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Sim Lab > Session 12: Extubation Process > Flashcards

Session 12: Extubation Process Flashcards

1
Q

Extubation process

A

reversal
anti-emetics
analgesics
safety
PACU

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2
Q

Timing criteria

A

starting to close?
look for small/dainty stitches of Sub Q fat

Wait until Stage 1for ETT removal

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3
Q

Closing stitches

A

thick/dark: muscle
small/dainty: Sub Q fat

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4
Q

if you reverse too soon you can cause

A

hernia

hole in muscle

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5
Q

never extubate in what stage

A

stage 2

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6
Q

Stage 1

A

analgesia

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7
Q

Stage 2 signs

A

uncontrolled airway
disconjugate eyes
reactive coughing

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8
Q

Stage 3

A

surgical anesthesia

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9
Q

Stage 3 Plane 1

A

regular respirations
cessation of eyeball mvmt
lactimation

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10
Q

Stage 3 Plane 2

A

corneal reflex abolished

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11
Q

what happens when you try to breath post-laryngospasm

A

negative pressure pulmonary edema

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12
Q

Vital signs (7)

A

NBIP/ART
EKG
SpO2
CO2
RR
Temp
TOF

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13
Q

Capnography shows

A

CO2
respiratory rate

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14
Q

BP for wake-up

A

~ +/- 20% of baseline for pt

130-140 w/systemic disease

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15
Q

Pulse Ox for wakeup

A

95%+

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16
Q

EtCo2 for wakeup

A

35-45mmhg

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17
Q

narcosis EtCO2

A

55+ mmHg

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18
Q

Properly Resuscitated Criteria

A

stable HR
stable BP

pt is ready for wake up

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19
Q

Paralytic Reversal Criteria

A

peripheral nerve stimulation to verify

4/4 twitches (least paralysis)
0/4 twitches (most paralysis)

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20
Q

4/4 twitches

A

least paralysis

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21
Q

0/4 twitches

A

most paralysis

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22
Q

peripheral nerve stimulation locations

A

Ulnar (Adductor Pollicis)
Facial (Orbicularis Oculi)
Posterior Tibial (flexor hallucis brevis)

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23
Q

TOF

A

Train of Four monitoringT

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24
Q

TOF mode

A

4 twitches delivered every 0.5 seconds

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25
Q

Tetanic mode

A

sustained twitches at high frequency

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26
Q

Double-Burst mode

A

2 short bursts separated by 750 msec

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27
Q

amperage for TOF

A

60-80mA

use highest setting

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28
Q

TOF measures

A

the magnitude of twitches
compares 1st and 4th twitch

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29
Q

facial nerve functions

A

closes eyelid
furrows brow

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30
Q

posterior tibial nerve function

A

flexes big toe

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31
Q

ulnar nerve function

A

adducts thumb

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32
Q

what does 4/4 correlation tell you

A

that the 4th twitch was a strong as the first twitch

you could have up to 75% of NMJs still blocked w/paralytic

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33
Q

if you get a 0/4 reading, what should you do?

A

conduct at post-tetanic TOF

increase suggamadex dosing

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34
Q

Post tetanic TOF

A

hold 100mA (max) sustained contraction for 5s

then repeat normal TOF

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35
Q

what does a Post tetanic TOF do in the body?

A

tetaning floods NMJ w/ACh
ACh competes with paralytic for receptor

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36
Q

4/4 with fade

A

4 twitches

4th < 1st

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37
Q

4/4 at 25%

A

25% correlation between the 4th and 1st twitches

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38
Q

what % correlation will a 2/4 TOF be?

A

0%

you only have correlation with 1st and 4th twitches. If you have less than 4 twitches, you wont have a correlation.

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39
Q

Paralytic reversal criteria: clinical signs

A

sustained head lift > 5 secs
forced inspiratory pressure -25cmH20 (or more negative)
sustained hand grip

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40
Q

Order of Return to function (first to last)

A

facial nerve
phrenic nerve
posterior tibial
ulnar nerve

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41
Q

facial nerve

A

orbicularis oculi

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42
Q

phrenic nerve

A

diaphragm
rectus abdominuis
laryngeal adductors

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43
Q

posterior tibial

A

flexor hallucis brevis

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44
Q

ulnar nerve

A

adductor pollicis

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45
Q

gold standard for TOF

A

adductor pollicis/ulnar nerve

guarantees function has also returned to diaphragm(phrenic)

46
Q

Pouiseuille’s Law

A

states that flow rate is proportional to the radius to the fourth power

47
Q

removing the ETT will _____ TV

A

increase tidal volume
higher flow rate due to larger radius of airway compared to ETT

48
Q

1st determinant of return to spontaneous breathing

A

CO2 (apneic threshold)

49
Q

what determines CO2 changes in body

A

chemosensitive area in medulla

50
Q

how can I increase pts CO2?

A

decrease minute ventilation
- decrease TV
- decrease RR

51
Q

2nd determinant of return to spontaneous breathing

A

O2
peripheral regulation carotid/aortic bodies by afferent nerves

52
Q

what PaO2 causes spontaneous breathing?

