Session 11 Flashcards
normal induction sequence (3)
pre-op
induction
extubation
8 phases of induction
anxiolysis
pt to room/table
monitors attached
pre-oxygenated
anesthetic time out
induction
airway management
prepare for incision
anxiolysis
fear
anxiolysis medications
versed (1-2mg up to 4mg)
fentanyl (25-50mcg)
versed should not be given to
elderly pts
progresses dementia/alzheimers
move to operating table
do not let IV get pulled out
move to operating table steps
- untie knots
- lock gurney and table
- pt move over
- ensure pt doesnt move too far
- secure pt w/belt
monitors
1) NIBP (3-5 min inter)
2) EKG (5 lead std)
3) pulse ox (iv arm ring)
4) temp
5) capnography (tight seal on mask, have pt exhale forcefully)
6) O2 analyzer (w/cap)
7) PNS (post induction)
Pre-Oxygenation
flush out nitrogen in alveoli
maximally saturate the hemoglobin/blood w/O2
denitrogenation
Situations where hypoxia can quickly occur
- supine obese pts
- sedation (drug induced)
- paralysis
PreOx Method: Tidal Volume Ventilation
*most effective
vol of air inhaled and exhaled w/normal breathing
3+ mins w/good seal
PreOx Method parameters
FiO2 100%
O2 10-12L/min
open APL valve
facemask seal
PreOx Method: Vital Capacity Ventilation
max vol of gas that can be exhaled following maximal inspiration
4 breaths over 30 sec
or
8 breaths over 60 sec
PreOx issues
claustrophobic pts
blow by technique w/higher %O2
or
have pt hold mask
How do we confirm pre-Ox successful?
EtO2 > 85%
SpO2 (not perfect measurement)
Anesthesia Time Out Steps (8)
- Name/Dob/Surgery
- allergies
- pre-op meds/proceds
- Plan
- general vs MAC
- LMA vs ETT
- suction, O2, monitors, vaporizers
- Additional procedures
- sequential compression devices
- misc items
induction overal steps (14)
- Pt head tilt/chin lift
- give meds
- confirm asleep verbal
- eyelid reflex test
- test ventilate
- tape eyes
- paralytic
- DL or LMA
- Ventilator
- Volatile agent
- reduce fresh gas flw
- tem p probe/PNS
- Position accordingly
- warming device
how to speed up induction speed
increase %
increase FGF
increase RR or TV (increase minute vent)
additional procedures to perform post inductions
PIV
A Line
Central Line
Foley
Block
sequential compression device prevent
DVT
common induction medications
fentanyl
lidocaine
propofol
rocuronium(post reflex check)
fentanyl onset
3-7 mins
fentanyl alleviates
alleviates sympathetic response to intubation
lidocaine induction effect
helps attentuate sting of propofol
lg doses reduce airway reflexes
lidocaine mechanism
Na+ antagonist
blocks nerve impulses
propofol effect
stings
high-lipid solubility
== fast speed
rocuronium onset
90-120 seconds to flow through entire body circulations
verbally test pt unconsciousness
ask pt to:
take deep breath
open eyes
etc
test eyelid reflex
rub eyelashes
test ventilate
Manual Mode
checking to see if mask ventilation is possible
test ventilate confirmation phrase
“I can mask ventilate this pt, you may paralyze”
test ventilation considerations
avoid corneal abrasion
CE mask technique
if test vent is difficult w/good mask seal
add an oral airway
if test vent is difficult w/oral airway
use 2 hand technique
ask preceptor/attending to help squeeze bag
tape eye process
tape upper eyelid first
use tape pulldown
seal
when do you paralyze
after you confirm that pt is unconscious and that pt can mask ventilate
Old drug to reverse rocuronium
neostigmine
if reversing Roc w/neostigmine how long do you have to wait to give neostigmine?
30 mins post-Roc
what drug immediately reverses rocuronium
suggamadex
prepare for incision (8 steps)
IV functioning/drip rate
position appropriate
muscle paralysis
airway/circuit clear
vent/flow/agent good
monitors/vitals good
analgesia adequate
antibiotics given
RSI
rapid sequence induction (RSI)
RSI goal
reduce risk of pulmonary aspiration of gastric content
RSI indications (9)
pt not achieved NPO
emergency
delayed gastric empty
pregnant
vomiting
+/- airway concerns
H/O gastric bypass
uncontrolled GERD
symptom hiatal hernia
RSI AKA
rapid sequence induction and intubation (RSII)
RSI steps (10)
Equipment ready
NG tube suction
PreOxygenate
Cricoid pressure (10N)
Induce
Paralyze
Cricoid pressure (30N)
Intubate (no twitches)
Confirm CO2
Release Cricoid
what do you skip during RSI?
Do not mask ventilate
RSI relative contraindications
avoidance increase ICP
avoidance increase BP/HR
what can cause ICP
unstable aneurysm
Arguments against cricoid pressure
induce lower esophageal sphincter relaxation (vomiting)
displace larynx
incorrect manipulation
induces nausea
Modified RSI
need for RSI
limitation exist that preclude proper RSI
Modified RSI indications
risk of rapid hypoxemia
lack of time to pre-ox
how is a modified RSI different?
ventilate w/mask prior to intubation
what pressure do you ventilate w/during modified RSI?
<20cmH20
RSI quick data
pre-oxygenation
cricoid pressure
avoid mask vent
Modified RSI quick data
possibly different NMBD
different NMBD timing
PPV prior to intubation
cricoid pressure timing
Induction Overview Steps (16)
pt into OR
time “it is 0730”
click EMR buttons
assist pt to table
monitors
pre-ox
verify/secure ETT/LMA
additional procedures
position pt
confirm monitor/line functioning
warming device
anesthesia ready
Abx (surgeon arrives)
Surgical Time Out
Surgery begins
EMR buttons once pt in OR - St Lukes
anesthesia start
in room
start data collection
EMR buttons once pt in OR - liberty
anesthesia start
fill in OR room time
auto vital
appropriate MACH
EMR Pre-Ox buttons - St Lukes
Pt chart reviewed
Time out
Pre OX
EMR Pre-Ox buttons - Liberty
pt evaluated
preoxygenation
call attending
EMR buttons post-ETT - St Lukes
induction
RSI/Cricoid
Intubation
LMA applied
EMR buttons post-ETT - Liberty
Induction
EMR buttons - anesthesia ready - St Lukes
anesthesia Ready
EMR buttons surgery starts - St Lukes
Surgery Starts
