Basic Anesthesia Case Management Flashcards
3 questions to ask yourself before each general anesthetic case?
- Should I intubate or place an LMA?
- Should I let the patient breath spontaneously, or should I breath for them (ventilator)?
- If I am going to use the ventilator, how am I going to suppress the respiratory drive, so that the patient will tolerate the vent?
Advantages to spontaneous ventilation?
- Know respiratory rate
- Wakeup will have one less step, because you won’t have to get the patient back breathing (you just have to turn the agent off)
Disadvantages to spontaneous ventilation?
- Smaller tidal volumes
2. Obesity or long procedure is contraindicated
Absolute contraindications for spontaneous ventilation?
- Intraabdominal surgery (requires MR)
- Laparoscopic surgery (requires MR)
- Cardiothoracic surgery (usually requires MR)
- Situations where EtCO2 must be tightly controlled (i.e. brain surgery)
- Morbidly obese patients
- Certain types of joint replacement, depending on surgeon
Relative contraindications to spontaneous ventilation?
- Long operations
- Elderly patients
- Non-supine position
Advantages of control ventilation?
- Larger Vt
2. We can control the patients CO2 levels
Disadvantages of control ventilation?
- We must knock out the respiratory drive (paralysis, higher narcotics)
- Wakeups will have an extra step (we have to get the patient breathing again at end of surgery)
Popular situations to use muscle relaxants?
- Smokers, asthmatics, and obese patients who need to be intubated
- “Sick” patients who are intubated
- Long operations on intubated patients
Contraindications to muscle relaxants?
- Neck surgery/neck dissection
- Thyroid surgery and parathyroid surgery
- Neurosurgery (back or brain)
- Breast/axillary surgery
Complications to using Sugammadex?
- Patients <17 years of age
- Renal disease
- Pregnacy and lactation
- Allergic reactions to sugammadex
Advantages of MR and ventilator?
- Patient won’t require as deep of anesthesia
2. Patient is guaranteed not to move
Disadvantages of choosing MR for patients on the vent?
- MR use requires the anesthetist to give reversal
- Surgery may end unexpectedly soon, doesn’t really matter with sugammadex
- Anesthetic awareness is theoretically more likely
If we cannot use MR, what is the best way to supress respiratory drive and the cough reflex (so patients can tolerate the ventilator)?
- Higher doses of narcotics (100-250mcg fentanyl on induction)
- Use “deeper” anesthetic (MAC>1)
Advantages of not paralyzing and on the vent?
- Zero chance of residual paralysis at end of case
- Patient won’t require reversal agents
- Curare clefts can indicate when more narcotic is needed
Common induction prior to intubation?
- Lidocaine
- Fentanyl
- Propofol
- Paralytic (sucs vs. roc)
Common induction prior to LMA placement?
- Lidocaine
- Propofol
- Fentanyl (optional <50mcg)
Management of LMA cases?
- Induce patient and place LMA
- Ventilate patient with positive pressure and volatile agent for 2-3 min
- After sevo is in system, let patient go apneic until they start breathing on their own
- Once breathing on their own, get MAC level >1 prior to incision and titrate narcotics to a slow RR
- Be prepared to treat hypotension (since MR aren’t being used and they have to be deeper)
Steps to prevent coughing on a tube with intubated or spontaneously ventilating patients?
- Adequate >1 MAC inhalation conc.
- Adequate narcotic dosing to a lower RR (8-12 breaths/min)
- Numbing of trachea (with LTA kit or lidocaine jelly)
Management of intubated and spontaneously ventilating patients?
- Induce pateint with sucs and intubate
- Ventilate patient with volatile agent for 3-5 min on the ventilator (until sucs wears off)
- When muscle function returns, let the patient go apneic until they start breathing on their own
- Once they start breathing, get MAC>1 prior to incision and titrate narcotics to slow RR
- Be prepared to treat hypotension
Management of intubated patients on the vent and not paralyzed?
- Induce with sucs and intubate, use 100-200mcg fentanyl to supress respiratory drive
- Turn off ventilator and deliver volatile agent
- Get MAC>1 prior to incision
- Be prepared to treat hypotension
Management of intubated and paralyzed patient?
- Induce with roc or sucs and intubate
- Turn vent off and deliver volatile agent
- Get patient to >0.8MAC before incision
- Since the patient is paralyzed, the anesthetist doesn’t have to have the patient as “deep” prior to incision (less likely hypotension)
