Induction and Emergence Flashcards
1
Q
What does MSMAID (P) stand for?
A
- Monitors on and alarms set
- Suction on and adquate/nearby
- Means of PPV (machine check
- Airway (LMA/ETT)
- IV and fluids
- 2nd IV kid
- fluid warmer/albumin/blood if needed
- Drugs- emergency and basic
- P-patient position
2
Q
Airway setup?
A
- Appropraite sized face mask
- means PPPV
- suciton on and accessible
- tongue depressor
- appropriate sized oral and nasal airways
- appropriate sized LMA
- laryngoscope handle
- 2 diff blades
- male mac 4/miller 3-4
- female mac 3/miller 2
- ETT 2 sizes
- male 7.5-8
- female 6.5-7
- any sx consideration? laser, nasal intubation, reinforced ETT
- Sylet and syringe
- tape
3
Q
Once you get patient on OR table, what should you ask patient to do?
A
Go into sniffing position- makes sure they’re able to without pain/discomfort
4
Q
How do you preoxygenate the patient?
A
- 5 min 100% Fio2 >6L flow= 10 minutes safe apnea time
- 4 vital capacity breaths in 30 seconds= 5 min safe apnea time
5
Q
If patient obese, how can you ensure the ramping is high enough?
A
External acoustic meatus lined with sternal notch= good indicator that axis aligned
6
Q
What are some standard induciton meds used?
A
- Antianxiety med
- versed/ativan/valium
- Narcotic
- fentanyl/dilaudid/morphine/demerol
- Consider use lidocaine- blunt SNS 1mg/kg
- Induction agent
- propofol 1-2.5 mg/kg, less in edlerly, more in peds (3mg/kg)
- Etomidate 0.2-0.6 mg/kg
- Ketamine 1-2 mg/kg
- taumra, sponaneous ventilation maintained
- avoid- ICU or someone that can’t handle SNS response
7
Q
Once you give induciton meds, now what?
A
- Test reflexes with eyelash reflex
- test ventilate!!
- troubleshoot:
- reposition
- use oral airway
- two hands on mask
- difficult airway algorithm
- plan b airway
8
Q
What can you insert if you’re unable to ventilate the patient?
A
LMA!
9
Q
If we can ventilate patient after induction meds, what is the next step?
A
- Apply PNS and check baseline twitches
- administer NMB
- Monitor effectiveness of NMB with PNS
- eye- asleep
- ulnar- wake up
10
Q
What happens after admin of NMB?
A
- Continue to ventilate while NMB action takes effect
- tape eyes
- loss of twitches confirmed with PNS
- attempt laryngoscopy and tracheal intubation
- Confirm ETT
- wathc pass VC
- fogging ETT
- B chest rise
- B breath sounds
- presence of three ETCO2 waveforms
- Tape ETT
- depth approx. ID X3
11
Q
After intubation and confirm ETT, next steps?
A
- Continue to ventilate by hand or ventilator
- adjust flows
- add other gases
- start infusion of anesthetic
- add VA
- DS/SEV/ISO
- overpressure!
- DS/SEV/ISO
12
Q
What should we do to prevent recall during intubation process?
A
- Keep in mind DOA of induciton agent in relation to onset of NMB
- may need additional inducation drug
- use inhalational agent during ventialtion
- BIS monitoring
13
Q
Effects of trachela intubaiton on body?
A
- Very noxious!
- HTN and increased HR- risk of MI
- Laryngospasm
- Bronchospasm
- Deepen plan of anesthesia with intubation by using lidocaine/narc/induciton agent
- consider prophylactic bronchodilator therapy
14
Q
Standard induction review?
A
- Position patient supine in sniffing position
- Turn on oxygen flow
- Begin pre-oxygenation
- Monitors on and vital signs taken (O2 sat, BP, ECG, PNS in place)
- Suction on and ready at head of bed
- Pre-induction medications
- Lidocaine (+/-)/ Induction agent
- Test Lash Reflex
- Give Test ventilation
- Check PNS working
- Continue ventilating by mask
- Paralytic drug
- Continue ventilating by mask
- Tape eyes closed
- Continue ventilation until paralytic drug takes effect (loss of twitches)
- Laryngoscopy and intubation
- Inflate ETT cuff
- Confirm ETT placement—bilateral breath sounds, chest rise and fall, presence of ETCO2 x 3 waveforms
- Tape ETT
- Continue ventilation by bag or ventilator
- Begin maintenance anesthetic
•
15
Q
What is RSI?
