Induction/Emergence

Question 1

How do you make an anesthetic plan?

Answer 1

1. chart review
2. history and physical
3. interpret pre-op labs
4. review ASA classification
5. determine monitoring requirements
6. develop anesthetic plan
   
   1. consider comorbidities
   2. consider specific surgery

Question 2

What do you prepare to deliver an anesthetic?

Answer 2

MSMAIDP

• M: monitors on and alarms set
• S: suction on, adequate, and nearby
• M: means of PPV/Machine check
• A: Airway (ETT/LMA)
• I: IV and fluids
• D: Drugs- Emergency and basic drugs
• P: patient position

Question 3

What is the induction process?

Answer 3

1. Position pt in sniffing position
2. turn on O2, begin preoxygenation
3. monitors on, take vital signs, PNS in place
4. Suction on and ready
5. pre-induction meds
6. lidocaine/induction agent
7. test lash reflex
8. give test ventilation
9. check PNS working
10. paralytic drug (continue ventilating)
11. tape eyes
12. when loss of twitches, laryngoscopy and intubation
13. Inflate cuff, check ETT placement
14. tape ETT
15. continue ventilation by bag or ventilator
16. begin maintenance anesthetic

Question 4

Optimal intubating position

Answer 4

“sniffing”

Oral, pharyngeal, and laryngeal axis

Most optimal for visualization of vocal cords and most effective mask ventilation

Question 6

ETT sizing

Answer 6

*always have two sizes available

• Female: 6.5-7.0 mm (depth ≈ 21 cm)
• Male: 7.5-8.0 mm (depth ≈23 cm)
• Ideal position: 4 cm above carina and 2 cm below vocal cords
• All ETT have 15mm outer diameter universal connector

Question 7

Pre- Oxygenation

Answer 7

• Goal to increas O2 concentration in functional residual capacity (FRC) by “washing out” nitrogen in the FRC with O2
  
  • 3-5 minutes of tight mask with normal breathing and 100% FiO2
    
    • = 10 minutes of safe apnea time
  • 4 vital capacity breaths within 30 seconds with 100% FiO2
    
    • =5 minutes safe apnea time.

Question 8

Airway set up

Answer 8

1. appropriately sized face mask
2. ambu bag, circuit (for pos pres)
3. suction
4. tongue depressor
5. oral and nasal airways
6. laryngoscope handle
7. 2 different blades
8. ETT, 2 sizes
9. stylet
10. syringe
11. LMA
12. tape

Question 9

why do you want to give narcotics and lidocaine before induction?

Answer 9

they both help to decrease the sympathetic response to laryngoscopy

Question 10

What should you consider when giving an anxiolytic like versed and a narcotic together?

Answer 10

they are synergistic

1+1=3

especially regarding respiratory depression

Question 11

How do you confirm ETT placement?

Answer 11

• watch it pass through the vocal cords
• fogging of the ETT
• Bilateral chest rise
• bilateral breath sounds
• presence of THREE ETCO2 waveforms

Question 12

How do you determine appropriate depth of ETT?

Answer 12

depth= internal diameter x 3

Question 13

What is rapid sequence intubation?

Answer 13

• technique that induces immediate unresponsiveness and muscular relaxation
• Fastest and most effective way of controlling emergency airway
• Used with full stomach or high risk of aspiration
• sellick’s maneuver- cricoid pressure
• no mask ventilation like in the standard sequence(?)

Question 14

How is RSI different?

Answer 14

• once you pre-oxygenate, start Sellick’s maneuver, gradually increasing pressure as pt falls asleep
• give induction agent, then Succ or high dose Roc
  
  • wait for fasciculation or 60 seconds, watching clock, not the block
• laryngoscopy and intubation
• confirm placement
• release cricoid pressure
• etc…

Question 15

During what phase do you NOT want to extubate your patient?

Answer 15

• Phase 2
• pt can be extubated either nearly fully awake or deeply anesthetized
• Determine what is best by comparing the risk of coughing vs obstruction vs aspiration

Question 16

If you did a RSI, how do you want your patient to be when you extubate?

Answer 16

They MUST be fully awake

Question 17

What are the criteria for extubation?

Answer 17

• Either fully awake or deeply anesthetized
  
  • TV > 6 mls/kg
  • VC > 10 mls/kg (vital capacity)
  • RR < 30 but > 5 and spontaneously breathing
  • SaO2 > 90%
  • ETCO2 < 50 mmHg (maybe 55-60 for COPD)
  • sustained tetanic contraction with PNS

Question 18

What is the process for a nearly fully awake extubation?

Answer 18

• Muscle relaxant fully reversed and confirmed with PNS
• All respiratory criteria are met
• Turn off anesthetic meds including VA
• suction oropharynx
• If patient is responsive to commands and can hold head lift for 5 sec, remove ETT while giving positive pressure breath

Question 19

What is the process for extubation whent the patient is deeply anesthetized?

Answer 19

• Muscle relaxant must be fully reversed and respiratory extubation criteria met
• suction oropharynx
• insert oral or nasal airway
• remove ETT while giving positive pressure breath
• turn off VA or infusions
• mask airway while patient is spontaneously breathing
• watch vigilantly until patient can protect their own airway

Question 20

What is laryngospasm and what are the signs?

Answer 20

• prolonged intense glottic closure
• may have high pitched squeek or no sound
• severe suprasternal and supraclavicular retractions

Question 21

what triggers laryngospasm?

Answer 21

• secretions
• foreing body
• pain
• pelvic or abdominal visceral stimulation
• stimulating glottis under light anesthesia
• RAD

Question 22

How can you prevent laryngospasm?

Answer 22

• Deep anesthesia before surgical stimulation starts
• Do not extubate during phase 2
• suction oropharynx prior to extubation
• remove ETT with positive pressure breath

Question 23

How do you treat laryngospasm?

Answer 23

1. Recognize the event!
2. remove stimulus
3. larson maneuver (jaw thrust)
4. administer 100% FiO2 with continuous positive pressure
5. deeper anesthetic (propofol)
6. small dose of short acting muscle relaxant
   
   1. succ 20-40 mg