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Flashcards in Induction and Emergence Deck (24)
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What does MSMAID (P) stand for?

  • Monitors on and alarms set
  • Suction on and adquate/nearby
  • Means of PPV (machine check
  • Airway (LMA/ETT)
  • IV and fluids
    • 2nd IV kid
    • fluid warmer/albumin/blood if needed
  • Drugs- emergency and basic
  • P-patient position


Airway setup?

  1. Appropraite sized face mask
  2. means PPPV
  3. suciton on and accessible
  4. tongue depressor
  5. appropriate sized oral and nasal airways
  6. appropriate sized LMA
  7. laryngoscope handle
  8. 2 diff blades
    • male mac 4/miller 3-4
    • female mac 3/miller 2
  9. ETT 2 sizes
    • male 7.5-8
    • female 6.5-7
    • any sx consideration? laser, nasal intubation, reinforced ETT
  10. Sylet and syringe
  11. tape


Once you get patient on OR table, what should you ask patient to do?

Go into sniffing position- makes sure they're able to without pain/discomfort


How do you preoxygenate the patient?

  • 5 min 100% Fio2 >6L flow= 10 minutes safe apnea time
  • 4 vital capacity breaths in 30 seconds= 5 min safe apnea time


If patient obese, how can you ensure the ramping is high enough?

External acoustic meatus lined with sternal notch= good indicator that axis aligned


What are some standard induciton meds used?

  • Antianxiety med
    • versed/ativan/valium
  • Narcotic
    • fentanyl/dilaudid/morphine/demerol
  • Consider use lidocaine- blunt SNS 1mg/kg
  • Induction agent
    • propofol 1-2.5 mg/kg, less in edlerly, more in peds (3mg/kg)
    • Etomidate 0.2-0.6 mg/kg
    • Ketamine 1-2 mg/kg
      • taumra, sponaneous ventilation maintained
      • avoid- ICU or someone that can't handle SNS response


Once you give induciton meds, now what?

  • Test reflexes with eyelash reflex
  • test ventilate!!
    • troubleshoot:
    • reposition
    • use oral airway
    • two hands on mask
    • difficult airway algorithm
    • plan b airway


What can you insert if you're unable to ventilate the patient?



If we can ventilate patient after induction meds, what is the next step?

  • Apply PNS and check baseline twitches
  • administer NMB
  • Monitor effectiveness of NMB with PNS
    • eye- asleep
    • ulnar- wake up


What happens after admin of NMB?

  • Continue to ventilate while NMB action takes effect
  • tape eyes
  • loss of twitches confirmed with PNS
  • attempt laryngoscopy and tracheal intubation
  • Confirm ETT
    • wathc pass VC
    • fogging ETT
    • B chest rise
    • B breath sounds
    • presence of three ETCO2 waveforms
  • Tape ETT
    • depth approx. ID X3


After intubation and confirm ETT, next steps?

  • Continue to ventilate by hand or ventilator
  • adjust flows
  • add other gases
  • start infusion of anesthetic
  • add VA
    • DS/SEV/ISO
      • overpressure!


What should we do to prevent recall during intubation process?

  • Keep in mind DOA of induciton agent in relation to onset of NMB
  • may need additional inducation drug
  • use inhalational agent during ventialtion
  • BIS monitoring


Effects of trachela intubaiton on body?

  • Very noxious!
  • HTN and increased HR- risk of MI
  • Laryngospasm
  • Bronchospasm
  • Deepen plan of anesthesia with intubation by using lidocaine/narc/induciton agent
  • consider prophylactic bronchodilator therapy


Standard induction review?

•Position patient supine in sniffing position

•Turn on oxygen flow

•Begin pre-oxygenation

•Monitors on and vital signs taken (O2 sat, BP, ECG, PNS in place)

•Suction on and ready at head of bed

•Pre-induction medications

•Lidocaine (+/-)/ Induction agent

•Test Lash Reflex

•Give Test ventilation

•Check PNS working

•Continue ventilating by mask

•Paralytic drug

•Continue ventilating by mask

•Tape eyes closed

•Continue ventilation until paralytic drug takes effect (loss of twitches)

•Laryngoscopy and intubation

•Inflate ETT cuff

•Confirm ETT placement—bilateral breath sounds, chest rise and fall, presence of ETCO2 x 3 waveforms

•Tape ETT

•Continue ventilation by bag or ventilator

•Begin maintenance anesthetic


What is RSI?

