Flashcards in RSI, reintubation, extubation complications and difficult airway Deck (44)
describe aspiration prevention
1)pharmacological aspiration prophylaxis
-goal: reduce amount ( 2.5 pH) of gastric contents
-liquid acid neutralizer (Bicitra)
-prokinetic agent (Reglan)
-acid secretion prevention with proton pump inhibitors (PPIs: Prilosec) and/or H2 antagonists (Pepcid/zantac)
2) preoxygenate/denitrogenate as usual
3) rapid sequence induction (RSI)
-rapid injection of propofol and succs
describe rapid sequence induction (RSI)
objective: prevent pulmonary aspiration
1) decreases time b/w when protective airway reflexes are eliminated and airway protection is secured (seconds matter!) *speeds up intubation
2) attempts to protect airway when protective reflexes are eliminated by occluding gastric pathway to airway (cricoid pressure: occludes gastric pathway to block anything from coming up)
what are RSI indications?
*patients at an increased risk for aspiration of gastric contents
-trauma (includes falls with fractures: once trauma occurs, digestion stops, so even if > 6 hrs consider "full stomach")
-NPO guidelines not followed
-acute abdomen and bowel obstruction
-active GI bleeding or upper airway bleeding (nausea)
-pregnancy (consider "full stomach")
-abdominal mass or ascites increasing risk of gastric content expulsion
-severe GERD (N/V)
describe RSI prep
-check equipment immediately prior to induction
-be sure ETT has stylet
-ensure competent airway personnel present for cricoid pressure
-position for optimal laryngoscopy
describe RSI procedure
-slam induction agent then immediately give paralytic
-perform cricoid pressure maneuver
-if bag mask ventilating while waiting for paralytic effect then do not exceed pressure > 20 cmH2O (introduces air into gastric cavity and gastric insufflation increases risk of aspiration)
-laryngoscopy, intubation, inflate cuff
**verify ETT position before releasing cricoid pressure
describe cricoid pressure procedure
using Sellick's maneuver
-thumb and index finger pressing downward on the cricoid ring will compress the esophagus against the cervical vertebrae
-cricoid pressure effectiveness often debated
*RSI with cricoid pressure prevents gastric contents form exiting up through esophagus and insufflation d/t PPV forcing air into stomach
*esophagus to the right of trachea in 75% of people
what are some complications of cricoid pressure?
-may produce poor view during intubation (mask ventilation NOT affected)
-increased risk for esophageal rupture if vomiting
what are contraindications to cricoid pressure?
-lack of properly trained assistant
-fractured larynx or cricoid
-esophageal foreign body near cricoid (C6)
-cervical fracture near the cricoid (C6)
*no suspected spinal injury
*do RSI w/o cricoid pressure
what are alternatives to RSI?
-regional anesthesia (*always be prepared for a tracheal intubation if regional fails or regional results in airway compromise such as a high spinal)
-awake intubation (maintains protective airway reflexes)
-tracheostomy under local
-delay in surgical procedure (if surgery is non-urgent/emergent)
what are some complications of intubation during laryngoscopy and intubating?
-malpositioning: esophageal intubation, endobronchial intubation, laryngeal cuff supraglottic
-airway trauma: tooth damage, lip/tongue/mucosal laceration, sore throat, dislocated mandible, retropharyngeal dissection
-physiologic reflexes(sympathetic outflow): HTN, tachycardia, intracranial HTN, intraocular HTN, laryngospasm
-tube malfunction: cuff perforation
what are some complications of intubation while the tube is in place?
-malpositioning: unintentional extubation, endobronchial intubation, laryngeal cuff position
-airway trauma: mucosal inflammation and ulceration, excoriation of nose
-tube malfunction: ignition, obstruction
what are some complications of intubation following extubation?
-airway trauma: edema and stenosis (glottis, subglottic, or tracheal), hoarseness (vocal cord granuloma or paralysis), laryngeal malfunction and aspiration
-occurs during intubation or extubation
-reactive airway disease (RAD) increases risks: asthmatics, bronchitis, URI
-characterize by inability to ventilate
how are bronchospasms treated?
-beta 2 agonist like albuterol
-lidocaine IV or ETT if intubated
-deepen volatile anesthetic if intubated or masked
-IV atropine, epinephrine, fentanyl
describe steps for emergence
-establish spontaneous breathing first
-increase CO2 level to stimulate breathing (do by decreasing TV and RR)
-stimulate to awaken: verbal and physical (moving arms and calling name); noxious stimulation (ETT movement; surgical field and incision) *blocks are reducing this stimulus
-removal of agents that promote sleep: versed (remains for hours), fentanyl (may or may not remain), volatile agent (remove by ventilation), paralytic (reverse)
describe the steps extubation
-can be done deep or awake depending on:
*surgery (hernia, ENT, sling, carotid endarterectomy want deep since coughing will increase pressure in areas of surgery)
*pt. history (aspiration risk, difficult intubation, OSA want light since pt. needs protective reflexes and want fully awake and breathing)
-desire smooth , atraumatic extubation
-avoidance of coughing: lidocaine, narcotic, pull deeper
what are criteria for extubation?
