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Health Assessment > Induction and Emergence > Flashcards

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
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2
Q

Airway setup?

A
  1. Appropraite sized face mask
  2. means PPPV
  3. suciton on and accessible
  4. tongue depressor
  5. appropriate sized oral and nasal airways
  6. appropriate sized LMA
  7. laryngoscope handle
  8. 2 diff blades
    • male mac 4/miller 3-4
    • female mac 3/miller 2
  9. ETT 2 sizes
    • male 7.5-8
    • female 6.5-7
    • any sx consideration? laser, nasal intubation, reinforced ETT
  10. Sylet and syringe
  11. tape
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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

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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
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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

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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
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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
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8
Q

What can you insert if you’re unable to ventilate the patient?

A

LMA!

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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
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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
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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!
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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
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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
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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

•

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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
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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
  • admin 100% fio2 with continuous positive pressure
  • deepen anesthetic (prop)
  • small dose short acting muscle relaxant
    • succ 20-40 mg

Health Assessment (7 decks)

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