Session 12: Extubation Process Flashcards
1
Q
Extubation process
A
reversal
anti-emetics
analgesics
safety
PACU
2
Q
Timing criteria
A
starting to close?
look for small/dainty stitches of Sub Q fat
Wait until Stage 1for ETT removal
3
Q
Closing stitches
A
thick/dark: muscle
small/dainty: Sub Q fat
4
Q
if you reverse too soon you can cause
A
hernia
hole in muscle
5
Q
never extubate in what stage
A
stage 2
6
Q
Stage 1
A
analgesia
7
Q
Stage 2 signs
A
uncontrolled airway
disconjugate eyes
reactive coughing
8
Q
Stage 3
A
surgical anesthesia
9
Q
Stage 3 Plane 1
A
regular respirations
cessation of eyeball mvmt
lactimation
10
Q
Stage 3 Plane 2
A
corneal reflex abolished
11
Q
what happens when you try to breath post-laryngospasm
A
negative pressure pulmonary edema
12
Q
Vital signs (7)
A
NBIP/ART
EKG
SpO2
CO2
RR
Temp
TOF
13
Q
Capnography shows
A
CO2
respiratory rate
14
Q
BP for wake-up
A
~ +/- 20% of baseline for pt
130-140 w/systemic disease
15
Q
Pulse Ox for wakeup
A
95%+
16
Q
EtCo2 for wakeup
A
35-45mmhg
17
Q
narcosis EtCO2
A
55+ mmHg
18
Q
Properly Resuscitated Criteria
A
stable HR
stable BP
pt is ready for wake up
19
Q
Paralytic Reversal Criteria
A
peripheral nerve stimulation to verify
4/4 twitches (least paralysis)
0/4 twitches (most paralysis)
20
Q
4/4 twitches
A
least paralysis
21
Q
0/4 twitches
A
most paralysis
22
Q
peripheral nerve stimulation locations
A
Ulnar (Adductor Pollicis)
Facial (Orbicularis Oculi)
Posterior Tibial (flexor hallucis brevis)
23
Q
TOF
A
Train of Four monitoringT
24
Q
TOF mode
A
4 twitches delivered every 0.5 seconds
25
Tetanic mode
sustained twitches at high frequency
26
Double-Burst mode
2 short bursts separated by 750 msec
27
amperage for TOF
60-80mA
use highest setting
28
TOF measures
the magnitude of twitches
compares 1st and 4th twitch
29
facial nerve functions
closes eyelid
furrows brow
30
posterior tibial nerve function
flexes big toe
31
ulnar nerve function
adducts thumb
32
what does 4/4 correlation tell you
that the 4th twitch was a strong as the first twitch
you could have up to 75% of NMJs still blocked w/paralytic
33
if you get a 0/4 reading, what should you do?
conduct at post-tetanic TOF
increase suggamadex dosing
34
Post tetanic TOF
hold 100mA (max) sustained contraction for 5s
then repeat normal TOF
35
what does a Post tetanic TOF do in the body?
tetaning floods NMJ w/ACh
ACh competes with paralytic for receptor
36
4/4 with fade
4 twitches
4th < 1st
37
4/4 at 25%
25% correlation between the 4th and 1st twitches
38
what % correlation will a 2/4 TOF be?
0%
you only have correlation with 1st and 4th twitches. If you have less than 4 twitches, you wont have a correlation.
39
Paralytic reversal criteria: clinical signs
sustained head lift > 5 secs
forced inspiratory pressure -25cmH20 (or more negative)
sustained hand grip
40
Order of Return to function (first to last)
facial nerve
phrenic nerve
posterior tibial
ulnar nerve
41
facial nerve
orbicularis oculi
42
phrenic nerve
diaphragm
rectus abdominuis
laryngeal adductors
43
posterior tibial
flexor hallucis brevis
44
ulnar nerve
adductor pollicis
45
gold standard for TOF
adductor pollicis/ulnar nerve
guarantees function has also returned to diaphragm(phrenic)
46
Pouiseuille's Law
states that flow rate is proportional to the radius to the fourth power
47
removing the ETT will _____ TV
increase tidal volume
higher flow rate due to larger radius of airway compared to ETT
48
1st determinant of return to spontaneous breathing
CO2 (apneic threshold)
49
what determines CO2 changes in body
chemosensitive area in medulla
50
how can I increase pts CO2?
decrease minute ventilation
- decrease TV
- decrease RR
51
2nd determinant of return to spontaneous breathing
O2
peripheral regulation carotid/aortic bodies by afferent nerves
52
what PaO2 causes spontaneous breathing?
