Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

N928 - Basic Principles > Intubation, Extubation, Emergence > Flashcards

Intubation, Extubation, Emergence Flashcards

1
Q

equipment for oral intubation (9)

A 
laryngoscope handle x2
laryngoscope blade x2
ETT x2 sizes, with stylet
oral airway
tongue depressor
ETT tape
suction
stethoscope
backup airway plan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

prep for intubation (9)

A
  • optimal patient position
  • OR table raised
  • adequate preoxygenation [ETO2 = 80% or 0.8]
  • anesthetic induction
  • test ventilate
  • baseline TOF
  • paralytic
  • TOF
  • tape eyes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

cuff should sit (in airway)

A

midway between cords and carina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

nasal intubation add ___ to depth

A

3-4cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

in children, advance tube until

A

2nd dark line is at or just below cords

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

ETT advance/retract with head flexion/extension

A

1.9cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

ETT movement with rotation of head

A

0.7cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

physiological responses to intubation (4)

A

CV [HTN, ↑HR or ↓HR, arrhythmias, MI]
↑IOP
↑ICP
Bronchospasm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

complications DURING laryngoscopy/intubation (12)

A 
dental injury
tissue injury
c-spine injury
damage to ETT cuff
esophageal intubation
submucosal dissection
bleeding
laryngospasm/bronchospasm/coughing
aspiration
eye injury
CV changes
hypoxemia & hypercarbia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

complications OF laryngoscopy/intubation (5)

A 
upper airway edema
glottic / subglottic granulation tissue → tracheal stenosis
vocal cord dysfunction
vocal cord granuloma
arytenoid dislocation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

contraindications for DEEP extubation (3)

A
  1. difficult airway
  2. risk of aspiration
  3. surgery that may produce airway edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

objective extubation criteria (6)

A 
vital capacity >15ml/kg
Pnegative InspP >25cm/H2O
TV >6ml/kg
sustained tetanic contraction
SpO2>90% (PaO2 >60mmHg)
RR <35
PaCO2 <45
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

subjective extubation criteria (6)

A
  • follows commands
  • clear airway
  • intact gag
  • sustained head lift 5sec, sustained grasp
  • adequate pain control
  • minimal end exp concentration of inhaled anesthetic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

extubation process (6)

A

100% O2
Suction oral/hypopharynx
Close APL
Deflate cuff; do not pull pilot balloon away from inflation tube
Remove ETT while applying positive pressure on bag
Apply positive pressure & 100% with FM immediately following extubation

*be ready to re-establish airway if necessary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

causes of ventilatory compromise during extubation (9)

A
  • residual anesthetic
  • poor central resp effort
  • ↓ respiratory drive
  • ↓ upper airway tone
  • ↓ gag/cough reflex
  • airway edema/compromise
  • vocal cord paralysis
  • laryngospasm
  • bronchospasm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

ACUTE complications after extubation (7)

A
  • laryngospasm
  • vomiting
  • aspiration
  • sore throat
  • hoarseness
  • laryngeal edema
  • subglottic edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

CHRONIC complications after extubation (5)

A
  • mucosal ulceration
  • tracheitis
  • tracheal stenosis
  • vocal cord paralysis
  • arytenoid cartilage dislocation → flaccid cords & airway edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

challenges with immediate reintubation (10)

A
  • known difficult airway
  • surgical distortion
  • limited access
  • edema
  • uncooperative/combative patient
  • emergent nature
  • blood/secretions
  • poor oxygenation/ventilation
  • occurrence during transport
  • unavailability of equipment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

nasal intubation indication (2)

A
  • maxillofacial or mandibular surgery

- oral/dental surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

nasal intubation contraindications (5)

A
  • coagulopathy
  • basilar skull fx
  • severe intranasal disorder
  • CSF leak
  • extensive facial fx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

equipment needed for nasal intubation (4 new, 12 total)

A 
laryngoscope handle x2
laryngoscope blade x2
oral airway
tongue depressor
NTT tape
suction
stethoscope
backup airway plan
*nasal airways
*neosynephrine spray
*Nasal tubes x2
*Magill Forceps
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

nasal intubation complications (5)

A
  • epistaxis
  • trauma
  • displaced adenoids or polyps → bleed → airway obstruction
  • bacteremia
  • sinusitis [with long term intubation]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Causes of inability to ventilate (5)

A
  • Laryngospasm [nerve injury, light anesthesia]
  • Supraglottic soft-tissue relaxation [tongue, epiglottis, soft palate, pharyngeal walls]
  • Chest wall rigidity [drug induced, breath holding]
  • Pathologic, glottic, subglottic [foreign body, edema, infx, vocal cord palsy, stenosis, compression]
  • Equipment failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q 
ILMA sizes
(intubating LMA)
A

Sizes 3, 4, 5

ETT up to 8.0 ID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Retrograde Intubation