  • Rapid sequence induction
  • airway mgmt technique that induces immediate unresponsiveness and muscular relaxation
  • fastest and most effective means of contorlling emergency airway
  • used in situation of full sotmachs-at risk for aspiration
    • pregnant
    • severe DM
    • uncontrolled acid reflux
    • hiatal hernia
    • trauma
  • Adds seliick's maneuver and removes ventilation from standard induciton sequence


RSI sequence?

•Identify patient in need of RSI

•Pre-operative prophylaxis for aspiration

• Bicitra/Reglan/Omeprazole/Pepcid or Zantac


•Narcotic (avoid loss of consciousness to early)

•Monitors on

•Suction on and at head of bed

•Supine-sniffing position


•Sellick’s maneuver= cricoid pressure –gradually increase pressure as patient falls asleep

•Induction agent

•Succinylcholine or high dose Rocuronium

•wait for fasciculation or 60 seconds (watch the clock- not the block) DO NOT VENTILATE!


•Tracheal intubation

•Confirmation of correct placement

•Give assistant permission to release cricoid pressure

•Secure ETT

•Ventilate or turn on ventilator

•Tape eyes

•Adjust flows

•Begin maintenance anesthetic


When can you extubate a patient?

when nearly fully awake or deeply anesthesized! no inbeween!

  • must evaluate relative risk of coughing vs obstruction vs aspiration when diciding b/w awake vs deep extubation
  • RSI must be awake!


Extubation criteria?

  • TV >6 ml/kg
  • VC> 10 mls/kg (won't get if extubating deep)
  • RR <30 breaths/min
  • Sao2 >90%
  • ETCO2 <50
    • except copd, asthmatics
  • sustained tetanic contraction with PNS


Nearly fully awake extubation sequence?

•Muscle relaxant fully reversed and confirmed with PNS (if applicable)

•All respiratory extubation criteria have been met

•Anesthetic medications including volatile agents and infusions turned off

•100% FiO2

•Oropharynx suctioned

•Patient is responsive to commands/purposeful movement

•Sustained (5 second) head lift indicates clinically adequate reversal of NMB

•Patient can maintain and protect own airway

•ETT removed while positive pressure breath is given



Deep extubation sequence?

•Muscle relaxant fully reversed and confirmed with PNS (if applicable)

•All respiratory extubation criteria have been met

•Oropharynx suctioned

•100% FiO2

•Oral or nasal airway may be inserted

•ETT removed while positive pressure breath is given

•Volatile agents or infusions turned off

•Mask airway maintained while patient spontaneously ventilating

•Remain vigilant until patient is responsive and maintaining own airway



What is a laryngospasm?

  • Prolonged, intense glottic closure
  • may be present with high pitched squeak to total absence of sound (ominous sign)
  • suprasternal an dsupraclavicular in drawing, increased diaphragmatic excursions, flailing of lower ribs resembling a "rocking horse"
  • caused by contraction of lateral cricoarytenoids, thyroarytenoids, and cricothyroid muscle form stimulation of vagus nerve
  • most often seen in induction/emergence


What are some triggers for laryngospasms?

  • Secretions (vomitus, blood, saliva)
  • foreign body
  • pain
  • pelvic or abd visceral stimulation
  • stimulating glottis in a light plane of anesthesia
  • reactive airway dx


How can you prevent larngospasm?

  • Deep plane of anesthesia reached prior to sx stimulation
  • either fully awake or deeply anesthetized wiht extubation
  • suciton oropharynx prior to extubation
  • remove ETT with positive pressure breath


Layngospasm treatment?

  • Recognize event!
  • immediate removal of offending stimulus
  • Larson maneuver
    • retromandibular ntoch/laryngospasm notch
      • condylar process of mandibular ramus anteriorly, mastoid process post, and external aud canal superiorly
  • admin 100% fio2 with continuous positive pressure
  • deepen anesthetic (prop)
  • small dose short acting muscle relaxant
    • succ 20-40 mg