Induction Emergence Flashcards
1
Q
What is an OR set up?
A
Setup:
· M- monitors
· S- suction
· M- means of PPV
· A- Airway supplied
· I- IV/ fluids
· D- drugs
P- position
2
Q
How do you set up for an airway?
A
- Appropriate sized face mask
- Means of Positive Pressure Ventilation (PPV)
- Suction on and easily accessible
- Tongue depressor
- Appropriate sized oral and nasal airways
- Appropriate sized LMA → #1 emergency airway
- Laryngoscope handle
- 2 different blades
- Male: Mac 4/ Miller 3-4
- Female: Mac 3/ Miller 2
- ETT- 2 sizes
- Male: 7.5-8.0 ID
- Female: 6.5-7.0 ID
- •Airway or surgical considerations? Reinforced tube? Nasal RAE?
- Stylet and Syringe
- Tape
- (LOST SEAL)
3
Q
Walk me through a standard induction sequence.
A
- Position patient supine in sniffing position- head on pillow neck extended
- Align external acoustic meatus to sternal notch
- Place monitors- obtain preinduction vitals
- Pre-oxygenate
- 5 minutes Fio2 >6l/min= 10 minutes safe apnea time
- Patients with reduced FRC will have decreased safe apnea time
- 4 VC breaths in 30 seconds= 5 minutes safe apnea time
- 5 minutes Fio2 >6l/min= 10 minutes safe apnea time
- Suction on and at head of bed
- Preinduction meds
- Lidocaine +/-/ induction agent
- Test lash reflex
- Give test ventilation
- Check PNS to see if working
- Continue ventilating by mask
- Paralytic drug
- Continue ventilating by mask
- Tape eyes closed
- Continue ventilation until paralytic drug takes effect
- Laryngoscopy and intubation
- Inflate ETT cuff
- Confirm ETT placement- B breath sounds, chest rise/fall, presence ETCO2 x 3
- Tape ETT
- Continue ventilation by bag or ventilator
- Begin maintenance anesthetic
4
Q
What can confirm ETT placement?
A
- Watch it pass Vocal cords
- Fogging of ETT
- Bilateral chest rise
- Bilateral breath sounds
- Presence of 3 ETCO2 waveforms
5
Q
What are some potential physiologic effects during a tracheal intubation? What can you do to mitigate those effects?
A
- Very noxious stimulus, need to be deep when intubating
- HTN and tachycardia → risk of MI!
- Laryngospasm
- Bronchospasm- especially in reactive airway dx!
- Deepen plane of anesthesia with intubaiton by using lidocaine/narcotic/additional induction agents
- Use adjuncts
- Consider prophylactic bronchodilator therapy!
6
Q
Why do we perform an RSI? What is different about an RSI induction?
A
- RSI is done for anybody that is at high risk for aspiration (trauma, pregnancy >12 weeks, uncontrolled acid reflux, hiatal hernia, etc)
- Adds the Sellick’s Maneuver and removes ventilation from the standard induction sequence
- Pre op:
- Reglan 30 min before
- Bicitra 30 min before
- • Pepcid
- • Omeprazole
- • Zantac
- Pre op:
- – Succs dose: 1.5 mg/kg
- – Roc: 1.2 mg/kg
- Ensure cricoid pressure is held once loss of consciousness—> tube placement
7
Q
You have given your patient versed, lidocaine and propofol and he is now asleep. When you go to ventilate, you are unable to see bilateral chest rise on the patient and have no ETCO2 waveform.
What are some initial interventions you can do to improve ventilation?
A
- Reposition (realign sniffing position to align oral, pharyngeal, laryngeal axis)
- Use oral airway
- Try two hands on the mask
- Difficult airway algorithm
- Plan B airway (LMA?)
8
Q
What are some extubation guidelines?
A
- · TV > 6 ml/kg
- · VC > 10 ml/kg
- · RR < 30
- · *spontaneously breathing!!!!
- · SaO2 > 90%
- · ETCO2 < 50
- · Sustained tetanic contraction with PNS
9
Q
What are some requirements to perform before an awake extubation?
A
- Check PNS: 1-2 twitches to reverse
- Reverse → sustained head lift for 5 secs
- All respiratory extubation criteria met
- OFF VA
- 100% FiO2
- Oropharynx suctioned
- Pts responsive to commands/purposeful movements
- Pt can maintain and protect own airway
- ETT removed while PP breath given
10
Q
What is the process for a deep extubation?
A
- Increase VA to 2 MAC
- Muscle relaxer fully revered and confirmed on PNS
- Expiratory criteria met
- Oropharynx suctioned
- 100% FiO2
- Oral/nasal airway inserted
- ETT removed while providing PP breath
- Turn off VA and infusions
- Mask airway maintained while pt spontaneously ventilating
- Remain vigilant until pt is responsive and maintaining own airway
11
Q
What causes an laryngospasm and what are some signs of a laryngospasm?
A
- Prolonged, intense glottic closure by contraction of lateral cricoarytenoids, thyroarytenoids, and cricothyroid muscles from stimulation of vagus nerve
- Most often occurring during emergence/induction
- Signs:
- § High pitched squeak
- § Total absence of sound
- § Suprasternal/supraclavicular indrawing
- § Decreased disaphragmatic excursions
- § Flailing of lower ribs → “rocking horse”
12
Q
What are some laryngospasm triggers?
A
Anything irritating vagus nerve!
- Secretions (vomitus, blood, saliva)
- Foreign body
- Pain
- Pelvic or abdominal visceral stimulation
- Safer to do ETT vs LMA
- Stimulating glottis in a light plane of anesthesia
- Reactive airway disease
- Loud noises – peds
13
Q
What can you do to prevent an laryngospasm?
A
- Deep extubation/awale extubation → no phase 2!
- Suctioning prior to extubation
- Deep plan of anesthesia prior to surgical stimulation
- Remove ETT on positive pressure breath
14
Q
You extubate your patient and notice a rocking horse chest movement, absence of sound, and suprasternal indrawing. What are the next steps you should take?
A
- Recognize the event!–> patient is having a laryngospasm!!
- Immediate removal of the offending stimulus
- Saliva- Suction
- Sx stim- stop it
- Larson maneuver
- Pressure behind jaw at base of ear
- Retromandibular notch/ laryngospasm notch
- condylar process of the mandibular ramus anteriorly, the mastoid process posteriorly, and the external auditory canal superiorly
- Pressure for 3-5 seconds and released for 5-10 seconds (peds)
- Administration of 100% FiO2 with continuous positive pressure
- If still good oxygenation→ 100% O2, close APL valve→ PP breath (air forces VC apart)
- Deepen anesthetic (propofol – 50 mg)
- Small dose of short acting muscle relaxant: Succinylcholine 20-40 mg
- If they do it once, probably will do it again (intubate and take care of it)
15
Q
What is a brief summary of the difficult airway algorithm?
A
(unsure if this is a likely question…)
- If intubation unsuccessful
- consider
- calling for help
- returning to spontaneous ventilation
- awakening pt
- consider
- Face mask ventailate the pt
- if not adequate–> consider LMA
- If LMA not adequate
- emergency pathway–> call for help
- Emergency non invasive airway ventilation ( Rigid bronchoscope, esophageal-tracheal ventilation, transtraheal jet ventilation)
- if failed–> emergency invasive airway access
- percutaneous trach/cricothyrotomy
- if failed–> emergency invasive airway access
