Induction & Emergence

Question 1

Placing a pillow under a patient’s head aligns these axes

Answer 1

PA and LA

(pharyngeal and laryngeal)

Question 2

Placing a patient in sniffing position aligns these axes

Answer 2

OA with PA and LA

Question 3

How can you best prepare yourself for a smooth intubation?

Answer 3

Properly positioning yourself and the patient!!

Question 4

These induction meds burn

Answer 4

Propofol and etomidate (use lidocaine with these guys)

Question 5

What is the FIRST thing you should do after giving your induction med and your patient doesn’t have a lash reflex?

Answer 5

1. Test ventilate. (This is the highest priority afer induction)
   
   • Make sure we can mask ventilate our patient as early as possible in the sequence.
2. THEN test TOF and give paralytic.

• If you can’t initially mask your patient try:
  
  • changing position
  • using oral or nasal airway.
• MUST be able to mask patient prior to giving a muscle relaxant

Question 6

Relationship between induction meds and safe apnea time.

Answer 6

• Most of our induction meds last for about 5 min, and we have 10 min of safe apnea time.
• So if we can’t ventilate, we just need to wait, and the pt will start spontaneously breathing again.

Question 7

In a standard induction, if you can _____________ it is NOT and emergency!

Answer 7

Mask Ventilate

Question 8

Explain Recall at induction. What are two clinical signs of recall?

Answer 8

can happen when the duration of induction agent (propofol = 8-10 minutes) wears off and the NMB agent kicks in (3-5 min)

Clinical signs that may predict recall:

• Movement
• Autonomic response (increased HR and BP)

(Also take a look at the BIS monitor)

Question 9

Rapid Sequence Induction

Answer 9

1. Consider giving bicitra and a pro-kinetic
2. Pre-oxygenate (5min or 4-5 VC breaths)
3. Begin Sellick’s Maneuver (pressure as they go off to sleep)
4. Give versed, fentanyl
5. Give induction agent (propofol, etomidate ketamine)
6. AS SOON AS INDUCTION AGENT IN →Give Sux(1 mg/kg) or Roc (1.2 mg/kg)
7. WAIT 60 SECONDS–> watch the clock, not the block!!
8. Intubate and confirm placement
9. Release cricoid pressure (do not release cricoid pressure until placement is confirmed!!!****)
10. Secure ETT and begin maintenance

Question 10

What is the intra-op goal of someone with HTN?

Answer 10

Hemodynamic stability. Want to keep BP within 20% of normal MAP.

Question 11

Respiratory criteria for extubation

Answer 11

1. TV > 6 mL/kg
2. VC > 10 mL/kg
3. RR
4. SaO₂ > 90% (correlates to a PaO2 of 60)
5. EtCO₂
6. Higher = MV is insufficient
7. Sustained tetanic contraction
8. Sustained head lift > 5 sec

Question 12

When do we turn off the anesthetic gasses in a deep extubation?

Answer 12

After the ETT has been removed!

Question 13

Extubation when nearly fully awake

Answer 13

1. Muscle relaxant must be fully reversed
2. Anesthetic meds/gases all turned off
   
   • hold-off on giving narcotics during emergence
3. Patient meets respiratory criteria for extubation
4. Assess responsiveness
   
   • Purposeful movement? (Peds grab for tube is purposful)
   • Following commands?
5. Sustained head lift > 5 sec
6. ETT removed while positive pressure breath is given
   
   • allows subsequent expulsion of secretions away from the glottis

Question 14

When and why is a deep extubation performed?

Answer 14

Generally deep extubation for a reactive airway

1. Performed after reversal of relaxant
2. Patient MUST meet respiratory extubation criteria
   
   • BUT not following commands or having purposeful movement.

(situations where we don’t want the patient to be aware of the ETT tube- sever asthma)

Question 15

How to perform a deep extubation

Answer 15

1. Reverse relaxant if required
2. MUST meet respiratory criteria for extubation
3. Suction oropharynx
4. Oral or nasal airway may be inserted
5. Remove ETT
6. TURN OFF THE GAS - after removal of ETT
7. Mask remains on pt while they are spontaneously breathing (support their breaths if needed)
8. Vigilantly maintain mask airway until patient is responsive and maintaining their own airway

(Nasal and oral airways are kept in place until the pt can no longer tolerate them - will generally take them out themselves)

Question 16

What can trigger laryngospasm?

Answer 16

1. Respiratory secretions (biggest offender)
2. Pain
3. Blood
4. Vomit
5. Foreign bodies
6. Loud noises in the room (startle reflex)
7. Pelvic or abdominal visceral stimulation

Question 17

What is laryngospasm and what are the s/s?

Answer 17

Prolonged intense closure of the glottis caused stimulation of the vagus causing contraction of the:

1. Lateralcricoarytenoids (RLN)
2. Thyroarytenoids (RLN)
3. Cricothyroid (SLN)

Sighs and symptoms may include:

1. high-pitched sqeuaks or no sound at all.
2. Suprasernal and supraclavicular in-drawing
3. Increased diaphragmantic excursions
4. Flailing of the lower ribs “Rocking horse”
5. It is most ofeten seen in emergence

Question 18

Treatment of laryngospasm

Answer 18

1. Jaw-Lift
2. O2 with PPV via mask (strong intermittent pressure to force gas through the adducted cords)
3. Removal of the offending stimulus*****
4. Sux 20-40mg (give if precious maneuvers don’t work and the sats are dropping).

Question 19

What should we always remember to do before extubation?

Answer 19

1. Suction the oropharynx!!
2. Remember that secretions can cause laryngospasm.
3. Risk for laryngospasm is greatest on emergence rather than induction.

Question 20

What could trigger a laryngospasm?

Answer 20

• Secretions (vomitus, blood, saliva)
• Foreign body
• Pain
• Pelvic or abdominal visceral stimulation
• Stimulating the glottis in a LIGHT plane of anesthesia (Phase 2)
• Reactive Airway disease

Question 21

Prevention of laryngospasm

Answer 21

1. Deep plane of anesthesia prior to incision
2. Extibation ONLY nearly fully awake or deep
   
   1. NO INBETWEEN (Stage 2)
3. Suction Oropharynx prior to extubation
4. Remove ETT with a positive pressure breath!