1.  Injury to soft tissue, gums, lips

2.  Dental trauma

3.  Nose bleeds

4.  Puncture of tearing of trachea

What is required if dental trauma occurs, and fragments are not found?

What are some tricks to help reduce the risk of nose bleed with intubation?

CXR 

Use lubricated nasal airway first, neosynephrine, and lubrication

What are some causes of ETT obstruction?

Any ideas on prevention?

What is a complication of ETT obstruction?

Biting the tube (use oral airway)

Kinking the tube or foreign material, such as vomit, sputum, water, blood, and tissue

Negative pressure pulmonary edema

What is the most common post op anesthesia complaint?  How long does it usually take to resolve?

What are some contributing factors?

Sore throat.  It is usually transient and not severe, resolving with fluid intake over a 24 hour period of time.

1.  Size of ETT

2.  DVL attempts

3.  NG of OG

4.  Smoking hx

5.  Females

What are signs of esophageal intubation?

What can delay desaturation in esophageal intubation?

What should you do following esophageal intubation?

1.  No breath sounds

2.  Epigastric gurgling with bag inspiration

3.  Lack of sustained ETCO2

4.  Others (eventually will desaturate)

Preoxygenation

Place OG or NG and empty stomach

What side is most common for endobronchial intubation in adults, and why?

What are signs of endobronchial intubation?

Right, branches at 25 degree angle

1. Uneven chest rise

2.  Increase peak inspiration pressures

3.  Decreased breath sounds on unventilated side

4.  Drop in ETCO2

5.  Tachycardia

6.  Hypoxemia/desaturation (infants esp)

7.  Bronchospasm

What is the cause of 23% of all critical post op respiratory events in adults?

What is laryngospasm?

What are the nerves involved?

A forceful, involuntary spasm of the laryngeal musculature.

Afferent occurs through stimulation of the internal branch of the superior laryngeal nerve, and the laryngeal muscle response vial the recurrent laryngeal nerve.

What patients are most likely to develop laryngospasm?

What are some causes?

Those with a history of smoking, asthma, bronchitis, COPD and URI's.

Stimulation of the supraglottic region during a light plane of anesthesia, pain during a light plane, pelvic or abdominal visceral stimulation.

How many phases are associated with laryngospasm?

Describe them.

Two.  The first phase is described as a shutter phase where the vocal cords are spasming, but not producing total occlusion.

The second phase is describes as a ball-valve phase, where the vocal cords are fully adducted, and the false cords and supraglottic tissue produce complete occlusion.

What are laryngospams difficult to differentiate from?

How can partial occlusion be detected?

What does total occlusion lead to?

Airway occlusion due to the tongue or soft palate.

By a higher pitch sound as air exchanges.

No air exchange, no ETCO2, and no chest rise or breath sounds.

How will placement of an oral airway affect laryngospasm?

What is the treatment?

It will not help.

1.  Gentle positive pressure ventilation with 100% O2.

2.  Lidocaine 1-1.5 mg/kg IV

3.  Succinylcholine 0.25-1 mg/kg IV

4.  Succs 4 mg/kg IM

5.  Intubation

When can laryngospasm occur?

When is it least likely to occur?

Induction, during mask management, LMA insertion and maintenance, emergence, and post op.

Least likely to occur in the fully awake patient.

How does intraop bronchospasm usually manifest?

What patients are most likely to develop bronchospasm?

Wheezing, increased peak inflation pressures, decreasing exhaled tidal volumes or a slow rising waveform on ETCO2.

Most often associated with asthmatics and patients with reactive airways (URIs, smokers)

When is the most critical time for a patient at risk for bronchospasm?

How do regionals and general anesthesia with mask technique affect bronchospasm?

During instrumentation of the airway during DVL.

They may reduce the risk, but bronchospasm can still occur.

What types of drugs are associated with bronchospasm?

When can surgical stimulation potentially trigger bronchospasm?

Histamine releasing drugs, as well as volatile anesthetics (cold, dry gas).  Desflurane is more irritating.

