do induction agents need to suppress? What must be maintained?

A
  1. voluntary motor nerve function and sensation
  2. sympathetic nervous system
  3. cerebral cortex function and awareness (consciousness)
  • cardiac output
  • airway patency, oxygenation, ventilation
  • midbrain function
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4
Q

What stage of anesthesia is necessary for intubation? What is the goal of induction?

A

Stage III - no signs of gagging, swallowing, or chewing upon opening of the mouth

get patients from stage I to III efficiently, quickly, and safely

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5
Q

What are 6 reasons that a patient must be sedated prior to induction?

A

inducing an agitated, excited, or unsedated patient may cause:

  1. GI response, like gagging, regurgitation, and vomiting
  2. loss of protective reflexes, like airway, baroreceptors, and chemoreceptors
  3. spinal subluxation
  4. increased distributive shock
  5. increased awareness and memory
  6. increased pain via stress
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6
Q

What is the progression into unconsciousness like in aroused and sedated paitents?

A

AROUSED = uncontrolled, surge of epinephrine, accidents common, operative period rocky

SEDATED = more controlled, reduced stress response, accidents uncommon, operative period steady

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7
Q

What should be done if a patient isn’t sedated enough to induce anesthesia?

A
  • give more premedication, usually 1/3-1/2 of original
  • administer through a more effective route (IV)
  • give more time, IM can take 30 mins for effect and SQ is not effective
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8
Q

How should a catheter be placed in cases of an amputation?

A

amputations put a lot of stress on the directly opposite limb, try a diagonal one

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9
Q

What are 2 types of patent airways?

A
  1. nose, nasopharynx, glottis, trachea - sedated or TIA patients with extended necks and tongue pulled forward and out
  2. ET tube - fully anesthetized patient, low pulse ox when unintubated,regurgitation possibility
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10
Q

Why do we intubate?

A
  • allows for better oxygenation
  • ventilates
  • maintenance with gas anesthetics
  • protects airway from regurgitation and aspiration
  • conduit for IT drugs during CPR
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11
Q

Are masked airways an option in veterinary patients?

A

NO —> creates an anatomic dead space

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12
Q

What are some risks of intubation?

A
  • risk factor for anesthesia morbidity and mortality
  • requires trained, task efficient personnel
  • can result in bronchospasm
  • can increase pulmonary and tracheal infectious disease
  • can cause laryngeal and tracheal damage
  • requires a deep plane of anesthesia since the laryngeal gag reflex is difficult to subdue
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13
Q

What are the 2 options for cuffs in ET tubes?

A
  1. low pressure, high volume
  2. high pressure, low volume
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14
Q

What are most modern ET tubes made out of? Whar are 3 other types?

A

polyvinylchloride

  1. silicone
  2. PVC
  3. red rubber
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15
Q

What is the key factor in resistance associated with ET tubes?

A

radius —> need proper size for individual patient

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16
Q

How is the radius and length of ET tubes determined for patients?

A

RADIUS = (BW x 5)^1/2, should be largest allowed to decrease resistance, but not cause laryngeal trauam

LENGTH = measure tip of nose to thoracic inlet or incisors to point of the shoulder

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17
Q

What trick is used when determining the diameter of ET tubes?

A

width of nose between the nares is an approximation of tracheal diameter

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18
Q

How is BW used to determine ET tube size?

A

based on lean BW

  • obese cats and dogs do not have larger tracheas
  • brachycephalics tend to have narrow tracheas
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19
Q

What are safe seal ET tubes?

A

utilizes a series of silicone baffles to replace the inflation cuff to eliminate the risks of overinflation, underinflation, and leaky tubes

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20
Q

What are laser-resistant ET tubes?

A

tubes wrapped in protective metal (aluminum, copper, stainless steel) so that lasers can still be used in a procedure

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21
Q

What are the 4 major points in equipment where there is mechanical dead space?

A
  1. portion of ET tube outside of the trachea (from mouth to breathing circuit)
  2. elbow of the breathing circuit
  3. any connector used between the ET tube and breathing circuit (CO2 adaptor, apnea alarm)
  4. Y piece at the end of the Y circuit
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22
Q

What are 2 consequences of mechanical dead space? In what patients is this worse?

