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
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
3
Q
cuff should sit (in airway)
A
midway between cords and carina
4
Q
nasal intubation add ___ to depth
A
3-4cm
5
Q
in children, advance tube until
A
2nd dark line is at or just below cords
6
Q
ETT advance/retract with head flexion/extension
A
1.9cm
7
Q
ETT movement with rotation of head
A
0.7cm
8
Q
physiological responses to intubation (4)
A
CV [HTN, ↑HR or ↓HR, arrhythmias, MI]
↑IOP
↑ICP
Bronchospasm
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
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
11
Q
contraindications for DEEP extubation (3)
A
- difficult airway
- risk of aspiration
- surgery that may produce airway edema
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
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
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
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
16
Q
ACUTE complications after extubation (7)
A
- laryngospasm
- vomiting
- aspiration
- sore throat
- hoarseness
- laryngeal edema
- subglottic edema
17
Q
CHRONIC complications after extubation (5)
A
- mucosal ulceration
- tracheitis
- tracheal stenosis
- vocal cord paralysis
- arytenoid cartilage dislocation → flaccid cords & airway edema
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
19
Q
nasal intubation indication (2)
A
- maxillofacial or mandibular surgery
- oral/dental surgery
20
Q
nasal intubation contraindications (5)
A
- coagulopathy
- basilar skull fx
- severe intranasal disorder
- CSF leak
- extensive facial fx
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
22
Q
nasal intubation complications (5)
A
- epistaxis
- trauma
- displaced adenoids or polyps → bleed → airway obstruction
- bacteremia
- sinusitis [with long term intubation]
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
24
Q
ILMA sizes (intubating LMA)
A
Sizes 3, 4, 5
ETT up to 8.0 ID
25
Retrograde Intubation
18g through cricothyroid membrane → cephalad at 45 degree angle
- thread J-wire through needle & out through mouth
- follow ETT over guidewire & into trachea
26
Endotracheal intubation indications/procedures (8)
- aspiration risk
- head/neck procedures
- intracranial procedures
- intrathoracic procedures
- intraabdominal procedures
- procedures requiring mechanical ventilation
- airway anomalies
- positioning where airway is unavailable to anesthesia
27
How ETT sized
internal diameter
| 2.5mm - 9.0mm
28
ETT material
polyvinyl chloride (PVC)
American Society for Testing Materials (ASTM) Standard 21 applied to ETT construction
29
Size & depth
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
30
recommended ETT cuff inflation pressure & tracheal perfusion pressure
20-25mmHg
25-30mmHg
31
uncuffed ETT used in children < X age
air leak should be heard @ ____
in children <8yr old
| airleak @ 15-20cmH2O
32
Prep of ETT:
secure ______
insert/shape _____
Check _____
1. 15mm adaptor connection
2. stylet
3. check cuff
33
Laryngoscope blades:
MacIntosh (valleculae) [size 1-4]
| Miller (lifts epiglottis) [size 0-4]
34
AIRWAY MANAGEMENT PEARLS (10)
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!
35
"Smooth" intubation avoids:
1. Coughing
2. Bucking
3. Straining
4. Hypertension
36
additional risks of emergence when not "smooth" (6)
1. suture rupture
2. wound dehiscence
3. hemorrhage
4. increased ICP
5. increased IOP
6. edema
37
NMB Monitoring Face Nerve
orbicularis oculi
38
NMB Monitoring Ulnar Nerve
adductor pollicis
39
NMB Monitoring Posterior Tibial Nerve
flexor hallucis brevis
40
twitches & estimation of NMB (6)
```
# = block
0 = 100%
1 = 95%
2 = 90-95%
3 = 80-85%
4 = 75-80%
```
41
NMB Reversal Agents
anticholinesterase inhibitor + anticholinergic
Neostigmine + Glycopyrrolate
Pyridostigmine + Glycopyrrolate
Edrophonium + Atropine
*coupled by onset of action
42
```
Neostigmine dose
(Prostigmine)
```
0.05mg/kg
43
Neostigmine onset
1-3 min
44
Neostigmine peak
5-7 min
45
Neostigmine duration
20-30 min
46
Neostigmine co-administered drug
glycopyrrolate
47
Edrophonium dose
1mg/kg
48
Edrophonium onset
1-2 min
49
Edrophonium duration
10 min
50
Edrophonium peak
1-2 min
51
Edrophonium co-administered drug
Atropine
52
```
Pyridostigmine dose
(Regonal)
```
0.1-0.2 mg/kg
53
Pyridostigmine onset
2-5min
54
Pyridostigmine peak
5-15min
55
Pyridostigmine duration
90min
56
Pyridostigmine co-administered drug
glycopyrrolate
57
How do you know it is time to extubate?
