Lecture 6: Emergence, Extubation, Transport, Handoff

stages of anesthesia created by

Arthur Guedel in 1937

4 stages

Stages of anesthesia are primarily used for what now?

emergence

differences of anesthesia stages

respiratory changes

pupillary alterations

eye movements

changes in vomiting and swallowing response

at what stage of anesthesia does medullary paralysis occur?

stage 4

stage 1

amnesia and analgesia

from beginning of anesthesia to loss of consciousness

stage 2 starts with

starts with loss of consciousness

stage 2 indicators

-coughing, vomiting, struggling

-divergent eyes

-risk for laryngospasm

-excitement periord with irregular breathing

stage 3

surgical anesthesia; planes

planes of stage 3

plane 1-4

plane I

sleep

plane II

sensory loss

plane III

loss of muscle tone

plane IV

intercostal paralysis

stage 4

medullary paralysis

from the arrest of respiration to death

stage 4 indicators

respiratory arrest and circulatory collapse

pupils widely dilated and muscles relaxed

preparation for emergence

estimate remaining duration of surgery

decrease concentration of gas/rate of iv agent

hypoventilate patient

administer NDMR reversal (wait for fascia closure)

what does hypoventilating do for the patient for emergence? Do COPD patients need a higher or lower buildup of CO2?