A

«100mmHg

53
Q

O2 tension

A

=5xFiO2

54
Q

breathing adequate criteria - pulse oX

A

> 97% SpO2

55
Q

best vital sign for determining if breathing is adequate

A

CO2

unless on ventilator assistance (pressure support)

56
Q

best monitor for analgesic needs

A

Respiratory rate (for spontaneous ventilation)

57
Q

target respiratory rate on SV for wakeup

A

12-18 breaths per minute

18+: more pain
<12: longer wakeup time

58
Q

Anti-Emetic Regime

A

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
Q

when do you give zofran

A

20 mins prior to wakeup
it takes 20 mins to peak effect

60
Q

zofran common dosage

A

4mg

61
Q

PONV is caused by

A

narcotics
volatile agents

62
Q

when is decadron administered?

A

beginning of case
prior to sevo

long lasting

63
Q

decadron negative side effect

A

perineal burning

64
Q

decadron common dose

A

4 mg

65
Q

propofol anti-emetic dosing

A

25-150 mcg/kg/min infusion

66
Q

common antiemetics

A

zofran
haloperidol
scopolamine
reglan
decadron

67
Q

zofran class

A

serotonin antagonist

68
Q

haloperidol class

A

dopamine antagonist

69
Q

reglan class

A

dopamine antagonist

70
Q

scopolamine class

A

Ach antagonist

71
Q

Oral suctioning process

A

deep: use yankeur to suction
use bend to advantage
gentle

can illicit coughing/bucking

72
Q

ETT suctioning indications

A

often used for severe colds and smokers

indicated if high pressures or presence of secretions

73
Q

ETT suctioning process

A

disconnect circuit advance catheter until slight resistance

occlude orifice and slowly retract suctioning

74
Q

Bite block

A

placed to prevent the pt from biting the tube and occluding the ETT

75
Q

biting on the tube could cause

A

negative pressure pulmonary edema

76
Q

2 types of bite block

A

4x4s wedged between molars
oral airway

77
Q

when do you place bite block?

A

while in stage 3
closer to when you want to start waking them up

78
Q

Awake Extubation Process (11)

A

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
Q

how do you let pt breathe off gasses?

A

turn off volatile agent
increase fresh gas >10-15 LPM

80
Q

what MAC do pts usually convert to stage I?

A

0.1 MAC

81
Q

0.1 MAC Des

A

0.6%

82
Q

0.1 MAC Sevo

A

0.2%

83
Q

0.1 MAC Iso

A

0.12%

84
Q

what signals out of stage 2 and into stage 1?

A

appropriately following commands
conjugated pupils
opening eyes
reaching for tube

85
Q

when to deflate the ETT cuff?

A

as the ventilation bag starts to inflate
during the expiration

86
Q

3 ways to confirm ventilation after extubation

A

Fog in Mask
chest rise
CO2 on monitor (delayed 2-3s)

87
Q

3 most common oxygen delivery systems

A

nasal cannula (NC)
face mask (simple)
non-rebreather

88
Q

nasal cannula flow/FiO2

A

flow: 1-6 L/min
FiO2: 25-40%
(4%/L of flow)

89
Q

face mask flow/FiO2

A

flow: 5-10 L/min
FiO2: 40-60%

90
Q

non-rebreather flow/FiO2

A

flow: 12-15 L/min
FiO2: 80-95%
(nonspecific flow rate)

91
Q

venturi mask flow/FiO2

A

flow: 2-15 L/miin
FiO2: 24-60%

92
Q

face tent flow/FiO2

A

flow: 10-15 L/min
FiO2: 40%

93
Q

High flow nasal cannula flow/FiO2

A

flow: up to 60 L/min
FiO2: 21-100%

94
Q

Deep Extubation Process (12)

A

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
Q

how do you ensure pt is in stage 3 for deep extubation?

A

giving 1.0 MAC of agent

96
Q

deep extubation complications

A

laryngospasm
bronchospasm
obstruction (loss of airway/swelling)
coughing/retching
excitation/agression
hypertension/tachycardia
negative pressure pulmonary edema

97
Q

how do you treat wakeup agression?

A

dexmetedomidine
narcotics

98
Q

what can make aggression wore?

A

benzodiazepams
(versed)

99
Q

Awake extubation pros

A

less complications
first to assess comfort level

100
Q

awake extubation cons

A

longer (potentially)
less efficient

101
Q

deep extubation pros

A

no coughing (first phase)
can be quicker (if no complications)

102
Q

deep extubation cons

A

pass through stage 2 w/unprotected airway
increased potential for laryngospasm

103
Q

PACU transport

A

simple facemask
dont steer bed, just push
watch the pt ventilate

104
Q

PACU handoff

A

Name
Age
Allergies
Pert medical history
Surgery
Pre-op meds/prcedures
OR meds
Inputs/Outputs
LDAs
Misc
Comments, questions, concerns?

105
Q

PACU handoff: Allergies

A

food
drugs
etc

106
Q

PACU handoff: Medical History

A

relevant conditions that could impact recovery
(heart, lungs, etc)

107
Q

PACU handoff: Pre-Op meds/Procedures

A

meds
blocks
epidural
etc

108
Q

PACU handoff: Meds in OR

A

anxiolytics
analgesics
anti-emetics
reversal agents
uncommon meds

109
Q

PACU handoff: Inputs/Outputs

A

Fluids given
blood products given
urinary output (UOP)
estimated blood loss (EBL)
ascites
etc

110
Q

PACU handoff: LDA

A

line drain and airway
any new lines placed
anything specific about them

111
Q

SBAR

A

situation
background
assessment
recommendation

AKA PACU handoff

112
Q
A

Sim Lab (23 decks)

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