During a light anesthetic plane.

1.  Deepening the anesthetic volatile agent

2.  Beta 2 agonist (albuterol) delivered to the inspiratory limb of the circle system

3.  Hydrocortisone 1.5-2 mg/kg

4.  Lidocaine 1-1.5 mg/kg

5.  Atropine or glycopyrolate (1 mg)

What causes post anesthetic croup?

Who is this most often seen in?

When does it usually occur?

Result of subglottic edema

Children

After extubation, if not immediately, within 2-4 hours

What characterizes post extubation croup?

What are other signs?

Barky cough

tachypnea, labored respirations, retracting, arterial desaturation.

Mild cases require little more than humidified oxygen.

Racemic epi aerosol treatment is next.  0.5 ml of 2% solution diluted into a volume of 2-4 ml

Steroids may be used (dexamethasone 0.1-0.5 mg/kg)

Severe cases with hypoxemia requires intubation or advanced airway management.

How does the patient history help us determine induction sequence?

Give an example of how site of surgery can help determine induction?

Helps to identify co-existing diseases that may benefit from one technique vs the other.  (Ex. asthma may benefit from regional or LMA vs intubation d/t reactive airway.)

Tonsillectomy is painful, requires goo airway control to prevent blood and tissue from entering the lungs, so intubation is best choice.

Why would duration of surgery impact choice of induction sequence?

How might recovery time/post anesthetic care impact anesthetic choice?

Age?

Long surgeries may be not be appropriate for masking or for LMA

If a patient is going home, they shouldn't have long acting blocks, whereas a patient that will be admitted might benefit from a longer acting SAB

Although you can use a SAB for kids, they probably won't stay still for the surgery

Regional

Peripheral nerve blocks

General Anesthesia (mask, RSI, non-rapid)

MAC

Sedation cases in the OR (d/n involve CRNA)

Combination

What is included in regional anesthesia?

What about peripheral nerve blocks?

What is an example of combination technique?

subarachnoid blocks or epidurals

Femoral nerve blocks, ankle blocks, brachial plexus blocks, digital blocks, etc

A pt with a spinal for a knee replacement will also receive a MAC (narcotic, versed, ketamine) to provide comfort, amnesia, and sedation.  Another example is general anesthesia with an epidural that is bolused prior to emergence for post-op pain control

Optimal patient safety and satisfaction

Optimal operating conditions

Rapid recovery, few post op side effects

Low cost

Early transfer or DC from PACU/hospital

Good pain control

Permit optimal turn over times

Analgesia

Amnesia

Producing unconsciousness

Inhibiting normal body reflexes to make surgery safe and easier to perform

Relaxing the muscles of the body

What are the pre-requisites for general anesthesia?

(8)

Oxygen

Suction

Checked machine and confirmed circuit

Monitoring

Drugs

Airway equipment

Skilled assistance

Emergency equipment and drugs in room

What does general anesthesia mean?

What is the triad of general anesthesia?

A total loss of consciousness.  May or may not have spontaneous ventilation.

Hypnosis, muscle relaxation, analgesia

What are the steps of hypnosis, ranging from awake to death?

What volatile is least pungent?  What is it used for (in terms of induction)?

What are the two divisions of IV induction?

Awake, amnesia, sedation, hypnosis, coma, death.

Sevoflurane, inhalation induction.

Rapid or non-rapid sequence induction.

What mac % sevo might you use for inhalation induction, and how long before you will reach LOC?  How long before you achieve intubating or LMA conditions?

If you intubate or insert an LMA without IV meds, what is required?  What trick can help achieve this quicker?

8%, LOC can occur in 1 minutes, intubating or LMA insertion can be achieved within 2 minutes.

Requires a patient in deep anesthetic state (surgical conditions).  A trick is to prime the circuit by opening the APL, run high flows, and set the vaporizer to 8%

As the patient drifts off to sleep with mask induction, what stage do they enter?  What should you do?

If you are not planning to intubate, once the patient is deep, what might you do next?