builds up CO2

-higher

when can you administer NDMR reversal

after fascia/last layer closed and at least 1 twitch

for NDMR reversal

assess depth of neuromuscular blockade via train of four

where do we do TOF

adductor pollicis ulnar nerve

orbicularis oculi facial nerve

0 twitch %

~100%

1 twitch %

95 and no free drug

2 twitch %

90-95 and no free drug

3 twitch %

80-85 and no free drug

4 twitch %

70-80 and no free drug

do you reverse with 4 twitches

YES

types of reversal agents

cyclodextrin

anticholinesterases with concurrent anticholinergics

types of cyclodextrin

sugammadex

types of anticholinesterases

edrophonium and neostigmine

types of concurrent anticholinergics

atropine and glycopyrrolate

atropine

matches with edrophonium

quick onset

crosses BBB and can cause sedation/hallucinations

atropine dose with edrophonium

0.015-0.03mg/kg with 0.5-1mg/kg of edrophonium

glycopyrrolate

better timing with neo

strong antisialagogue

quaternary structure does not cross BBB

glycopyrrolate dose with neostigmine

0.2 mg per 1 mg of neo

1 ml glyc 1 ml neo

objective cues of giving enough reversal

TOF 4/4

sustained tetany for more than 5 sec without fade

subjective cues of giving enough reversal

5 sec head lift

forced hand grip

spontaneous breathing with adequate TV

what to do if patient isnt fully reversed

wait it out

drugs to bridge during emergence

-propofol

-anesthetic gases concentration or N2O

-override ventilation if patient trying to self ventilate

preparing for post op pain

timing narcotics

titrate narcotics to RR

use adjuncts

timing narcotics

onset

duration

potency

titrate narcotics to respiratory rate

only when self ventilating

adjuncts for pain

acetaminophen

ketorlac

local infiltration

causes of PONV

risk factors

surgical risk factors

opioids

N2O

pain

hypovolemia

risk factors of PONV

-past history or motion sickness

-female

-GA

-non smoker

-ENT, laparoscopic, gyn surgery

-opioid use

-younger age

high risk PONV patients

female

prior PONV/motion sick

nonsmoker

post op opioids

zero factors PONV

10% risk

zofran 4mg

one factor PONV

20 % risk

zofran and decadron 4mg

two factors PONV

40% risk

zofran decadron and +/- propofol infusion

three factors PONV

60% risk

zofran, decadron, propofol infusion, +/- scopolamine patch

four factors PONV

80% risk

zofran, decadron, propofol infusion, and scopolamine patch

fresh gas flows

100% oxygen for 5-10 mins

low flows until gas turned off then 10+L/min

emergence positioning

return patient to supine or back up prior to extubating

might have to reintubate

emergence equipment

equipment to re-intubate

assess for airway obstruction

during closing steps

check TOF

reverse NDMR

lighten anesthetic

increase ETCO2

return to spontaneous breathing

titrate narcotics to RR

surgery over steps

gas off

O2 flows high

suction

extubate when patient meets criteria

when to extubate

usually stage 1

signs to extubate

-eyes midline

-regular breathing pattern

-return of consciousness

-airway secured and protected

-extubation criteria met

types of extubation

awake and deep

awake extubation

-stage 1

-follows commands and can can protect airway

-respiratory mechanics appropriate

-strong and fully reversed

-hemodynamically stable

ways to protect airway

coughing, gagging, bucking

respiratory mechanics

TV, RR, ETCO2, SpO2

deep extubation

-stage III

-adequately reversed

-greater than 1 MAC agent

-suction first

-extubate, gas off, high O2 flows

-OAW/NAW and mask in face

always prepare for _____ when deep extubation

laryngospasm and reintubation

extubation complications

bucking

slow to wake up

apnea

respiratory failure

bucking

reflexive response to noxious stimulus

how to stop bucking

-narcotics attenuate-25 ug fentanyl

-lidocaine can numb airway

-turn vent off when recognizing wakefullness

slow to wake up

dependent on ventilation, FGF, concentration gradient, intravenous agents, and patient

low flow and hypoventilation =

slow to wake up

high flow and hyperventilation =

fast to wake up

intravenous agents

dependent on half life and length of infusion

apnea upon extubation

rule our laryngospasm vs apena

laryngospasm on extubation

jaw thrust, APL on 20 10L/min O2 positive pressure breath, and succinylcholine

if apnea on extubation

attempt to vent off residual gas and stimulate

consider naloxone or residual NMB

respiratory failure

the need to reintubate after extubation or the need for continued mechanical ventilation beyond 48 hours after end of surgery

common causes of respiratory failure

opioid overdose

residual NMB

-surgical swelling or hematoma

-airway obstruction

-laryngospasm

-bronchospasm

-V/Q mismatch

V/Q mismatch due to

-aspiration of gastric contents

-pulmonary edema

-pulmonary embolism

-atelectasis

transport to PACU

transport with oxygen

visual monitoring

appropriate position

monitors as needed

palmar capnography

chin lift and feel hot warm air on hand

appropriate transfer position

lateral vs supine vs sitting

lateral if vomit

sit up if can

transport to ICU

-ambu bag/transport ventilator

-transport monitors

-drugs

-airway equipment

what monitors do you need when transporting to ICU

BP, pulse ox, ambu bag, EKG

arrival in PACU steps

1. lock bed

2. switch stretcher O2 to wall O2

3. apply monitors and cycle BP

4. reassess patients airway and respiratory pattern

5. assess additional vital signs

6. assess patient's mental status and overall well being

PACU report

patient name

your name and role

procedure

surgeon and anesthesiologist

-allergies

-pertinent past medical history

-pertinent events in surgery

-drugs given

-fluid ins and outs

-any concerns?

potential pacu problems

-agitation and delerium

-airway edema

-obstructive sleep apnea

-opioid overdose

benzodiazepine overdose

-hypothermia and shivering

agitation and delirium common in

children and older patients

how to treat agitation and delirium

haldol 2.5-5mg for elderly

delirium often resolves

spontaneously within a few minutes

differential diagnosis of delerium

-poor pain control

-drug side effects

-hypoglycemia

-bladder distension

-hypoxia or PE

what drugs can cause delerium

ketamine

atropine

airway edema

-prolonged prone or trendelenburg positioning

-large fluid volumes

-procedures on tongue, pharynx, neck, hematoma

obstructive sleep apnea

CPAP from home

think about narcotic usage

transport with OAW/NAW

sit patient up

opioid overdose

use Naloxone

use when depressed respirations and mental status but will reverse analgesia

naloxone and analgesia

use carefully will block pain receptors and cause pain

-want pt breathing but not in pain

naloxone dilute

dilute from 0.4mg/ml to 0.04mg/ml

naloxone administartions

start with 20-40 ug

nalaxone administrations

monitor respirations and level of consciousnness

benzodiazepine overdose

use romazicon (flumazenil)

can be used in combination with naloxone

flumazenil dosing

200 ug every 1-2 mins

comes as 100ug/ml

when administering flumazenil

level of consciousness not adequate and monitor patient

shivering

physiological response to hypothermia, using striated muscle contraction to produce heat