Induction and Emergence Flashcards
MS MAIDS
Everything should be OUT and ready to go prior to patient arrival!!!
M: monitors and alarms set (for your patient parameters)
S: suction on and AT HEAD OF BED
M: means of positive pressure ventilation (circuit checked), ambu bag (behind machine), jet ventilator
A: airway (ETT/LMA)
I: IV and fluids (2nd IV ready to go if needed), fluid warmer, etc.
D: Drugs - Emergency and basic drugs
- P henylephrine (DOUBLE DILUTION)
- E phedrine (SINGLE DILUTION)
- A tropine
- S uccinylcholine
- *sometimes glycopyrrolate**
S: special equipment, positioning, etc.
Airway Setup
NO MATTER WHAT TYPE OF CASE, NEED A FULL AIRWAY SET UP AND WHEN YOU’RE A NEW PROVIDER, IT SHOULD PROBABLY BE OUT AND READY TO GO ON THE MACHINE
- appropriate sized face mask
- means of PPV
- suction on and easily accessible
- tongue depressor
- appropriate sized oral and nasal airways
- appropriate sized LMA
- laryngoscope handle
- 2 different blades
- –male: Mac 4/Miller 3-4
- –female Mac 3/Miller 2
- ETT: 2 sizes
- –male: 7.5-8 ID
- –female: 6.5-7.0 ID
- –airway or surgical considerations?
- stylet and syringe
- tape
Goal and methods of pre-oxygenation
De-nitrogenation of FRC and replace with 100% O2
5 minutes of 100% fiO2 at >6L/min flow = 10 minutes of safe apnea time
4 vital capacity breaths in 30 seconds = 5 minutes of safe apnea time
Caveats: morbidly obese and pregnant women (go through FRC much faster)
Standard Induction: medications
Anti anxiety pre med
-versed, ativan, valium
narcotic
- fentanyl, dilaudid, morphine, demerol
- blunt response to SNS surge for DL
**don’t always have to give anti-anxiety premed and remember that anti-anxiety + narcotic = synergistic for RESPIRATORY DEPRESSION
consider use of lidocaine
-block sympathetic surge to DL, dec pain with propofol
induction agent
-propofol, etomidate, ketamine, thiopental
How to confirm ETT placement.
- watch it pass the vocal cords
- Fogging of ETT
- bilateral chest rise
- bilateral breath sounds
- presence of three ETCO2 waveforms - while masking
How to estimate appropriate depth to tape ETT.
ID x 3
Standard induction review
- position patient in supine sniffing position
- turn on oxygen flow
- begin pre oxygenation
- monitors on and vital signs taken (O2 sat, BP, ECG, PNS in place) – place BP cuff first so that you can cycle for BP while placing other monitors!
- suction on and read at HOB
- 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 x3 waveforms)
- tape ETT
- continue ventilation by bag of ventilator
- begin maintenance anesthetic
- decrease gas flows
What is RSI?
an airway management technique that induces immediate unresponsiveness and muscular relaxation and is the fastest and most effective means of controlling the emergency airway
(you don’t breathe for the pt because you don’t want any chance of air getting down to the stomach and causing them to aspirate)
RSI used in situations of full stomach - at risk for aspiration: EXAMPLES
- trauma
- pregnant > 12 weeks
- severe DM with gastroparesis
- symptomatic GERD
Before you ever put a patient a sleep, you should have a plan for ______?
How to wake them up!!
Everything you do during the case will influence your emergence
If you did an RSI on a pt, do you extubate NEARLY FULLY AWAKE or DEEPLY ANESTHETIZED?
nearly fully awake!!
“If they were a full stomach at the beginning, they’re a full stomach at the end.”
Extubation criteria
- TV > 6ml/kg
- VC > 10ml/kg (will not be able to obtain if patient deeply anesthetized and not able to follow commands)
- RR < 30 breaths/min - pt must be spontaneously breathing!! (don’t forget to take them off ventilator)
- SaO2 > 90%
- EtCO2 < 50 mmHg
- —Caveat: severe COPD, severe asthma
- sustained tetanic contraction with PNS
Nearly full awake extubation process
- muscle relaxant fully reversed and confirmed with PNS (if applicable); 4 twitches, sustained tetany w/o fade
- all respiratory extubation criteria have been met
- anesthetic medications including volatile agents and infusions turned off
- 100% fiO2 - pre oxygenate prior to extubation
- oropharynx suctioned
- pt is response to commands/purposeful movement
- sustained (5 second) head lift indicates clinically adequate reversal of NMB
- pt can maintain and protect own airway
- ETT removed while positive pressure breath is given
- —causes patient to cough (gets rid of secretions, anything in airway—> decrease risk of laryngospasm)
Deep extubation process
- muscle relaxant full reversed and confirmed with PNS (if applicable)
- all respiratory extubation criteria have been met
- oropharynx suctioned
- 100% fiO2 - pre oxygenate
- oral or nasal airway may be inserted
- -should be spontaneously breathing (because they met extubation criteria), but may need head manipulation to assist in opening up airway
- ETT removed while positive pressure breath is given
- volatile agents or infusions turned off (should be in surgical plane of anesthesia at time of extubation)
- mask airway maintained while patient spontaneously ventilating
What is a laryngospasm?
prolonged intense glottic closure
caused by the contraction of the: -lateral cricoarytenoids -thyroarytenoids -cricothyroid muscles from stimulation of the vagus nerve
laryngospasm triggers
- secretions (vomit, blood, saliva)
- foreign body
- pain
- pelvic or abdominal visceral stimulation (puling or stretching)
- stimulating glottis in a light plane of anesthesia
- reactive airway disease
- pediatric patients – loud noise
laryngospasm prevention
- deep plane of anesthesia reached prior to surgical stimulation
- either fully awake or deeply anesthetized with extubation - not in between!!
- suction oropharynx prior to extubation
- remove ETT with positive pressure breath
laryngospasm treatment
RECOGNIZE THE EVENT! – IMMEDIATE REMOVAL OF THE OFFENDING STIMULUS
- larson maneuver
- -retromandibular notch/laryngospasm notch
- —condylar prcoess of the mandibular ramus anteriorly, the mastoid process posteriorly, and the external auditory canal superiorly – works well in peds
- —pressure for 3 - 5 seconds and released for 5-10 seconds
- administration of 100% fiO2 (with flows of at least 6 L/min) with continuous positive pressure
- —closed APL valve, hold bag, don’t breathe, just hold pressure
-deepen anesthetic (propofol) - gas won’t help because the AW is closed
- small dose of short acting muscle relaxant: succinylcholine 20-40 mg
- may feel weak afterwards and you may need to assist them breathing*
if patient laryngospasms once, likely to do it again and again