If using an IV, when would you insert one?  If planning to intubate, what would you do with your gases?

Stage II (excitement).  Place a hand behind the head to be able to GENTLY follow the patient.

Place an oral airway, and use the mask straps to hold the mask in place.

Once deep, place IV.  Nitrous should be dc'd, so you can preoxygenate with 100% oxygen.

*monitors on  *nitrous/oxygen mix (70/30)/sevo 

*place hand behind head  *watch stages  *as patient enters stage 3 and tidal volume decreases, assist ventilation  *tape eyes (stop here if doing mask case)  *IV started, meds delievered  *100% oxygen and sevo  *intubate once drugs circulated and preoxygenated  *check placement, etc

1.  The airway is not secure

2.  The maximum pressure that should be used is 20 cm H2O.

3.  Requires frequent hands on time

4.  Tired hands

5.  If the case requires a muscle relaxant, the patient should be intubated.

What is the risk with an unsecure airway?

What conditions might be problematic maintaining a pressure under 20 cm H2O with mask ventilation?

Potential loss of airway or obstruction, with an inability to ventilate.  Unsecure airway can lead to aspiration.

Restrictive airway pattern (obesity) or non compliant lungs.  Trendelenberg. 

Why should a patient requiring muscle relaxant be intubated?

What is the most important anesthetic skill to obtain?

MR reduces airway muscle tone and the esophageal sphincter because it has some skeletal muscle

Good mask technique

When is non rapid intubation utilized?

What is used to render a patient unconconscious?

What happens after an induction agent is given?

When a patient does not need rapid sequence.

IV medication

The eyes are taped and the patient can be ventilated.

During non-rapid sequence induction, what happens once the induction agent peaks?

How do you know the patient is paralyzed?

Mask management can procedure or an LMA can be placed.  If the patient is to be intubated, first give a couple of ventilation breaths.  Then give an intubating dose of paralytic.  Once the paralytic works, the patient is intubated.

Loss of twitches.

1. Length of action of the NDMR.  If you do a NRSI with a longer lasting paralytic but the case is only 15 minutes, the patient will not be ready to reverse.

2.  Delayed airway control.

3.  Difficult airway--would not want to give long lasting NDMR if concerned about not being able to intubate.

*Preoxygenate *Narcotic *Induction agent *Tape eyes *Attempt ventilation *Mask management or LMA insertion or *Paralytic *Ventilate with volatile anesthetic until paralytic has worked (TOF) *Intubate

*Follow steps after intubation

*Preoxygenate *Priming NDMR dose/defasciculation dose *IV induction drugs *Succinylcholine or Rocuronium *Cricoid pressure *Tape eyes *DO NOT VENTILATE--once TOF indicates paralysis, intubate

*Check tube placement

Why do we use a priming dose with RSI?

What is most commonly used?

A small dose will make the next dose work faster (if using Roc) or it is used for fasciculations.

Rocuronium 0.4-0.6 mg

1.  Rocuronium is used when succs if contraindicated.

2.  Rocuronium produces a lengthier paralysis

3.  Cricoid pressure is not released until tube placement is confirmed

What are some contraindications with succs?

Name the inhalation anesthetics. (5)

Hyperkalemia, someone with musculoskeletal issues such as quad, prolonged bedrest.

Nitrous oxide

Isoflurane

Sevoflurane

Desflurane

Halothane

Pentothal--Gold standard

Propofol--most commonly used

Etomidate

Benzodiazepines

Ketamine

Good analgesia = what?

What effect does analgesia have?

What are some examples?  (general classes)

Good anestesia

Hypnotic sparing effect

Opiates

Local anesthetics

NSAIDS

*Aids intubation

*Helps surgery/surgeon

*Surgery of long duration

*Reduces maintenance dose of anesthetic agents

What is a MAC?

What does it do?

When is it used?

Monitored Anesthesia Care

Provides analgesia, some amnesia while the patient maintains airway reflexes

Used in conjunction with localization or other regional techniques.

Depolarization down the T-tubules activates what?

What is in close proximity?