A
  1. increases resistance
  2. increases PaCO2, ETCO2, and ITCO2

smaller patients

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23
Q

How can appropriate lengths of ET tubes be made to cut out dead space?

A
  • measure amount outside of patient
  • cut tube on a diagonal, watching for the pilot line
  • widen distal flange with spreading hemostats
  • reattach breathing circuit
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24
Q

What are some additional consequences of increased dead space?

A
  • respiratory acidosis
  • sympathetic stimulation
  • cardiac arrhythmias
  • variable peripheral vasoconstriction followed by vasodilation
  • CNS depressant
  • increased cerebral blood flow and ICP
  • arterial O2 levels may eventually decreased enough to cause hypoxemia
  • inadequate ventilation interferes with adjustments in anesthetic levels
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25
Q

How should a laryngoscope be checked before use?

A
  • cleanliness
  • appropriate length of the blade
  • light working
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26
Q

How should an ET tube be checked before use?

A
  • cuff inflation syringe
  • cuff inflation: symmetric, holds pressure
  • lube while inflated
  • deflate without complete negative suction, without creating sharp edges on the cuff
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27
Q

What is the Sellick manuever?

A

applying gentle pressure to the left cranial esophageal furrow at the level of the cricoid cartilage to help align the airway structures during endotracheal intubation

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28
Q

In what patients should the Sellick maneuver be used?

A

those as risk of aspiration

  • obese patients
  • GI foreign bodies
  • chronically sick ICU patients
  • hepatic or pancreatic disease cats
  • brachycephalics
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29
Q

What is the best body position for patients being induced/intubated?

A

preserve natural body positions, particularly in older patients and bug dogs with hanging limbs

  • obese and brachycephalics have difficulty ventilating, keep their head up
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30
Q

What causes heat loss during anesthesia?

A
  • conduction
  • convection
  • evaporative losses
  • radiation
31
Q

When does heat loss occur most? How?

A

during anesthesia

  • radiation and conduction
  • cold surfaces and environment
  • drug-induced vasodilation and altered hypothalamic activity
32
Q

Why do we preoxygenate? In what patients is this most helpful? How is it commonly done?

A

analgesics and anesthetics cause respiratory depression and hypoxia —> preoxygenation saturates extra hemoglobin binding sites

animals with cardiac disease, pulmonary dysfunction, and anemia

flow-by for 3-5 mins pre-induction

33
Q

Why is the use of masks for preoxygenation avoided?

A

tight-fitting masks add to dead space and anxiety, which causes increased CO2 and decreased O2

34
Q

Why is pulse rate taken pre-induction?

A

titration of a drug is dependent on existing cardiac output

  • slow pulse rate = slower circulation time = slow titration and must wait longer for effect
  • faster pulse = faster induction (can tolerate a bolus-like induction)
35
Q

How should critical or high-risk patients be prepped?

A
  • obtain more than resting pulse and respiratory rate
  • apply monitors to premeded patient BEFORE induction
36
Q

How is induction handled in more critical patients?

A
  • titrate induction agent
  • have IV fluids going
  • attach monitors with atraumatic clips before induction (Doppler!)
  • assess regurgitation potential
  • watch neck and head position
37
Q

What are the 10 steps to an induction sequence?

A
  1. preoxygenate
  2. take vital stats
  3. deliver agent to effect
  4. intubate
  5. confirm intubation
  6. secure tube to head before cuff inflation (tie can occlude!)
  7. inflate cuff
  8. attach capnograph and turn on oxygen within breathing circuit
  9. take vital state
  10. turn inhalant percentage on
38
Q

How do anesthetics compare to other drugs, like famotidine or clavamox?

A

there is no established dose, given to effect depending on signalment, problem list, premed agents, existing drugs, and cardiopulmonary state

39
Q

Where should fingers be placed when opening a patient for intubation? How should the tongue be pulled? How is the laryngoscope blade tip placed?

A

outside and lateral to upper canines

horizontally out (NOT over the mandible = trauma)

back of the tongue, just cranial to and under the base of the epiglottis - by exerting gentle pressure, the epiglottis will lower and move forward slightly

40
Q

What can happen if intubation is attempted before reaching the critical depth of anesthesia?