A

18g through cricothyroid membrane → cephalad at 45 degree angle

  • thread J-wire through needle & out through mouth
  • follow ETT over guidewire & into trachea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Endotracheal intubation indications/procedures (8)

A
  • aspiration risk
  • head/neck procedures
  • intracranial procedures
  • intrathoracic procedures
  • intraabdominal procedures
  • procedures requiring mechanical ventilation
  • airway anomalies
  • positioning where airway is unavailable to anesthesia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

How ETT sized

A

internal diameter

2.5mm - 9.0mm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

ETT material

A

polyvinyl chloride (PVC)

American Society for Testing Materials (ASTM) Standard 21 applied to ETT construction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Size & depth

A

Men: 8.0 or 9.0 @ 24-26cm at lip
Women: 7.0 or 8.0 @ 20-22 cm at lip

Children:
Size- (4 + age) / 4
Depth- (12 + age) / 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

recommended ETT cuff inflation pressure & tracheal perfusion pressure

A

20-25mmHg

25-30mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

uncuffed ETT used in children < X age

air leak should be heard @ ____

A

in children <8yr old

airleak @ 15-20cmH2O

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Prep of ETT:
secure ______
insert/shape _____
Check _____

A
  1. 15mm adaptor connection
  2. stylet
  3. check cuff
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Laryngoscope blades:

A

MacIntosh (valleculae) [size 1-4]

Miller (lifts epiglottis) [size 0-4]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

AIRWAY MANAGEMENT PEARLS (10)

A
  1. take a careful history
  2. perform detailed assessment
  3. carefully plan for intubation, extubation & backup plans
  4. learn & repeatedly practice ALL airway management skills
  5. YOU CANNOT BEAT A GOOD VIEW
  6. Do not give wakefulness, spontaneous ventilation, or muscle tone away lightly
  7. New techniques should demonstrate superiority over existing options – sometimes the old way is better
  8. Don’t be afraid to stop and come back another day.
  9. If time runs out, be definitive and oxygenate
  10. Be aware of your own skills, be willing to call for help!
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

“Smooth” intubation avoids:

A
  1. Coughing
  2. Bucking
  3. Straining
  4. Hypertension
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

additional risks of emergence when not “smooth” (6)

A
  1. suture rupture
  2. wound dehiscence
  3. hemorrhage
  4. increased ICP
  5. increased IOP
  6. edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

NMB Monitoring Face Nerve

A

orbicularis oculi

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

NMB Monitoring Ulnar Nerve

A

adductor pollicis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

NMB Monitoring Posterior Tibial Nerve

A

flexor hallucis brevis

40
Q

twitches & estimation of NMB (6)

A 
# = block
0 = 100%
1 = 95%
2 = 90-95%
3 = 80-85%
4 = 75-80%
41
Q

NMB Reversal Agents

A

anticholinesterase inhibitor + anticholinergic

Neostigmine + Glycopyrrolate
Pyridostigmine + Glycopyrrolate
Edrophonium + Atropine

*coupled by onset of action

42
Q 
Neostigmine dose
(Prostigmine)
A

0.05mg/kg

43
Q

Neostigmine onset

A

1-3 min

44
Q

Neostigmine peak

A

5-7 min

45
Q

Neostigmine duration

A

20-30 min

46
Q

Neostigmine co-administered drug

A

glycopyrrolate

47
Q

Edrophonium dose

A

1mg/kg

48
Q

Edrophonium onset

A

1-2 min

49
Q

Edrophonium duration

A

10 min

50
Q

Edrophonium peak

A

1-2 min

51
Q

Edrophonium co-administered drug

A

Atropine

52
Q 
Pyridostigmine dose
(Regonal)
A

0.1-0.2 mg/kg

53
Q

Pyridostigmine onset

A

2-5min

54
Q

Pyridostigmine peak

A

5-15min

55
Q

Pyridostigmine duration

A

90min

56
Q

Pyridostigmine co-administered drug

A

glycopyrrolate

57
Q

How do you know it is time to extubate?

2

A
  1. talk to your patient
  2. what is the end tidal concentration of volatile?
    - how to “wash out”? [increase flow, nitrous towards end of case?]
58
Q

time to end volatile agent depends on (3)

A
  1. BGPC - blood gas partition coefficient / patient’s adipose
  2. RR (spontaneous?)
  3. speed of closure of surgical site
59
Q

considerations prior to extubation (11)

A
  1. TOF 4/4 with sustained tetany 50-100Hz >5 seconds without fade
  2. TOF ratio >0.7
  3. 5 second head lift
  4. strong, bilateral grip (near baseline)
  5. follows commands
  6. Regular, spontaneous RR
  7. TV ~6ml/kg
  8. Airway reflexes intact
  9. Hemodynamically stable
  10. Normothermic >35.5
  11. duration of surgery & possible considerations (ie. edema, should patient be extubated?)
60
Q

