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Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1Anesthesia 1
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    ANESTHESIA   AND RESUSCITATION   Dr. H. Braden   David Grynspan, Virjanand Naraine and Elsie Nguyen, editors   eil Fam, associate editor    THE ABC’s   REGIONAL ANESTHESIA   . . . . . . . . . . . . . . . .   20   AIRWAY   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   2   Definition of Regional Anesthesia   Tracheal Intubation   Preparation of Regional Anesthesia   Extubation   erve Fibres   Epidural and Spinal Anesthesia   BREATHING (VENTILATION)   . . . . . . . . . . . . . . . .   5   IV Regional Anesthesia   Manual Ventilation   Peripheral Nerve Blocks   Mechanical Ventilation   Obstetric Anesthesia   Supplemental Oxygen   LOCAL INFILTRATION,   . . . . . . . . . . . . . . . . . .   23   CIRCULATION   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   6   HEMATOMA BLOCKS   Fluid Balance   IV Fluid Therapy   LOCAL ANESTHETICS   . . . . . . . . . . . . . . . . . . .   24   IV Fluid Solutions   Blood Products   SPECIAL CONSIDERATIONS   . . . . . . . . . . . . .   25   Transfusion Reactions   Atypical Plasma Cholinesterase   Shock    Endocrine Disorders   Malignant Hyperthermia   ANESTHESIA   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   12   Myocardial Infarction   Preoperative Assessment   Respiratory Diseases   ASA Classification   Postoperative Management   MONITORING   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   14   Commonly Used Monitoring Devices   Less Frequently Used Monitors   TYPES OF ANESTHESIA   . . . . . . . . . . . . . . . . . . . .   15   GENERAL ANESTHETIC AGENTS   . . . . . . . . . . . .   15   Definition of General Anesthesia   Balanced Anesthesia   Premedication   IV Anesthetics (excluding Opioids)   arcotics/Opioids   Volatile Inhalational Agents   Muscle Relaxants + Reversing Drugs   MCCQE 2000 Review Notes and Lecture Series   Anesthesia 1       Notes   THE ABC’s - AIRWAY   t   most acute airway problems in an unconscious patient can be   managed using simple techniques such as:   ã 100% O   with the patient in the lateral position   2   (contraindicated in known suspected C-spine #)   ã head tilt via extension at the atlanto -occipital joint   (contraindicated in known/suspected C-spine #)   ã jaw thrust via subluxation of TMJ   ã suctioning (secretions, vomitus, foreign body)   ã inserting oro - or naso-pharyngeal airway   t   nasopharyngeal airway indicated when an oropharyngeal airway is   technically difficult (e.g. trismus, mouth trauma)   ã large adult 8 -9 ID, medium adult 7-8 ID, small adult 6-7 ID   t   complications of nasopharyngeal airway include:   ã tube too long - enters the esophagus   ã laryngospasm   ã vomiting   ã injury to nasal mucosa with bleeding and aspiration of clots into the trachea   t   oropharyngeal airway holds tongue away from posterior wall of the pharynx   ã large adult 100 mm, medium adult 90 mm, small adult 80 mm   ã facilitates suctioning of pharynx   ã prevents patient from biting and occluding ETT   t   complications of oropharyngeal airway include:   ã tube too long - may press epiglottis vs. larynx and obstruct   ã not inserted properly - can push tongue posteriorly   t   more advanced techniques include:   ã tracheal intubation (orally or nasally)   ã cricothyroidotomy   ã tracheostomy   TRACHEAL INTUBATION   t   definition: the insertion of a tube into the trachea either orally or nasally   Indications for Intubation - the 5 P's   t   P   atency of airway   ã decreased level of consciousness   ã facial injuries   ã epiglottitis   ã laryngeal edema, e.g. burns, anaphylaxis   t   P   rotect the lungs from aspiration   ã absent protective reflexes, e.g. coma, cardiac arrest   t   P   ositive pressure ventilation   ã hypoventilation - many etiologies   ã apnea, e.g. during general anesthesia   ã during use of muscle relaxants   t   P   ulmonary Toilet (suction of tracheobronchial tree)   t   P   harmacology also provides route of administration for some drugs   Equipment Required for Intubation   t    bag and mask apparatus (e.g. Laerdal/Ambu)   ã to deliver O   and to manually ventilate if necessary   ã mask sizes/shapes appropriate for patient facial type, age   t    pharyngeal airways (nasal and oral types available)   ã to open airway before intubation   ã oropharyngeal airway prevents patient biting on tube   t   laryngoscope   ã used to visualize vocal cords   ã MacIntosh = curved blade (best for adults)   ã Magill/Miller = straight blade (best for children)   t   Trachelight - an option for difficult airways   t   Fiberoptic scope - for difficult, complicated intubations   t   endotracheal tube (ETT): many different types for different indications   ã inflatable cuff at tracheal end to provide seal which    permits positive pressure ventilation and prevents aspiration   ã no cuff on pediatric ETT (physiological seal at level of cricoid  cartilage)   ã sizes marked according to internal diameter; proper size for    adult ETT based on assessment of patient   ã adult female usually 7.0 to 8.0 mm   ã adult male usually 8.0 to 9.0 mm   ã child (age in years/4) + 4 or size of child's little finger = approximate ETT size   ã length approximately 21 cm to 23 cm (adult female and male)   Anesthesia 2   MCCQE 2000 Review Notes and Lecture Series       Notes   THE ABC’s - AIRWAY   . . . CONT.   