Module 8: Part 4 (70-92)

Question 1

Risk factors for difficult face mask:

Answer 1

age older than 55, BMI > 26kg/m2, presence of a beard, lack of teeth, snoring history

Question 2

What constitues an Impossible mask ventilation?

Answer 2

inability to exchange air during bag-and-mask ventilation despite multiple providers, adjuncts, neuromuscular blockade

Question 3

What constitutes a Difficult laryngeal mask ventilation?

Answer 3

inability within three attempts of device insertion to produce expired tidal volumes more than 7ml/kg

Question 4

What are the percentges of difficult intubation in OB and general populations?

Answer 4

.45-5.7% of obstetric patients
5.8% of general surgical population

Question 5

What are the percentges of failed intubation in OB and general populations?

Answer 5

.4% of obstetric population
.045% of general surgical population

Question 6

Consequences of difficult intubation may be greater in the obstetric population T/F

Answer 6

TRUE

Question 7

What are the 3 pulmonary risks in pregnancy?

Answer 7

Maternal Hypoxia
Maternal Aspiration
Failed Intubation

If we can prevent #3, then #1 and #2 would be a moo point.

Question 8

What is goal #1 for OB patients?

Answer 8

AVOID INTUBATION!!

“The approach to the potentially difficult airway begins with preferential application of regional anesthesia to prevent the need for intubation”

Question 9

Why might you choose GA?

Answer 9

Maternal compromise not responsive to resuscitation
Acute fetal compromise (SAB/awake Fiberoptic not feasible)
Failed regional
High spinal
Aspiration
Cardiac Arrest

Question 10

Failed intubation rates in obstetrics is ____X higher than nonobstetric surgical populations

Answer 10

8

Question 11

What factors increase in maternal obesity?

Answer 11

May have a higher incidence of failed neuraxial
Difficult mask fit
Poor head and neck positioning
Inappropriately applied cricoid pressure

Question 12

What are the best ways to prevent maternal hypoxia?

Answer 12

Preoxygenation with 100% Oxygen
- 3 minutes of tidal volume breathing or 4-8 vital capacity breaths (via close fitting facemask)
- Monitor the end-tidal fractional oxygen concentration (FETO2) which may be one of the best markers for lung denitrogenation

Proper positioning
RSI with cricoid
Successful, quick intubation

Question 13

What are the steps/methods for prevention of aspiration?

Answer 13

Fasting requirements
Rapid sequence induction
- Succinylcholine/Rocuronium
- Cricoid pressure
Aspiration prophylaxis
Successful, quick intubation

Question 14

What is the correct way to apply cricoid pressure?

Answer 14

Question 15

What are the patient positioning factors a/w successful + quick intubation?

Answer 15

External auditory meatus/sternal notch
Pillows, blankets, intubating ramp
Elevating the back of the OR table
LUD

Question 16

Difficult airway equipment includes:

Answer 16

Video laryngoscope
Flexible fiberoptic bronchoscope
At least one device for emergency non surgical airway ventilation (lightwand, jet ventilator, Combitube, 2nd generation LMA (ProSeal/Supreme), FasTrach LMA
Cricothyrotomy kit
Retrograde intubation equipment
Tube exchangers
Topical anesthetics and vasoconstrictors

Question 17

What is included in the anticipated difficult airway algorithm?

Answer 17

Question 18

What are the benefits of video laryngoscope?

Answer 18

Provides a better view of the larynx
Increases the success of intubation
Minimizes airway swelling and friability that come with multiple attempts

Question 19

_______ May be used to ventilate or as a conduit for blind or fiberoptic intubation

Answer 19

Intubating LMA (Fastrach™/AirQ
LMA)

Question 20

equipment for failed intubation includes what?

Answer 20

Laryngeal Mask Airway
- Intubating LMA (Fastrach™/AirQ LMA)
- ProSeal™ LMA/LMA SupremeTM

Question 21

Question 22

Question 23

SHE SAID TO KNOW THIS

Question 24

What are the steps/criteria for emergence and extubation?

Answer 24

Suction of gastric contents
Clear oropharynx of secretions/blood (repeated attempts at laryngoscopy)
100% O2 (3-5 minutes)
Return of full neuromuscular function
Patient responds to commands
Place bed in head-up position
- 30°
- Improves FRC

Question 25

What are the factors a/w Difficulty reestablishing airway/quicker desaturation with apnea?

Answer 25

Previous airway manipulation Obesity History of obstructive sleep apnea Administration of large volumes of crystalloids or colloids Lengthy surgical procedure Underlying disease that increases the risk of airway edema

Question 26

What are the goals of extubation?

Answer 26

ensure uninterrupted oxygen delivery, avoid airway stimulation, allow ventilation and possibly reintubation with minimum difficulty and delay should extubation fail

Question 27

Answer 27

The position of the laryngeal mask airway (LMA) with and without cricoid pressure. The blue-shaded area indicates the distal part of the LMA that occupies the hypopharynx. The dashed lines indicate anatomic correlation. 1, Posterior view of the larynx. 2, Lateral view of the larynx. 3, Position of the tip of the LMA when cricoid pressure is applied. When cricoid pressure is applied before placement, the LMA, in theory, might be wedged in the hypopharynx but is more likely to occupy the space behind the arytenoid cartilages. The LMA is positioned at least 2 cm more proximal than usual. 4, Position of the LMA when no cricoid pressure is applied. When the LMA is placed correctly, the distal tip is at the distal end of C5 (fifth cervical vertebra), and the distal part of the LMA should fully occupy the hypopharynx and the pharyngeal space behind both the arytenoid and cricoid cartilages.