Induction and Emergence Flashcards
Placing a pillow under a patient’s head aligns these axes
PA and LA (pharyngeal and laryngeal)
Placing a patient in sniffing position aligns these axes
OA with PA and LA
How can you best prepare yourself for a smooth intubation?
Properly positioning yourself and the patient!!
These induction meds burn
Propofol and etomidate (use lidocaine with these guys)
What is the FIRST thing you should do after giving your induction med and your patient doesn’t have a lash reflex?
Give a test ventilation. This is what we are most concerned about after inducing our patient!! We want make sure we can mask ventilate our patient as early as possible in the sequence. THEN test TOF and give paralytic.
If you can’t initially mask your patient, try changing position or using oral or nasal airway. We want to make sure we are able to mask our pt SOMEHOW before proceeding!!
Relationship between induction meds and safe apnea time.
Most of our induction meds last for about 5 min, and we have 10 min of safe apnea time. So if we can’t ventilate, we just need to wait, and the pt will start spontaneously breathing again.
What do we need to remember if your pt receives botox injections?
a PNS will not work in this location (at the brow)
Remember that our induction agents have a limited DOA. We want want it to wear off before we start our maintenance anesthetic, as this could cause recall. These are two clinical signs predicting occurrence of recall.
Movement Autonomic response (increased HR and BP)
Also take a look at the BIS monitor
Rapid Sequence Induction
Consider giving bicitra and a pro-kinetic
Pre-oxygenate (5min or 4-5 VC breaths)
Begin Sellick’s Maneuver (pressure as they go off to sleep)
Give induction agent
Give sux (WAIT 60 SECONDS–> watch the clock, not the block!!)
Intubate and confirm placement
Release cricoid pressure (do not release cricoid pressure until placement is confirmed!!!**)
Secure ETT and begin maintenance
What is the intra-op goal of someone with HTN?
Hemodynamic stability. Want to keep BP within 20% of normal MAP.
Resp / movement criteria for extubation
TV > 6mL/kg
VC > 10mL/kg
RR < 30bpm (if >30, the pt is probs in pain)
SaO2 > 90% (correlates to a PaO2 of 60)
EtCO2 < 50 (>50 could indicate that their MV is insufficient)
Sustained tetanic contraction
Sustained head lift for 5 sec
When in the procedure can we consider extubating the patient?
1) Nearly fully awake
2) Deeply anesthetized
Extubation when nearly fully awake
Muscle relaxant must be fully reversed
Anesthetic meds/gases all turned off (hold-off on giving narcotics during emergence)
Pt meets resp criteria for extubation
Assess responsiveness (Purposeful movement? Following commands?)
Sustained head lift for 5 sec
ETT is removed while a positive pressure breath is given to allow subsequent expulsion or secretions away from the glottis
When and why is a deep extubation performed?
Performed after reversal of relaxant and patient is meeting resp criteria, but not yet following commands or having purposeful movement.
May do this in a severe asthmatic (reactive airway), where we don’t want them to be aware that they have the tube in.
How to perform a deep extubation
Reverse relaxant if required
Pt must meet resp criteria for extubation
Suction oropharynx
Oral or nasal airway may be inserted
Remove ETT
Mask remains on pt while they are spontaneously breathing (support their breaths if needed)
Vigilantly maintain mask airway until anesthetic is off and pt is responding and maintaining their own airway
Nasal and oral airways are kept in place until the pt can no longer tolerate them (will generally take them out themselves)
