Assessment of GA

Question 1

What to do if failed intubation?

Answer 1

1. Informs team and calls for help
2. 100% O2 + BMV between each stage of failed attempts
3. Reposition: ensure sniffing position, pillow under head & shoulders
4. Simple equipment (OP airway) and Change of equipment (different blade, different size tube)
5. Cricoid adjustment
6. 2nd Intubation attempt
7. LMA
8. Cricothyroidotomy

Question 2

I: (Basics):

Answer 2

1. IV line
2. Machine check
3. Airway trolley
4. Emergency drugs
5. Baseline vitals
6. Gloves

Question 3

INDUCTION PHASE: SSSTOPAAA

Answer 3

SSS:

1. Suction: suction in right hand, no suction: no induction
2. “Sniffing” position with pillow under head
3. Stethoscope around neck

T: Tube:
Tell anaesthetic nurse if RSI or elective sequence induction
Need for cricoid
LMA vs ETT + size

0: Pre-Oxygenate to ETO2 >80%
Check capnography is reading

P: Pharmacology for induction:
IV induction agent vs gas induction
May need muscle relaxant (start timer)

A: APL valve open (on zero) to start - while pre-oxygenating and awake
Pre-set ventilator if you can whilst pre- oxygenating
APL 20-30cm H20 to bag when asleep in ESI

A: Antibiotics (not needed for induction but need to be in 30mins before skin incision)

A: Asleep with agent
Turn on volatile after giving mm. relaxant

Question 4

MAINTENANCE PHASE - ABCDE

Answer 4

A: Airway - Intubate + confirm placement:
1. Visualisation passing cords/ Misting/ Chest rise/ Auscultation/ Capnography

B: Breathing:
RR, VT, Peep, l:E ratio
FiO2 (45-50%) target to saturation
ETCO2 (4.7 - 5.5 kPa)
PiP < 20 cmH20 if LMA/using BVM/manual spontaneous
PiP < 40 cmH20 if ETT - look for causes of increased pressure when P > 30cmH20

C: Circulation:
Check ECG for arrhythmias
MAP target (normotensive 60-65mmHg; hypertensive 70-75mmHg)
HR
Starting Hb

D: Disability
Hypnosis - ETaa 1 MAC
Analgesia - opioids/ ketamine/ paracetamol/ NSAIDs/ local
Mm relaxation - more required

E: Exposure:
Protect pressure points
Protect eyes
Ensure FAW on
Insert temperature probe

Question 5

EMERGENCE PHASE: GROOSS

Answer 5

G: Gases off (volatile) to wake patient
Turn up fresh gas flow
Give local for wound

R: Reverse if NMDR given (3 twitches on TOF)
Adequate = TOF ratio > 90%

O: OP airway
Prevent biting of ETT and negative pressure pulmonary oedema

O: Pre-oxygenate before extubation
100% FiO2 (ETO2 >80%)
High flow
Face mask & puffer ready

S: Suction (insert OPA before suctioning)

S: Spontaneously breathing
Pt. triggering ventilator on PSV prior to extubation

Question 6

Post extubatlon & Recovery

Answer 6

1. Confirm adequate TV achievable with face mask
2. Confirm Pt. able to maintain sats on RA
3. Elevate head 45 degrees if patient fully awake
4. Take OP airway & mask with to recovery
5. In Recovery: Check Airway, apply monitors and handover to Recovery Room Sister