ã if nasotracheal intubation, ETT 1 -2 mm smaller and 2-3 cm longer    ã should always have ETT smaller than predicted size   available in case estimate was inaccurate   t   malleable stylet should be available; it is inserted in ETT to change   angle of tip of ETT, and to facilitate the tip entering the larynx; removed   after ETT passes through cords   t   lubricant optional   t   local anesthetic spray optional   t   Magill forceps used to manipulate ETT tip during nasotracheal intubation   t   suction, with pharyngeal rigid suction tip (Yankauer) and tracheal   suction catheter    t   syringe to inflate cuff (10 ml)   t   stethoscope to verify placement of ETT   t   detector of expired CO   to verify placement   2   t   tape to secure ETT and close eyelids   t   remember    “SOLES”   S   uction   O   xygen   L   aryngoscope   E   TT   S   tylet   Preparing for Intubation   t    performed only by trained, experienced personnel   t   failed attempts at intubation can make further attempts difficult   due to tissue trauma   t    plan and prepare (anticipate problems!)   ã assess for potential difficulties (see Preoperative Assessment Section)   t   ensure equipment (as above) is available and working e.g. test cuff of ETT, and   means to deliver positive pressure ventilation e.g. Ventilator, Laerdal bag   t    preoxygenation of patient   t   may need to suction mouth and pharynx first   Proper Positioning for Intubation   t   FLEXION of lower C-spine and EXTENSION of upper C-spine at   atlanto- occipital joint (“sniffing position”)   t   sniffing position provides a straight line of vision from the oral cavity to   the glottis (axes of oral cavity, pharynx, glottis, and trachea are aligned)   t   above CONTRAINDICATED in known/suspected C-spine fracture   t   once prepared for intubation, the normal sequence of induction can vary   Rapid Sequence Induction   t   indicated in all situations predisposing the patient to   regurgitation/aspiration   ã acute abdomen   ã bowel obstruction   ã emergency operations, trauma   ã hiatus hernia with reflux   ã obesity   ã pregnancy   ã recent meal (< 6 hours)   ã GERD   t    procedure as follows   ã patient breathes 100% O   for 3-5 minutes prior to induction of    2   anesthesia (e.g.thiopental) perform Sellick's manoeuvre”   (pressure on cricoid cartilage) to compress esophagus, thereby    preventing gastric reflux and aspiration   ã induction dose is quickly followed by muscle relaxant   (e.g. succinylcholine), causing fasciculations then relaxation   ã intubate at time determined by clinical judgement - may use end   of fasciculations if no defasciculating NMJ Blockers have been given   ã inflate cuff, verify correct placement of ETT, release of cricoid   cartilage pressure   ã manual ventilation is not performed until the ETT is in place   (to prevent gastric distension)   Confirmation of Tracheal Placement of ETT   t   direct   ã visualization of tube placement through cords   ãCO   in exhaled gas as measured by capnograph   2   ã visualization of ETT in trachea via bronchoscope   MCCQE 2000 Review Notes and Lecture Series   Anesthesia 3       Notes   THE ABC’s - AIRWAY   . . . CONT.   t   indirect   ã auscultate lung fields for equal breath sounds bilaterally   and absence of breath sounds over epigastrium   ã condensation of water vapor in tube during exhalation   ã refilling of reservoir bag during exhalation   ã chest movement and no abdominal distension   ã feel the normal compliance of lungs when bagging patient   t   no one indirect method is sufficient   t   esophageal intubation is suspected when   ã capnograph shows end tidal CO   zero or near zero   2   ã abnormal sounds during assisted ventilation   ã hypoxia/cyanosis   ã presence of gastric contents in ETT   ã distention of stomach/epigastrium   Complications during Laryngoscopy and Intubation   t   mechanical   ã dental damage   ã laceration (lips, gums, tongue, pharynx, esophagus)   ã laryngeal trauma   ã esophageal or endobronchial intubation   t   systemic   ã activation of sympathetic nervous system (HTN, tachycardia, dysrhythmias)   ã bronchospasm   Problems with ETT and Cuff    t   too long - endobronchial intubation   t   too short - comes out   t   too large - trauma   t   too narrow - increased airway resistance   t   too soft - kinks   t   too hard - tissue damage   t    poor curvature - difficult to intubate   t   cuff insufficiently inflated - allows leaking and aspiration   t   cuff excessively inflated - pressure necrosis   Medical Conditions associated with Difficult Intubation   t   arthritis - decreased neck ROM (e.g. RA - risk of atlantoaxial subluxation)   t   obesity   t   tumours - may obstruct airway or cause extrinsic compression or    tracheal deviation   t   infections (oral)   t   trauma - increased risk of cervical spine injuries, basilar skull   and facial bone fractures, and intracranial injuries   t    burns   t   Down’s Syndrome - may have atlantoaxial instability and macroglossia   t   Scleroderma - thickened, tight skin around mouth   t   Acromegaly - overgrowth and enlargement of the tongue, epiglottis, and vocal cords   t   Dwarfism - associated with atlantoaxial instability   t   congenital anomalies   EXTUBATION   t    performed by trained, experienced personnel because reintubation   may be required at any point   t   laryngospasm more likely in semiconscious patient, therefore must   ensure level of consciousness is adequate   t   general guidelines   ã check that neuromuscular function is normal   ã check   that patient is breathing spontaneously with adequate rate and tidal volume   ã allow patient to breathe 100% O   for 3-5 minutes   2   ã suction secretions from pharynx   ã deflate cuff, remove ETT on inspiration (vocal cords abducted)   ã ensure patient breathing adequately after extubation   ã ensure face mask for O   delivery available   2   ã proper positioning of patient during transfer to recovery   room e.g. sniffing position, sidelying   Complications Discovered at Extubation   t   earlyã aspiration   ã laryngospasm   t   late ã transient vocal cord incompetence   ã edema (glottic, subglottic)   ã pharyngitis, tracheitis   Anesthesia 4   MCCQE 2000 Review Notes and Lecture Series  
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