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Intro to Anesthesia Summer 18 > L2: Induction and Emergence > Flashcards

L2: Induction and Emergence Flashcards

1
Q

What do you need to have set up prior to pt arrival?

A 
M-Monitors and alarms set
S-Suction on and adequate
M-Means of PPV/Machine check
A-Airway (ETT/LMA)
I-IV and fluids
D-Drugs: emergency and basic 
P-Patient position
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2
Q

Airway Set up

A

“LOST SEAL”

L- LMA (appropriately sized)
O- Oral/Nasal airway (appropriately sized)
S- Suction (on and accessible)
T- Tape and Tongue depressor

S- Stylet and Syringe
E- ETT 2
A- Ambu bag/ PPV/ Circuit
L- Laryngoscope handle and 2 blades

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3
Q

Blade sizes

A

Male: Mac 4/ Miller 3-4
Female: Mac 3/ Miller 2

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4
Q

ETT sizes

A

Male 7.5-8 mm ID

Female 6.5-7 mm ID

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5
Q
  1. Standard Induction Prep
A

Position- supine sniffing
Place monitors-preinduction vitals
Preoxygenate- >6L 100% FiO2
-3-5mins normal breathing = 10mins safe apnea time
-4 VC breaths in 30secs = 5mins safe apnea time

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6
Q
  1. Induction Medications
A

Consider co-morbidities, dose, on-set, and duration of action

  1. Anti-anxiety (Versed, Ativan, Valium)
  2. Narcotic (Fentanyl/Dilaudid/Morphine/Demerol)
  3. Lidocaine
  4. Induction agent (Propofol/Etomidate/Ketamine/Thiopental)
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7
Q
  1. Induction meds given, now what?
A
  1. Confirm LOC eyelash reflex
  2. Test ventilate
    - Re-position
    - Oral Airway
    - Two hand masking
    - Difficult airway algorithm
    - Plan B airway
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8
Q
  1. We can ventilate, whats next?
A
  1. Apply PNS, check baseline twitches
  2. NMB- think co-morbidities, dose, on-set, and duration. Consider sugery, surgeon desire/need for paralysis, length of procedure. (Succ/Roc/Vec/Atracurium/Cistracurium/Pancuronium
  3. Monitor effectiveness with PNS
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9
Q
  1. While waiting for Paralysis…
A
  1. Cont’ to ventilate pt
  2. Tape eyes
  3. PNS- no twitches
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10
Q
  1. Steps after patient is paralyzed
A
  1. Laryngoscopy with tracheal intubation
  2. Confirm ETT placement
  3. Tape ETT- dept approx ID x3
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11
Q
  1. Steps after Intubation
A
  1. Continue to ventilate (hand or vent)
  2. Adjust flows
  3. Add gases (air/N2O)
  4. Start anesthetic infusion (TIVA)
  5. Add volatile anesthetic (Des/Sevo/Iso)
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12
Q

Concerns with Induction

A
  1. Duration of action of induction agent in relation to onset of NMB
  2. May need additional induction drug
  3. Use inhalational agent during ventilation
  4. BIS monitoring
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13
Q

Concerns with Induction regarding intubation

A
  1. HTN, Tachycardia = Myocardial ischemia
  2. Laryngospasm
  3. Bronchospasm
  4. Deepen plane of anesthesia by lidocaine/narcs/ induction agent
  5. Consider bronchodilator therapy
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14
Q

Standard Induction Review

A
  1. Position patient supine in sniffing position
  2. Turn on oxygen flow
  3. Pre-oxygenation
  4. Monitors on and vital signs taken (O2 sat, BP, ECG, PNS in place)
  5. Suction on and ready
  6. Pre-induction medications
  7. Lidocaine (+/-)/ Induction agent
  8. Test Lash Reflex
  9. Give Test ventilation
  10. Check PNS working
  11. Continue ventilating by mask
  12. Paralytic drug
  13. Continue ventilating by mask
  14. Tape eyes closed
  15. Continue ventilation until paralytic drug takes effect (loss of twitches)
  16. Laryngoscopy and intubation
  17. Inflate ETT cuff
  18. Confirm ETT placement—bilateral breath sounds, chest rise and fall, presence of ETCO2 x 3 waveforms
  19. Tape ETT
  20. Continue ventilation by bag or ventilator
  21. Begin maintenance anesthetic
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15
Q

What is RSI?