A
- Rapid sequence induction
- airway mgmt technique that induces immediate unresponsiveness and muscular relaxation
- fastest and most effective means of contorlling emergency airway
- used in situation of full sotmachs-at risk for aspiration
- pregnant
- severe DM
- uncontrolled acid reflux
- hiatal hernia
- trauma
- Adds seliick’s maneuver and removes ventilation from standard induciton sequence
16
Q
RSI sequence?
A
- Identify patient in need of RSI
- Pre-operative prophylaxis for aspiration
- Bicitra/Reglan/Omeprazole/Pepcid or Zantac
- Anxiolytic
- Narcotic (avoid loss of consciousness to early)
- Monitors on
- Suction on and at head of bed
- Supine-sniffing position
- Pre-oxygenate
- Sellick’s maneuver= cricoid pressure –gradually increase pressure as patient falls asleep
- Induction agent
- Succinylcholine or high dose Rocuronium
- wait for fasciculation or 60 seconds (watch the clock- not the block) DO NOT VENTILATE!
- Laryngoscopy
- Tracheal intubation
- Confirmation of correct placement
- Give assistant permission to release cricoid pressure
- Secure ETT
- Ventilate or turn on ventilator
- Tape eyes
- Adjust flows
- Begin maintenance anesthetic
17
Q
When can you extubate a patient?
A
when nearly fully awake or deeply anesthesized! no inbeween!
- must evaluate relative risk of coughing vs obstruction vs aspiration when diciding b/w awake vs deep extubation
- RSI must be awake!
18
Q
Extubation criteria?
A
- TV >6 ml/kg
- VC> 10 mls/kg (won’t get if extubating deep)
- RR <30 breaths/min
- Sao2 >90%
- ETCO2 <50
- except copd, asthmatics
- sustained tetanic contraction with PNS
19
Q
Nearly fully awake extubation sequence?
A
- Muscle relaxant fully reversed and confirmed with PNS (if applicable)
- All respiratory extubation criteria have been met
- Anesthetic medications including volatile agents and infusions turned off
- 100% FiO2
- Oropharynx suctioned
- Patient is responsive to commands/purposeful movement
- Sustained (5 second) head lift indicates clinically adequate reversal of NMB
- Patient can maintain and protect own airway
- ETT removed while positive pressure breath is given
20
Q
Deep extubation sequence?
A
- Muscle relaxant fully reversed and confirmed with PNS (if applicable)
- All respiratory extubation criteria have been met
- Oropharynx suctioned
- 100% FiO2
- Oral or nasal airway may be inserted
- ETT removed while positive pressure breath is given
- Volatile agents or infusions turned off
- Mask airway maintained while patient spontaneously ventilating
- Remain vigilant until patient is responsive and maintaining own airway
21
Q
What is a laryngospasm?
A
- Prolonged, intense glottic closure
- may be present with high pitched squeak to total absence of sound (ominous sign)
- suprasternal an dsupraclavicular in drawing, increased diaphragmatic excursions, flailing of lower ribs resembling a “rocking horse”
- caused by contraction of lateral cricoarytenoids, thyroarytenoids, and cricothyroid muscle form stimulation of vagus nerve
- most often seen in induction/emergence
22
Q
What are some triggers for laryngospasms?
A
- Secretions (vomitus, blood, saliva)
- foreign body
- pain
- pelvic or abd visceral stimulation
- stimulating glottis in a light plane of anesthesia
- reactive airway dx
23
Q
How can you prevent larngospasm?
A
- Deep plane of anesthesia reached prior to sx stimulation
- either fully awake or deeply anesthetized wiht extubation
- suciton oropharynx prior to extubation
- remove ETT with positive pressure breath
24
Q
Layngospasm treatment?
A
- Recognize event!
- immediate removal of offending stimulus
- Larson maneuver
- retromandibular ntoch/laryngospasm notch
- condylar process of mandibular ramus anteriorly, mastoid process post, and external aud canal superiorly
- retromandibular ntoch/laryngospasm notch
- admin 100% fio2 with continuous positive pressure
- deepen anesthetic (prop)
- small dose short acting muscle relaxant
- succ 20-40 mg