| 2
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
time to end volatile agent depends on (3)
1. BGPC - blood gas partition coefficient / patient's adipose
2. RR (spontaneous?)
3. speed of closure of surgical site
59
considerations prior to extubation (11)
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
Advantages of deep extubation (3)
- decreased coughing/bucking/straining
- avoids possible prolonged stress while waking up
- useful with: hernia repair, tympanoplasty, asthmatics, smokers, open globe surgery
61
disadvantages of deep extubation
- increased incidence of upper airway obstruction
| - aspiration
62
DEEP extubation SHOULD occur when: (8)
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
stage 1 of awareness
conscious awareness with explicit recall
64
stage 2 of awareness
Conscious awareness with no explicit recall
65
stage 3 of awareness
subconscious awareness with implicit recall (Planes 1-4)
66
stage 4 of awareness
no awareness or recall
67
When do I turn off volatile anesthetic?
| Dependent upon:
- Vent rate/volume
- FGF
- Concentration gradient
- amount of patient stimulation
68
Post extubation goal*
patient to sustain adequate TV sufficient to maintain sat >94%
69
FAST wake up (2)
```
hyperventilation (↑ speed of wash-out)
high FGF (↑ speed of wash-out)
```
70
SLOW wake up (2)
hypoventilation
| low FGF
71
ideal anesthetic techniques focuses on 4 things:
1. patient safety & satisfaction
2. provides excellent operating conditions for the surgeon
3. allow rapid recovery
4. avoid post op side effects
72
goals during maintenance of anesthesia (4)
1. amnesia
2. analgesia
3. skeletal muscle relaxation
4. control SNS reponses
73
locations of regional anesthesia (4)
- spinal
- epidural
- caudal
- peripheral nerve block
74
spinal vs epidural
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
ETT markings
marking F-29, Z-79, I.T.
| means it has been tested & no toxicity
76
epidural pros (4)
- 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
spinal pros (3)
- takes less time to perform
- more rapid onset; better quality sensory & motor anesthesia
- associated with less pain during surgery
78
how to get oral pharynx to align with naso/pharyngeal axis
head extension
79
how to get nasopharynx & laryngopharynx aligned
lift head (pillow)
80
How to prepare for smooth emergence/extubation (6)
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
zero twitches = ___ of receptors blocked
100%
82
one twitch = ___ of receptors blocked
95%
83
two twitches = ___ of receptors blocked
90-95%
84
three twitches = ___ of receptors blocked
80-85%
85
four twitches = ___ of receptors blocked
75-80%
86
timing of NMBD reversal factors (4)
1. spontaneous resp effort?
2. # of twitches [can reverse with 1 twitch]
3. timing/last dose of paralytic?
4. when will reversal peak?
87
objective vital capacity for extubation
>15mL/kg
88
objective Pnegative InspP >25cm/H2O for extubation
>25cmH2O
89
objective TV for extubation
>6mL/kg
90
NMBD monitoring assessment for extubation
sustained tetanic contraction
91
objective SpO2 for extubation
with PaO2 > _____
>90%
with PaO2 > 60mmHg
92
objective RR for extubation
<35
93
objective PaCO2 for extubation
<45mmHg
94
TOF assessment extubation criteria
1. TOF 4/4 with sustained tetany 50-100Hz >5 seconds without fade
2. TOF ratio >0.7
95
Tetany tested at ____ Hz
50-100Hz