A
  • patient gaging, which can lead to regurgitation, vomiting, and increased ICP/IOP
  • stimulation back to stage II
  • bradycardia and excessive vagal tone
  • laryngospasm
41
Q

What medication can be used if there is trouble intubating? How does it differ in dogs and cats? What should be avoided?

A

topical 2% Lidocaine and saline

  • DOGS: can be liberal
  • CATS: 0.5 mL of each on laryngeal cartilages

progressive attempts —> deepens plane of anesthesia

42
Q

What can be done in large dogs if there is trouble intubating?

A
  • lateral recumbency
  • straighten airway path by hyperextending the neck
43
Q

What are 6 signs if inappropriate (esophageal) intubation?

A
  1. patient can vocalize
  2. patient fails to remain unconscious
  3. gagging and swallowing efforts persist
  4. air ingestion and bloating
  5. palpable ET tube in cervical area
  6. no capnography readings

(pulse ox may be satisfactory!)

44
Q

What are 4 means to assure correct intubation?

A
  1. visualize the glottis
  2. capnography
  3. palpate fo ET tube, should not be able to feel it!
  4. listen to breaths in both sides of the chest (also confirms it’s not too deep)
45
Q

What are the next steps once a patient is intubated?

A
  • secure tube to head, jaw, or face with tape/gauze/plastic (keep place of surgery in mind)
  • inflate cuff after securing
46
Q

In what 2 situations does micro damage due to intubation occur?

A
  1. simple movements - taping or adhering tube
  2. head and oral manipulation - dental, ophtho procedures
47
Q

How much should the ET cuff be inflated?

A

with the smallest amount of air possible to provide effective protection of the airway —> inflate to the point of not hearing leak and stop

48
Q

How should the machine be set up when the patient is first hooked up?

A
  • O2 flow meter at 1-2 L/min
  • no inhalant
  • capnograph in place
  • take pulse
  • turn on inhalant dependent on pulse
49
Q

What initial settings are recommended on the oxygen flow in non-rebreathing and rebreathing circuits?

A

NON-REBREATHING = high flow ALWAYS, 150-300 mL/kg/min

REBREATHING = initially high flow where the patient is saturated for the first 30 mins, then can switched lower when patient reaches steady state

50
Q

What 5 things does patient steady state on oxygen flow depend on?

A
  1. circulation
  2. albumin
  3. respiration
  4. induction agents
  5. solubility
51
Q

What initial settings are recommended for the inhalant percentage?

A
  • 0%, but on until cuff is inflated
  • HR near preinduction = 1-2%
  • HR 50-100% preinduction = 1%
  • HR <50% = 0% until rate rises or manual signs dictate
52
Q

What are the minimal, moderate, and high flow ranges on oxygen flows? How do most practices start?

A
  • 4-10 mL/kg/min
  • 10-20 mL/kg/min
  • 20-40 mL/kg/min

start high, then minimize throughout surgery —> check scavenger before starting low

53
Q

In what patients is laryngeal spasms or closed glottis more common? How is it resolved?

A

cats and light patients

  • inject or titrate more IV induction agent
  • remove stimulation, spray cartilages with lidocaine, allow patient to relax, massage thorax
54
Q

In what patients is gagging and gross movements during intubation common? How is it resolved?

A

cats and light patients

  • deepen plane of anesthesia PRIOR to continuing intubation
  • hold jaw, tobue, and maxillar differently (more gently)
  • allow oxygenation
55
Q

What can be done if there is difficulty visualizing the glottis in brachycephalic breeds? Small/pocket pets? Obese?

A

use laryngoscope blade to elevate soft palate

place capnograph, point patients nose to ceiling, turb tube 90-180 degrees when glottis is reached

place in dorsal recumbency and intubate upside down with a towel under their neck

56
Q

When are pharyngostomy ET tubes recommended? Retrograde over catheter? Tracheostomy tube?

A

dental procedures or jaw fracture

oral, pharyngeal, laryngeal, or tracheal masses

tracheal or pharyngeal mass

57
Q

In what 4 situations is fiberoptic intubation recommended?

A
  1. masseter myositis
  2. retrobulbar disease
  3. one lung ventilation for thoracic surgery
  4. jaw fracture
58
Q

Why can a capnograph not read?

