Induc & Emergence Flashcards
Anesthetic plan = 8
Chart review. H&P. Interpret lab tests. ASA status. Anesthetic plan development: comorbidities, preop labs/dx, surgical consid
Anesthetic plan includes details on which things: 8
Preop consid, monitoring, induction, a/w management, maintenance technique, fluid plan, emergence. Alternative anesthetic plan
MSMAIDP
M (monitors on, alarms set), S (suction on and near), M (PPV/machine check), A (ett and lma), I (IV&fluids), D (drugs, emergency and basic), P (pt position)
Airway set up: 11
Appropriate sized face mask, PPV (ambu, jet vent, vent checked), suction on and near, tongue depressor, appropriate sized oral/nasal airways, LMA, laryngoscope handle, 2 blades, 2 ETT, stylet, syringe, tape
ETT sizes male and female
Male 7.5-8, female 6.5-7
Blade sizes male and female
Male Mac 4 miller 3-4. Female Mac 3 miller 2
Standard induction: positioning to pre-oxygenation
Pt supine and in sniffing position. Place monitors and get pre-induction vitals. Pre 02: 5 min 100% fio2 @ 6 LPM flow, 10 safe min. 4 VC breaths in 30 sec= 5 min safe time
Induction: med considerations, sequence
Antianxiety meds (benzos), narcotic (sns response), lidocaine, induction agent
What to do after induction meds given
Confirm LOC w eyelash reflex. Test ventilate: reposition, use oral a/w, 2 hands on mask, difficult a/w alg, plan b a/w
Steps after induction for NMB and intubation
Apply PNS, check baseline twitch. Give NMB, monitor effective ness w PNS. Ventilate while NMB kicks in, tape eyes. Then attempt laryngoscopy and confirm ett placement, tape
What to do after ETT secured
Ventilate w machine or by hand. Adjust flows. Add air/n20. Start propofol, add volatile anesthetic
Effects of tracheal intubation: 5
Htn, tachycardia, laryngospasm, bronchospasm, MI risk
How to prevent effects of tracheal intubation
Deepen plane of anesthesia, use lidocaine/narcotics/additional induction agent. Consider bronchodilator prophylactically
Standard induction review 21
- Pt supine, sniffing pos. 2. Turn on 02 flow 3. Pre-oxygenate 4. Monitors on and vs taken 5. Suction on and ready at HOB 6. Pre-induction meds 7. Lidocaine +/- induction agent 8. Lash reflex 9. Test vent 10. Check PNS 11. Ventilate by mask 12. NMB 13. Vent w mask 14. Tape eyes 15. Vent until twitches lost 16. Intubate 17. Inflate cuff 18. Confirm ett 19. Tape 20. Vent w bag/machine 21. Maintenance anesthetic
How RSI different from standard induction
Add sellicks maneuver, removes ventilation
RSI sequence 19
ID need for RSI 2. Pre-op aspir prophylaxis 3. Anxiolytic 4. Narcotic 5. Monitors on 6. Suction at hOB 7. Sniffing position and supine 8. Pre-o2 9. Sellicks maneuver 10. Induction agent 11. Sux or roc, wait 60 sec 12. Intubate 13. Confirm placement 14. Have assistant release cric pressure 15. Secure ett 16. Vent 17. Tape eyes 18. Adjust flows 19. Maintenance anesthetic
Choices for maintenance anesthesia
IA, TIVA, short or long acting narcotic, intubating NMB or continued paralysis
Extubation criteria 6
TV >6ml/kg, VC >10 ml/kg, RR <30 on own, Sao2 >90 on <60% fio2, etco2 <50, no fade on pns
Nearly fully awake extubation
Muscle relaxant reversed, confirm w pns. Extubation criteria met. Anesthetic meds and volatiles off. Suction. Pt responsive. 5 sec head lift. Pt can protect own a/w. ETT removed while PPV given
Deep extubation steps
NMB reversed and confirmed w pns. Suctioned. Oral or nasal a/w placed. ETT removed while PPV given. Agents and infusions off. Mask a/w while spontaneously venting. Vigilance until pt responsive.
Laryngospasm: what it is, signs
Prolonged glottic closure. High pitch squeak to total silence. Supra sternal and Supra clavicular in-drawing, inc diaphragmatic excursions, flailing of lower ribs (rocking horse)
Laryngospasm: what its caused by, when its often seen
Contraction of LCA, thyroarytenoids, and cricothyroid from stim of vagus. Induction and emergence
Laryngospasm triggers: 6
Secretions, foreign body, pain, pelvic/abd visceral stim, stim glottis in light plane of anesthesia, reactive a/w disease
Laryngospasm prevention 4
Deep plane of anesthesia reached before surgical stim, either fully awake or deep before extubation, suction oropharynx before extubation, remove ett w PP breath