-adequate NMBA reversal
-4/4 TOF with sustained 5 second tetanus w/o fade
-TV and RR adequate to eliminate CO2
-strong hand grip, cough, and sustained head lift > 5 sec.
-airway reflexes: swallowing and tongue movement
-maintain oxygenation/ventilation w/o stimulation
what are crucial questions to ask before extubating?
-can I maintain a patent airway post-extubation? (effectively ventilate and oxygenate)
-can I reintubate easily if needed? (don't take tube if difficult intubation unless positive pt. is awake, following commands, and can maintain ventilation)
-are aspiration risks reduced?
-can pt. maintain oxygentation and ventilation as evidenced by adequate RR rate and TV?
-is paralytic reversed?
-have protective airway reflexes returned? (aspiration risks are reduced)
describe extubation procedure
-suction the oropharyngeal cavity
-administer a positive pressure breath
-remove air from cuff and gently remove ETT while monitoring the airway for exhalation (exhalation during extubation ensures that secretions are projected away from cords)
*do not pull at the end of expiration or secretions will be sucked in on inspiration
-immediately apply supplemental O2 and PPV via facemask while maintaining seal
-listen and feel for air movement (crowing and turbulent sounds indicate air movement but partially obstructed airway; risk laryngospasm)
*PP breathing good with crowing since pushes air in
-glottic closure reflex
-more prevalent in young adults and children
-light anesthesia, stage 2 extubation (hyperirritable)
-direct glottis, supraglottic stimulation
-irritation from inhaled agents
-foreign bodies on cords (blood/secretions)
-stimulation of periosteum, celiac plexus or dilation of rectum
-high pitched squeaking or crowing indicates some air is moving
-absence of sound indicates complete closure
describe the treatment of laryngospasms
-suction all secretions from cords and mouth
-forward displacement of mandible (jaw thrust) moves tongue off posterior pharynx
-continuous PP with 100% O2
-paralytic agent: Succs 10-20 mg (1/2- 1 cc)
-laryngospasm notch (at soft tissue just behind earlobes, push both sides firmly inward towards skull base while simultaneously pushing anterior similar to jaw thrust; should break within 1-2 breaths)
*work quickly to prevent desaturation and negative pressure pulmonary edema
*reintubate if unable to maintain oxygenation
describe negative pressure pulmonary edema (NPPE)
-results when a strong inspiratory effort against a totally occluded airway generates increased negative intrathoracic cavity pressure (occluded ETT, laryngospasm)
-fluid enters the lungs resulting in pulmonary edema
-more pronounced in young, muscular patients
-light pink or white frothy foam with coughing
-unable to maintain oxygen saturation
-CXR to confirm
how is NPPE treated?
describe glottic edema
-repeated intubation attempts resulting in trauma to laryngeal structures and glottic opening
-stridor can indicate glottic edema
-results in partial or total airway obstruction
-ETT too large and tight fitting
-excessive coughing while intubated
what is the treatment for glottic edema?
-IV steroids (Decadron)
-may require reintubation or tracheostomy in severe cases
what are common complications of extubation?
*break incisions/sutures and hernia repairs
*promote vomiting and aspiration
*increase intraocular and intracranial pressure
*trauma to glottic opening and arytenoids
-HTN and tachycardia d/t increased SNS outflow
-hypoventilation and transient hypoxemia
what surgeries and conditions are associated with a high risk extubation?
-thyroid surgery: hematoma or swelling, nerve injury (RLN or ex-SLN), tracheomalacia
-deep neck infections
-cervical spine surgery
-posterior fossa surgery
-preexisting airway obstruction: Parkinson's syndrome, rheumatoid arthritis, epidermolysis bullosa, pemphigus
-tracheomalacia or bronchomalacia
-airway instrumentation: diagnostic laryngoscopy or rigid bronchoscopy
-paradoxical vocal cord motion (dysfunction)
-"...potentially and fundamentally different from the original intubation"
-70% r/t anesthesia management (pulled too early)
-usually urgent or emergent
-pt. likely hypoxic, hypercapnic, acidotic, agitated, or hemodynamically unstable
-larynx and tongue edematous
what are indications of re-intubation?
-post-extubation airway compromise
-sustained hypoxemia and hemodynamic instability