Extubation Flashcards
Steps to prepare for safe extubation
AROSE
Anaesthesia off
Reversal of neuromuscular blockade
Oxygen - high flow
Suction
Expiring (spont breathing)
(Or 6 steps below)
1) Check neuromuscular blockade
2) Stop anaesthetics and give high flow O2
3) Suction
4) Assess respiratory effort
5) Consider recovery position
6) Assess maintenance of airway
Methods of testing if muscle relaxant has worn off
Peripheral nerve stimulator:
- Train of Four
- Double burst stimulation (DBS)
- Tetanus
- Twitch
Setting for peripheral nerve stimulation TOF
60-80 mA (supramaximal stimulus)
4 separate impulses at 2 Hz frequency
Double burst stimulation for peripheral nerve stimulation
3 impulse bursts separated by 750 ms
Use of tetanus peripheral nerve stimulation
Tests for profound neuromuscular blockade
Can count post tetanic twitches
What is Sugammadex
Modified cyclodextrins
Use of sugammadex
Only for aminosteroid muscle relaxants:
Rocuronium and Vecuronium
Peak effect time of sugammadex
Almost immediate
What is Neostigmine
Anticholinesterase
When to use Neostigmine + Glycopyrrolate
When at least 2 twitches present of TOF
Peak effect time of neostigmine + glycopyrrolate
10 mins
Categorisation for patient slow to wake
Patient factors
Anaesthetic factors
Surgical factors
Common anaesthetic causes for slow waking
Residual paralysis
Residual opioids
Residual anaesthetic agent
Factors which prolong neuromuscular blockade
Hypothermia
Acidosis
Electrolyte abnormalities
Drug interactions
Decreased excretion
Inadequate timing of reversal
Common electrolyte abnormality which prolongs neuromuscular blockade
Low magnesium
Drug interactions which prolong neuromuscular blockade
Volatile agents
Calcium channel blockers
Aminoglycosides
Lithium
Patient factors with increase slow waking
Extremes of age
Obesity - redistribution of anaesthetic agent
Chronic alcohol excess
Renal impairment
Metabolism of Suxamethonium
Plasma cholinesterase (pseudocholinesterase)
Pathophysiology of Suxamethonium apnoea
Congenital cause - lacks plasma cholinesterase enzymes to metabolise sux
Homozygous atypical gives characteristic prolonged block of several hours
Four alleles for plasma cholinesterase enzyme
Usual
Atypical
Silent
Fluoride
Management options for Suxamethonium apnoea
Usually supportive and wait
Can consider giving FFP - replaces enzyme