<<100mmHg
53
O2 tension
=5xFiO2
54
breathing adequate criteria - pulse oX
> 97% SpO2
55
best vital sign for determining if breathing is adequate
CO2
unless on ventilator assistance (pressure support)
56
best monitor for analgesic needs
Respiratory rate (for spontaneous ventilation)
57
target respiratory rate on SV for wakeup
12-18 breaths per minute
18+: more pain
<12: longer wakeup time
58
Anti-Emetic Regime
everyone gets Zofran
different agents work at different time frames/duration
some can last 72 hrs post wake-up so we need to ensure pts have proper anti-emetics to aid in the PONV
59
when do you give zofran
20 mins prior to wakeup
it takes 20 mins to peak effect
60
zofran common dosage
4mg
61
PONV is caused by
narcotics
volatile agents
62
when is decadron administered?
beginning of case
prior to sevo
long lasting
63
decadron negative side effect
perineal burning
64
decadron common dose
4 mg
65
propofol anti-emetic dosing
25-150 mcg/kg/min infusion
66
common antiemetics
zofran
haloperidol
scopolamine
reglan
decadron
67
zofran class
serotonin antagonist
68
haloperidol class
dopamine antagonist
69
reglan class
dopamine antagonist
70
scopolamine class
Ach antagonist
71
Oral suctioning process
deep: use yankeur to suction
use bend to advantage
gentle
can illicit coughing/bucking
72
ETT suctioning indications
often used for severe colds and smokers
indicated if high pressures or presence of secretions
73
ETT suctioning process
disconnect circuit advance catheter until slight resistance
occlude orifice and slowly retract suctioning
74
Bite block
placed to prevent the pt from biting the tube and occluding the ETT
75
biting on the tube could cause
negative pressure pulmonary edema
76
2 types of bite block
4x4s wedged between molars
oral airway
77
when do you place bite block?
while in stage 3
closer to when you want to start waking them up
78
Awake Extubation Process (11)
Bite block
Suction (while deep)
Extubation criteria met
Breathe off gases
Check for Stage 1 or Stage 2
Remove Tape (hold ETT, prep syringe)
Deflate Cuff
Facemask
Confirm ventilation
Simple facemask/nasal canula
Transport
79
how do you let pt breathe off gasses?
turn off volatile agent
increase fresh gas >10-15 LPM
80
what MAC do pts usually convert to stage I?
0.1 MAC
81
0.1 MAC Des
0.6%
82
0.1 MAC Sevo
0.2%
83
0.1 MAC Iso
0.12%
84
what signals out of stage 2 and into stage 1?
appropriately following commands
conjugated pupils
opening eyes
reaching for tube
85
when to deflate the ETT cuff?
as the ventilation bag starts to inflate
during the expiration
86
3 ways to confirm ventilation after extubation
Fog in Mask
chest rise
CO2 on monitor (delayed 2-3s)
87
3 most common oxygen delivery systems
nasal cannula (NC)
face mask (simple)
non-rebreather
88
nasal cannula flow/FiO2
flow: 1-6 L/min
FiO2: 25-40%
(4%/L of flow)
89
face mask flow/FiO2
flow: 5-10 L/min
FiO2: 40-60%
90
non-rebreather flow/FiO2
flow: 12-15 L/min
FiO2: 80-95%
(nonspecific flow rate)
91
venturi mask flow/FiO2
flow: 2-15 L/miin
FiO2: 24-60%
92
face tent flow/FiO2
flow: 10-15 L/min
FiO2: 40%
93
High flow nasal cannula flow/FiO2
flow: up to 60 L/min
FiO2: 21-100%
94
Deep Extubation Process (12)
bite block
suction (while deep)
extubation criteria met
ensure stage 3
remove tape (hold ETT/prep syringe)
deflate cuff
volatile agent off / FGF 10-15 Lpm
facemask
confirm ventilation
maintain airway until stage 1
simple facemask/cannula
transport
95
how do you ensure pt is in stage 3 for deep extubation?
giving 1.0 MAC of agent
96
deep extubation complications
laryngospasm
bronchospasm
obstruction (loss of airway/swelling)
coughing/retching
excitation/agression
hypertension/tachycardia
negative pressure pulmonary edema
97
how do you treat wakeup agression?
dexmetedomidine
narcotics
98
what can make aggression wore?
benzodiazepams
(versed)
99
Awake extubation pros
less complications
first to assess comfort level
100
awake extubation cons
longer (potentially)
less efficient
101
deep extubation pros
no coughing (first phase)
can be quicker (if no complications)
102
deep extubation cons
pass through stage 2 w/unprotected airway
increased potential for laryngospasm
103
PACU transport
simple facemask
dont steer bed, just push
watch the pt ventilate
104
PACU handoff
Name
Age
Allergies
Pert medical history
Surgery
Pre-op meds/prcedures
OR meds
Inputs/Outputs
LDAs
Misc
Comments, questions, concerns?
105
PACU handoff: Allergies
food
drugs
etc
106
PACU handoff: Medical History
relevant conditions that could impact recovery
(heart, lungs, etc)
107
PACU handoff: Pre-Op meds/Procedures
meds
blocks
epidural
etc
108
PACU handoff: Meds in OR
anxiolytics
analgesics
anti-emetics
reversal agents
uncommon meds
109
PACU handoff: Inputs/Outputs
Fluids given
blood products given
urinary output (UOP)
estimated blood loss (EBL)
ascites
etc
110
PACU handoff: LDA
line drain and airway
any new lines placed
anything specific about them
111
SBAR
situation
background
assessment
recommendation
AKA PACU handoff
112