A
  • patient not intubated properly
  • patient is dead: no circulation, CV arrest, embolus
  • patient not breathing
  • little patient requires a non-rebreathing circuit
59
Q

What are 3 common reasons for low capnograph readings after induction?

A
  1. circulation decreased secondary to IV induction agent and inhalant
  2. respiration decreased secondary to IV induction agent and inhalant
  3. hypothermia
60
Q

Why are patients’ eyes lubed?

A

prevents corneal dryness and lacerations

61
Q

Anesthesia emergency drug doses may be considered less than standard CPR drug doses because:

a. patient is already intubated and normally on 100% oxygen and the arrest is often immediately perceptible
b. patient is recumbent
c. patient is readily arousable
d. induction agent drugs and doses are not cardiovascularly depressant
e. positioning of the patient is not conducive to ventricular tachycardia

A

A

62
Q

An appropriately anesthetized patient can be intubated in which of the following stages of general anesthesia?

A

Stage III

63
Q

Inducing a patient that is not unconscious or sedate enough can induce all of the following deleterious happenings EXCEPT:

a. increased ICP from gagging
b. decreased IOP from gagging
c. furthered cardiovascular decline and distributive shock
d. spinal subluxation
e. increased pain

A

B

64
Q

If the patient is NOT sedate enough from its premed, when you go to induce anesthesia, which of the following is the BEST option?

a. give a bit more premedication IV to further sedate
b. give induction agent regardless
c. mask patient into submission
d. hold patient down sternally
e. give induction agent little by little until you obtain the correct plane of anesthesia necessary for intubation

A

E

65
Q

The large black number commonly associated with “size” of an endotracheal tube refers to its:

a. external or outer diameter
b. cuff length
c. length of tube
d. breathing circuit dimension
e. internal diameter

A

E

66
Q

When choosing an endotracheal tube, which of the following most affects airway resistance?

a. length
b. viscosity
c. radius

A

C

67
Q

All of the following techniques are suitable for choosing an appropriate diameter of endotracheal tube EXCEPT:

a. for magill tubes, take the square root of the BW x 5
b. just try to fit the largest tube down regardless of diameter
c. nasal planum trick
d. use an established approximation chart based on lean weight
e. gently palpate the trachea and estimate diameter

A

B

68
Q

The endotracheal tube should terminate (have the 15 mm breathing circuit connector exit the patient) at the nose level but not beyond to avoid:

a. dead space
b. dead heat
c. dry heat
d. humidity of tissues
e. excessive time changes in vaporizer settings

A

A

69
Q

You are readying yourself to actually inject propofol to induce a patient. Before you do though, all of the following should be reviewed EXCEPT:

a. pulsed rate
b. pain score
c. ability to open mouth to intubate
d. possibilities of regurgitation
e. adequate sedation

A

B

70
Q

True or false: A patient with a slower pulse rate pre induction can tolerate a bolus of induction drug to effect.

A

FALSE —> faster pulse rate

71
Q

All of the following are essentials to appropriate intubation technique EXCEPT

a. assistant holds head and neck carefully avoiding subluxation and with fingers outside of the mouth
b. assistant pulls tongue forward
c. assitant pulls tongue forward and down over mandible
d. laryngoscope is placed ventral to the epiglottis
e. patient should not be reflexively spitting the tube out

A

C

72
Q

You have just induced a patient and he/she fails to remain asleep although the vaporizer setting is high and oxygen flow appears adequate. You palpate the cervical area of the patient and “feel” your endotracheal tube. Which of the following is a likely cause of the failure to remain unconscious?

a. malplaced ET tube
b. ran out of isoflurane
c. sevoflurane is not the appropriate anesthetic
d. oxygen flow is not accurate
e. need further administration of induction agent

A

A

73
Q

The average initial oxygen flow for a NON rebreathing circuit is:

a. 2 L/min
b. 2-3 L/min
c. 10-40 mL/kg/min
d. 150-300 mL/kg/min
e. 700 mL/kg/hr

A

D —> needs high flow ALWAYS

74
Q

In what 5 situations is CPCR done?

A
  1. pupils dilated or pinpoint
  2. eyes positioned straight ahead
  3. no palpebral response
  4. jaw tone extremely lax
  5. no palpable pulse

Anesthesia (40 decks)

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