Basic Anesthesia Case Management

Question 1

3 questions to ask yourself before each general anesthetic case?

Answer 1

1. Should I intubate or place an LMA?
2. Should I let the patient breath spontaneously, or should I breath for them (ventilator)?
3. If I am going to use the ventilator, how am I going to suppress the respiratory drive, so that the patient will tolerate the vent?

Question 2

Advantages to spontaneous ventilation?

Answer 2

1. Know respiratory rate
2. Wakeup will have one less step, because you won’t have to get the patient back breathing (you just have to turn the agent off)

Question 3

Disadvantages to spontaneous ventilation?

Answer 3

1. Smaller tidal volumes

2. Obesity or long procedure is contraindicated

Question 4

Absolute contraindications for spontaneous ventilation?

Answer 4

1. Intraabdominal surgery (requires MR)
2. Laparoscopic surgery (requires MR)
3. Cardiothoracic surgery (usually requires MR)
4. Situations where EtCO2 must be tightly controlled (i.e. brain surgery)
5. Morbidly obese patients
6. Certain types of joint replacement, depending on surgeon

Question 5

Relative contraindications to spontaneous ventilation?

Answer 5

1. Long operations
2. Elderly patients
3. Non-supine position

Question 6

Advantages of control ventilation?

Answer 6

1. Larger Vt

2. We can control the patients CO2 levels

Question 7

Disadvantages of control ventilation?

Answer 7

1. We must knock out the respiratory drive (paralysis, higher narcotics)
2. Wakeups will have an extra step (we have to get the patient breathing again at end of surgery)

Question 8

Popular situations to use muscle relaxants?

Answer 8

1. Smokers, asthmatics, and obese patients who need to be intubated
2. “Sick” patients who are intubated
3. Long operations on intubated patients

Question 9

Contraindications to muscle relaxants?

Answer 9

1. Neck surgery/neck dissection
2. Thyroid surgery and parathyroid surgery
3. Neurosurgery (back or brain)
4. Breast/axillary surgery

Question 10

Complications to using Sugammadex?

Answer 10

1. Patients <17 years of age
2. Renal disease
3. Pregnacy and lactation
4. Allergic reactions to sugammadex

Question 11

Advantages of MR and ventilator?

Answer 11

1. Patient won’t require as deep of anesthesia

2. Patient is guaranteed not to move

Question 12

Disadvantages of choosing MR for patients on the vent?

Answer 12

1. MR use requires the anesthetist to give reversal
2. Surgery may end unexpectedly soon, doesn’t really matter with sugammadex
3. Anesthetic awareness is theoretically more likely

Question 13

If we cannot use MR, what is the best way to supress respiratory drive and the cough reflex (so patients can tolerate the ventilator)?

Answer 13

1. Higher doses of narcotics (100-250mcg fentanyl on induction)
2. Use “deeper” anesthetic (MAC>1)

Question 14

Advantages of not paralyzing and on the vent?

Answer 14

1. Zero chance of residual paralysis at end of case
2. Patient won’t require reversal agents
3. Curare clefts can indicate when more narcotic is needed

Question 15

Common induction prior to intubation?

Answer 15

1. Lidocaine
2. Fentanyl
3. Propofol
4. Paralytic (sucs vs. roc)

Question 16

Common induction prior to LMA placement?

Answer 16

1. Lidocaine
2. Propofol
3. Fentanyl (optional <50mcg)

Question 17

Management of LMA cases?

Answer 17

1. Induce patient and place LMA
2. Ventilate patient with positive pressure and volatile agent for 2-3 min
3. After sevo is in system, let patient go apneic until they start breathing on their own
4. Once breathing on their own, get MAC level >1 prior to incision and titrate narcotics to a slow RR
5. Be prepared to treat hypotension (since MR aren’t being used and they have to be deeper)

Question 18

Steps to prevent coughing on a tube with intubated or spontaneously ventilating patients?

Answer 18

1. Adequate >1 MAC inhalation conc.
2. Adequate narcotic dosing to a lower RR (8-12 breaths/min)
3. Numbing of trachea (with LTA kit or lidocaine jelly)

Question 19

Management of intubated and spontaneously ventilating patients?

Answer 19

1. Induce pateint with sucs and intubate
2. Ventilate patient with volatile agent for 3-5 min on the ventilator (until sucs wears off)
3. When muscle function returns, let the patient go apneic until they start breathing on their own
4. Once they start breathing, get MAC>1 prior to incision and titrate narcotics to slow RR
5. Be prepared to treat hypotension

Question 20

Management of intubated patients on the vent and not paralyzed?

Answer 20

1. Induce with sucs and intubate, use 100-200mcg fentanyl to supress respiratory drive
2. Turn off ventilator and deliver volatile agent
3. Get MAC>1 prior to incision
4. Be prepared to treat hypotension

Question 21

Management of intubated and paralyzed patient?

Answer 21

1. Induce with roc or sucs and intubate
2. Turn vent off and deliver volatile agent
3. Get patient to >0.8MAC before incision
4. Since the patient is paralyzed, the anesthetist doesn’t have to have the patient as “deep” prior to incision (less likely hypotension)