The Anesthetic Plan: Induction/Emergence Flashcards
Need to align these 3 axises?
- By adding a pillow - these 2 axises align?
- Head ___ in “sniffing position”
Oral, Pharyngeal, Laryngeal Axes
- Pharyngeal and laryngeal axes align
- extension
Induction Steps (Basic): While mask ventilating = good time to turn on the gas, keep them deep, also consider giving an \_\_\_ while you are waiting for your muscle relaxant to work.
additional narcotic
Induction Steps (Basic):
- Continue ___ while turning on gas, the higher your rate is the better your maintaining 1 MAC. Need to have enough time for your patient to get to one MAC. Other drugs helping you with surgical stimulation? While your waiting for your MAC remember to give more ___.
- When surgeon makes initial incision either nothing will happen OR HR/BP will increase –> if this occurs: Turn up gas, take them off the ventilator and hyperventilate for 60 seconds. Give more ___. Give ___.
hand ventilating opioids narcotics propofol opioid
- Patient gets cold if the flows are ? decreasing flow can decrease MAC.
- Add other gases (air, N20) so patient is not on 100% (Vicki keeps patient on 100% until they get to ?) and then she adds other gases.
Too high
One MAC
- Young, healthy people often require more ___ than usual. This is ok, give them more!
- On the other hand if you have an 80 y/o woman and no ___ in the hospital, will not give ___, essentially you are going to give her ___, ___ and ___. Her dose for propofol if she weighs 50 kg is ___, in this case give her 50 mg. If she is still awake, give it time, elderly have slow circulation. Do not want to give too much could drop her BP! If after giving her more time and still awake, could give her another ___.
- induction drugs
- etomidate
- versed
- fentanyl, lidocaine and propofol
- 50-150 mg
- half dose (25 mg)
Recall:
- Consider the time lapse since ___ was given.
- Consider the ___.
- 2 clinical signs predicting occurrence of recall?
- BIS monitoring = put on patient and when BIS monitor gets to ___ they are unconscious. Takes a few minutes.
- induction drug
- balance technique
- movement and autonomic response
- 60
Recall:
Most recall is period right before ___.
Induction is sacred as well as emergence. Try to keep the room calm and make it all about the patient.
Intubation
Rapid Sequence Induction:
- Need someone to apply cricoid pressure aka ___.
- The cricoid is the only full ring, closes the esophagus against the cervical vertebrae.
- After this induction agent and then give ___.
- After intubation and you have confirmed tracheal tube placement –> ?
- If they release too early, patient could ___, need to have ___ available.
- Sellick’s Maneuver
- Succinylcholine (wait 60 seconds total, not using PNS)
- tell assistant they can release cricoid pressure
- aspirate
- suctioning equipment
Maintenance of Anesthesia the Hypertensive Patient:
- Document - if hemodynamic instability show on record that you were addressing it during procedure!
- Give more ___, give more ___, if patient really hypertensive and tachycardic could give ___. Be very careful with use of esmolol make sure possible pain or recall issue has been addressed first prior to treating hemodynamics with esmolol!
- Unexplained tachycardia is also a tip off of possible ???
- gas
- narcotic
- esmolol
- Malignant Hyperthermia
Extubation Criteria - Respiratory Criteria:
Stop giving short acting narcotic, ask surgeon if he is going to use local at the end of the case (if yes, may not need anymore narcotic). What type of closure is occurring? Be checking twitches to make sure patient is reversible and be thinking of long term post-op pain relief.
If surgeon is going to be using local soon, can start to back off of ___. If surgeon while closing notices it is hard to close, muscles are starting to contract - can deepen with ___! Would probably do this over more ___, easier to breathe off and wake patient up with emergence.
- Inhalation agent
- gas
- muscle relaxer
Extubation Criteria - Respiratory Criteria:
Given patient NDMR and reversed it - patient needs to have a ___ - hand MUST grip for ___. This tells you enough muscles are available for patient to breathe successfully on their own post extubation. Can do a ___ and if you still get nothing, you just need to wait. Make sure you have given your reversal full time to take effect. If perform STC and patient has fade make sure you have given your FULL dose of reversal. If you do this and patient still has fade, now just need to wait.
sustained tetanic contraction
5 seconds straight
post-tetanic
Extubation Criteria - Respiratory Criteria:
If RR >30 patient could be ___ or ___. Talk to patient, let them know it is the end of the case.
Maybe consider giving patient a little ___ (a little! - 1 mg of morphine diluted in 10 cc). Slow incremental dosing is very important here!
- If they have ___ then ask them to raise their head.
- If they do not have ___ do not ask them to raise their head!
anxious or in pain
narcotic
sustained tetany
sustained tetany
Extubation Criteria - Respiratory Criteria:
- Need to have a stimulus for patient to breathe. Need to let the end tidal build up in order for their brain to say I need to start breathing again. If end-tidal is 32, consider decreasing their ___ (also could slow down their respiratory rate).
- ___ - will see tachycardia (but you need to think is this increase in HR from pain, anxiousness or medication itself).
- tidal volume
* Robinul
Extubation of the trachea may be performed while the patient is (2)??
nearly full awake
deeply anesthetized
Extubate the deeply anesthetized for a ___ to avoid ___.
*This is really preserved for the severe asthamtic! See more in peds cases than adults, but do see in adults. There is a risk for ___. But this will be a less stimulating wake up for someone with severe asthma.
severe asthmatic
bronchospasm
aspiration
