Induction/Emergence Flashcards
How do you make an anesthetic plan?
- chart review
- history and physical
- interpret pre-op labs
- review ASA classification
- determine monitoring requirements
- develop anesthetic plan
- consider comorbidities
- consider specific surgery
What do you prepare to deliver an anesthetic?
MSMAIDP
- M: monitors on and alarms set
- S: suction on, adequate, and nearby
- M: means of PPV/Machine check
- A: Airway (ETT/LMA)
- I: IV and fluids
- D: Drugs- Emergency and basic drugs
- P: patient position
What is the induction process?
- Position pt in sniffing position
- turn on O2, begin preoxygenation
- monitors on, take vital signs, PNS in place
- Suction on and ready
- pre-induction meds
- lidocaine/induction agent
- test lash reflex
- give test ventilation
- check PNS working
- paralytic drug (continue ventilating)
- tape eyes
- when loss of twitches, laryngoscopy and intubation
- Inflate cuff, check ETT placement
- tape ETT
- continue ventilation by bag or ventilator
- begin maintenance anesthetic
Optimal intubating position
“sniffing”
Oral, pharyngeal, and laryngeal axis
Most optimal for visualization of vocal cords and most effective mask ventilation
ETT sizing
*always have two sizes available
- Female: 6.5-7.0 mm (depth ≈ 21 cm)
- Male: 7.5-8.0 mm (depth ≈23 cm)
- Ideal position: 4 cm above carina and 2 cm below vocal cords
- All ETT have 15mm outer diameter universal connector
Pre- Oxygenation
- Goal to increas O2 concentration in functional residual capacity (FRC) by “washing out” nitrogen in the FRC with O2
- 3-5 minutes of tight mask with normal breathing and 100% FiO2
- = 10 minutes of safe apnea time
- 4 vital capacity breaths within 30 seconds with 100% FiO2
- =5 minutes safe apnea time.
- 3-5 minutes of tight mask with normal breathing and 100% FiO2
Airway set up
- appropriately sized face mask
- ambu bag, circuit (for pos pres)
- suction
- tongue depressor
- oral and nasal airways
- laryngoscope handle
- 2 different blades
- ETT, 2 sizes
- stylet
- syringe
- LMA
- tape
why do you want to give narcotics and lidocaine before induction?
they both help to decrease the sympathetic response to laryngoscopy
What should you consider when giving an anxiolytic like versed and a narcotic together?
they are synergistic
1+1=3
especially regarding respiratory depression
How do you confirm ETT placement?
- watch it pass through the vocal cords
- fogging of the ETT
- Bilateral chest rise
- bilateral breath sounds
- presence of THREE ETCO2 waveforms
How do you determine appropriate depth of ETT?
depth= internal diameter x 3
What is rapid sequence intubation?
- technique that induces immediate unresponsiveness and muscular relaxation
- Fastest and most effective way of controlling emergency airway
- Used with full stomach or high risk of aspiration
- sellick’s maneuver- cricoid pressure
- no mask ventilation like in the standard sequence(?)
How is RSI different?
- once you pre-oxygenate, start Sellick’s maneuver, gradually increasing pressure as pt falls asleep
- give induction agent, then Succ or high dose Roc
- wait for fasciculation or 60 seconds, watching clock, not the block
- laryngoscopy and intubation
- confirm placement
- release cricoid pressure
- etc…
During what phase do you NOT want to extubate your patient?
- Phase 2
- pt can be extubated either nearly fully awake or deeply anesthetized
- Determine what is best by comparing the risk of coughing vs obstruction vs aspiration
If you did a RSI, how do you want your patient to be when you extubate?
They MUST be fully awake
What are the criteria for extubation?
- Either fully awake or deeply anesthetized
- TV > 6 mls/kg
- VC > 10 mls/kg (vital capacity)
- RR < 30 but > 5 and spontaneously breathing
- SaO2 > 90%
- ETCO2 < 50 mmHg (maybe 55-60 for COPD)
- sustained tetanic contraction with PNS
What is the process for a nearly fully awake extubation?
- Muscle relaxant fully reversed and confirmed with PNS
- All respiratory criteria are met
- Turn off anesthetic meds including VA
- suction oropharynx
- If patient is responsive to commands and can hold head lift for 5 sec, remove ETT while giving positive pressure breath
What is the process for extubation whent the patient is deeply anesthetized?
- Muscle relaxant must be fully reversed and respiratory extubation criteria met
- suction oropharynx
- insert oral or nasal airway
- remove ETT while giving positive pressure breath
- turn off VA or infusions
- mask airway while patient is spontaneously breathing
- watch vigilantly until patient can protect their own airway
What is laryngospasm and what are the signs?
- prolonged intense glottic closure
- may have high pitched squeek or no sound
- severe suprasternal and supraclavicular retractions
what triggers laryngospasm?
- secretions
- foreing body
- pain
- pelvic or abdominal visceral stimulation
- stimulating glottis under light anesthesia
- RAD
How can you prevent laryngospasm?
- Deep anesthesia before surgical stimulation starts
- Do not extubate during phase 2
- suction oropharynx prior to extubation
- remove ETT with positive pressure breath
How do you treat laryngospasm?
- Recognize the event!
- remove stimulus
- larson maneuver (jaw thrust)
- administer 100% FiO2 with continuous positive pressure
- deeper anesthetic (propofol)
- small dose of short acting muscle relaxant
- succ 20-40 mg