A

Airway management technique that induces immediate unresponsiveness and muscular relaxation and is the fastest and most effective means of controlling the emergency airway

  • used in situations of full stomachs: aspiration risk
  • adds the Sellick’s Maneuver and removes ventilation from the standard induction sequence
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16
Q

RSI steps

A
  1. Identify patient in need of RSI
  2. Pre-operative prophylaxis for aspiration (Bicitra/Reglan/Omeprazole/Pepcid or Zantac)
  3. Anxiolytic
  4. Narcotic (avoid loss of consciousness to early)
  5. Monitors on
  6. Suction on and at head of bed
  7. Supine-sniffing position
  8. Pre-oxygenate
  9. Sellick’s maneuver= cricoid pressure –gradually increase pressure as patient falls asleep
  10. Induction agent (Succinylcholine or high dose Rocuronium) wait for fasciculation or 60 seconds (watch the clock- not the block)
  11. Laryngoscopy
  12. Tracheal intubation
  13. Confirmation placement
  14. Give assistant permission to release cricoid pressure
  15. Secure ETT
  16. Ventilate or turn on ventilator
  17. Tape eyes
  18. Adjust flows
  19. Begin maintenance anesthetic
17
Q

Maintenance Phase of Anesthesia

A
  • Period of time that starts at the end of induction.
  • Technique varies based on the pt’s comorbidities and surgical procedure.
  • Inhalational agent
  • TIVA
  • Short/long acting narcs
  • Paralysis throughout or just induction?
18
Q

Extubation Guidelines

A

Can be done nearly fully awake or deeply anesthesetized. NOT IN BETWEEN.
-Must evaluate the relative risk (coughing, obstruction, aspiration) when choosing awake or asleep

19
Q

Extubation Criteria

A

Resp Criteria:

  • TV >6mls/kg
  • VC >10 mls/kg
  • RR <30 breaths/min (must be spontaneously breathing)
  • SaO2 >90%
  • ETCo2 <50 mmHg
  • Sustained tetanic contractions with PNS
20
Q

Nearly Fully Awake

A
  1. Muscle relaxant fully reversed and confirmed with PNS (if applicable)
  2. All respiratory extubation criteria have been met
  3. Anesthetic medications including volatile agents and infusions turned off
  4. Oropharynx suctioned
  5. Patient is responsive to commands/purposeful movement
  6. Sustained (5 second) head lift indicates clinically adequate reversal of NMB
  7. Patient can maintain and protect own airway
  8. ETT removed while positive pressure breath is given
21
Q

Deep Extubation

A
  1. Muscle relaxant fully reversed and confirmed with PNS (if applicable)
  2. All respiratory extubation criteria have been met
  3. Oropharynx suctioned
  4. Oral or nasal airway may be inserted
  5. ETT removed while positive pressure breath is given
  6. Volatile agents or infusions turned off
  7. Mask airway maintained while patient spontaneously ventilating
  8. Remain vigilant until patient is responsive and maintaining own airway
22
Q

Laryngospasm

A
  1. Prolonged intense glottic closure
  2. May present with high pitched squeak to total absence of sound (ominous sign)
  3. Suprasternal and supraclavicular in-drawing, increased diaphragmatic excursions, and flailing of the lower ribs resembling a “rocking horse”
  4. Caused by the contraction of the lateral cricoarytenoids, thyroarytenoids, and the cricothyroid muscles from stimulation of the vagus nerve
  5. Most often seen during induction and emergence
23
Q

Laryngospasm Trigger

A
  • Secretions (vomitus, blood, saliva)
  • Foreign body
  • Pain
  • Pelvic or abdominal visceral stimulation
  • Stimulating glottis in a light plane of anesthesia
  • Reactive airway disease
24
Q

Laryngospasm Prevention

A
  • 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
25
Q

Laryngospasm Treatment

A
  • Recognize the event!
  • Immediate removal of the offending stimulus
  • Larson maneuver: 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
  • Administration of 100% FiO2 with continuous positive pressure
  • Deepen anesthetic (propofol)
  • Small dose of short acting muscle relaxant: Succinylcholine 20-40 mg
26
Q

How to confirm placement of ETT?

A
  • Watch it pass the vocal chords
  • Fogging of ETT
  • Bilateral chest rise
  • Bilateral breath sounds
  • Presence of three ETCo2 waveforms

Intro to Anesthesia Summer 18 (5 decks)

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