Advantages of deep extubation (3)

A
  • decreased coughing/bucking/straining
  • avoids possible prolonged stress while waking up
  • useful with: hernia repair, tympanoplasty, asthmatics, smokers, open globe surgery
61
Q

disadvantages of deep extubation

A
  • increased incidence of upper airway obstruction

- aspiration

62
Q

DEEP extubation SHOULD occur when: (8)

A
  1. the pt is NOT in stage 2
  2. pt has surgical level of anesthesia; depressed airway reflexes
  3. no response to suctioning of oropharynx (usually >1 MAC)
  4. spontaneous respirations
  5. ETCO2 <45
  6. TV maintains >90% SpO2
  7. no residual paralysis (sustained tetany >5 seconds)
  8. surgical stimulation ceases
63
Q

stage 1 of awareness

A

conscious awareness with explicit recall

64
Q

stage 2 of awareness

A

Conscious awareness with no explicit recall

65
Q

stage 3 of awareness

A

subconscious awareness with implicit recall (Planes 1-4)

66
Q

stage 4 of awareness

A

no awareness or recall

67
Q

When do I turn off volatile anesthetic?

Dependent upon:

A
  • Vent rate/volume
  • FGF
  • Concentration gradient
  • amount of patient stimulation
68
Q

Post extubation goal*

A

patient to sustain adequate TV sufficient to maintain sat >94%

69
Q

FAST wake up (2)

A 
hyperventilation (↑ speed of wash-out)
high FGF (↑ speed of wash-out)
70
Q

SLOW wake up (2)

A

hypoventilation

low FGF

71
Q

ideal anesthetic techniques focuses on 4 things:

A
  1. patient safety & satisfaction
  2. provides excellent operating conditions for the surgeon
  3. allow rapid recovery
  4. avoid post op side effects
72
Q

goals during maintenance of anesthesia (4)

A
  1. amnesia
  2. analgesia
  3. skeletal muscle relaxation
  4. control SNS reponses
73
Q

locations of regional anesthesia (4)

A
  • spinal
  • epidural
  • caudal
  • peripheral nerve block
74
Q

spinal vs epidural

A

spinal:

  • takes less time to perform
  • more rapid onset; better quality sensory & motor anesthesia
  • associated with less pain during surgery

epidural:

  • lower risk for post-dural headache
  • less systemic hypotension
  • ability to prolong anesthesia
  • option of using catheter to prolong delivery of post-op analgesia
75
Q

ETT markings

A

marking F-29, Z-79, I.T.

means it has been tested & no toxicity

76
Q

epidural pros (4)

A
  • lower risk for post-dural headache
  • less systemic hypotension
  • ability to prolong anesthesia
  • option of using catheter to prolong delivery of post-op analgesia
77
Q

spinal pros (3)

A
  • takes less time to perform
  • more rapid onset; better quality sensory & motor anesthesia
  • associated with less pain during surgery
78
Q

how to get oral pharynx to align with naso/pharyngeal axis

A

head extension

79
Q

how to get nasopharynx & laryngopharynx aligned

A

lift head (pillow)

80
Q

How to prepare for smooth emergence/extubation (6)

A
  1. begin plan pre-op
  2. carefully select meds & dosages
  3. choose agents with appropriate DOA, based on pt and surgery
  4. “less is more”
    • avoid excess pre-meds
    • eliminate or decrease dose of pre-meds
  5. consider combining anesthetic techniques
  6. recall pharmacology:
    - dose
    - onset
    - duration
    - peak effect
81
Q

zero twitches = ___ of receptors blocked

A

100%

82
Q

one twitch = ___ of receptors blocked

A

95%

83
Q

two twitches = ___ of receptors blocked

A

90-95%

84
Q

three twitches = ___ of receptors blocked

A

80-85%

85
Q

four twitches = ___ of receptors blocked

A

75-80%

86
Q

timing of NMBD reversal factors (4)

A
  1. spontaneous resp effort?
  2. # of twitches [can reverse with 1 twitch]
  3. timing/last dose of paralytic?
  4. when will reversal peak?
87
Q

objective vital capacity for extubation

A

> 15mL/kg

88
Q

objective Pnegative InspP >25cm/H2O for extubation

A

> 25cmH2O

89
Q

objective TV for extubation

A

> 6mL/kg

90
Q

NMBD monitoring assessment for extubation

A

sustained tetanic contraction

91
Q

objective SpO2 for extubation

with PaO2 > _____

A

> 90%

with PaO2 > 60mmHg

92
Q

objective RR for extubation

A

<35

93
Q

objective PaCO2 for extubation

A

<45mmHg

94
Q

TOF assessment extubation criteria

A
  1. TOF 4/4 with sustained tetany 50-100Hz >5 seconds without fade
  2. TOF ratio >0.7
95
Q

Tetany tested at ____ Hz

A

50-100Hz

N928 - Basic Principles (22 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions