Induction and Emergence Flashcards
What does MSMAID (P) stand for?
- 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
Airway setup?
11
- 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
Once you get patient on OR table, what should you ask patient to do?
safe apnea time?
Go into sniffing position- makes sure they’re able to without pain/discomfort in neck.
Place monitors on, pre-induction vitals.
Pre-oxygenate
5 minutes of 100% FIO2 at >6L/min = 10 minutes of safe apnea time.
4 VC breaths in 30 seconds = 5 minutes of safe apnea time
How do you preoxygenate the patient?
- 5 min 100% Fio2 >6L flow= 10 minutes safe apnea time
- 4 vital capacity breaths in 30 seconds= 5 min safe apnea time
If patient obese, how can you ensure the ramping is high enough?
External acoustic meatus lined with sternal notch= good indicator that axis aligned
Once you give induciton meds, now what?
- Test reflexes with eyelash reflex
- test ventilate with BVM,
- troubleshoot:
- reposition
- use oral airway
- two hands on mask
- difficult airway algorithm
- plan b airway
What can you insert if you’re unable to ventilate the patient?
LMA!
If we can ventilate patient after induction meds, what is the next step?
- Apply PNS and check baseline twitches
- administer NMB
- Monitor effectiveness of NMB with PNS
- eye- asleep
- ulnar- wake up
What happens after admin of NMB?
- Continue to ventilate while NMB action takes effect
- tape eyes
- loss of twitches confirmed with PNS
- attempt laryngoscopy and tracheal intubation
- Confirm ETT
- watch ETT pass VC
- fogging ETT
- Bil. chest rise
- Bil. breath sounds
- presence of three ETCO2 waveforms
- Tape ETT
- depth approx. ID X3
After intubation and confirm ETT, next steps?
- 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
What should we do to prevent recall during intubation process?
- 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
Effects of trachela intubaiton on body?
- 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
Standard induction review?
21 steps
- •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
•
What is RSI?
when is it used
what does it add/replace
- 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
RSI sequence?
22 steps
- •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
When can you extubate a patient?
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!
- plane 1 or plan 3, avoid plane 2
Extubation criteria?
6
- 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
Nearly fully awake extubation sequence?
9
- •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
Deep extubation sequence?
9
- •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
What is a laryngospasm?
how does it present
when is it seen?
5
- Prolonged, intense glottic closure
- may be present with high pitched squeak to total absence of sound (ominous sign)
- suprasternal and supraclavicular drawing in, 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
What are some triggers for laryngospasms?
6
- Secretions (vomitus, blood, saliva)
- foreign body
- pain
- pelvic or abd visceral stimulation - vagal
- stimulating glottis in a light plane of anesthesia
- reactive airway dx
How can you prevent larngospasm?
4
- Deep plane of anesthesia reached prior to sx stimulation
- either fully awake or deeply anesthetized with extubation
- suciton oropharynx prior to extubation
- remove ETT with positive pressure breath
Layngospasm treatment?
- Recognize event!
- immediate removal of offending stimulus
- Larson maneuver, pressure for 3-5 seconds, release for 5-10 seconds
- admin 100% fio2 with continuous positive pressure
- deepen anesthetic (prop)
- small dose short acting muscle relaxant
- succ 20-40 mg
Stage II anesthesia is dangerous because
highest risk for laryngospasm,
eyes will deviate
increase HR/BB
irregular RR, increase SNS STIM.
BREATH HOLDing, can be combative
