CRNA 560- Induction and Emergence

what is the "pre-op" check list for anesthesia providers

MS. MAIDS
Machine
Suction
Monitors- audible (BP, SpO2, EKG, ETCO2, temp)
Airway
IV- patent
Drugs
Special Monitors

Chart Review
Pt assessment, discussion, consent

what should be apart of your machine setup

check cylinder pressure
Ambu bag
run self test
check vaporizers- full and cannot be on at the same time
check CO2 absorbent
check scavenger suction level
suction for pt is on HIGH and reachable area (under pillow)
monitors audible
check circuit connections
do manual high pressure leak test (check APL and scavenger)
check piston/bellows function (and valves)

what do you need set out to be prepared for airway

Bag valve mask
-correct size

Tap for ETT and eyes

Oral/nasal airway x2
-tongue blade x2

ETTs x2
-check balloon
-stylet tube and shape
-check laryngoscope blade/handle/light x2

LMAs
-correct size, lubricant

Rescue equipment
-eschmann (bougie)
-video laryngoscope, McGrath

what are some preoperative sedatives you can give and the dose

Midazolam (1-2mg)
Fentanyl (25-100mcg)

what is the order of induction agents

Fentanyl

Lidocaine

Propofol or Etomidate (etomodiate more hemodynamically stable)
-when apneic check eyelash reflex before ventilating or paralyzing (tape eyes)
-make sure you can manually ventilate patient before paralyzing (back up means of ventilation)

Paralytic
-Rocuronium or vecuronium (or sucs for RIS)
-check TOF right after dose 4/4
-turn some gas on to maintain sedation since propofol is quick on and off
-typically takes 3 mins before TOF 1-2/4 then you can intubate
--remember to turn gas off before intubating other wise filling OR with anesthetic gas

what emergency drugs should be close by during induction

phenylephrine
ephedrine
succinylcholine (if not used for induction)

what special monitors may be needed

NG/OG
PNS
BIS monitor
Tape- for ETT and eyes
Temp prode

face to face interview with pt should consist of

1. Introduce yourself first, including title/role
2. Verify patient name and birthdate
3. Verify allergies
4. Discuss medication list
-what did they take, what did they hold
5. Past medical history
6. Patient or blood relative adverse outcomes or events with anesthesia?
-post-op N/V
-elayed emergence
-pseudocholinesterase deficiency (succinylcholine is metabolized by pseudocholinesterase)
-family history of malignant hyperthermia
7. Physical assessment
-Airway - mallampati, thyromental distance, teeth, subluxation of jaw; Head/Neck Mobility
-Heart/Lung
-Numbness/tingling issues in extremities (positioning and procedures can also cause this)
-Activity status
-check surgical site is marked and consent signed

what are the four stages of anesthesia

Stage 1: Analgesia (disorientation, conscious sedation)
Stage 2: Excitement/Delirium
Stage 3: Surgical Anesthesia (goal)
Stage 4: Overdose

describe stage 2 of anesthesia

Excitement/Delirium Phase

LOC but spontaneous breathing
Excited/uncontrolled movements
eye roaming- dilated pupils
eyelash reflex absent
increase HR and BP

what is stage 2 of anesthesia associated with

laryngospasm or vomiting
-do NOT intubate or extubate in this stage

describe stage 3 of anesthesia

target level
characterized by respiratory depression and ceased eye movement
broken into 4 planes

describe plane 1 of stage 3 of anesthesia

plane 1: spontaneous breathing, constricted pupils, central gaze
loss of eyelid, conjunctival, swallowing reflexes

describe plane 2 of stage 3 of anesthesia

plane 2: intermittent cessation of breathing, loss of corneal and laryngeal reflexes, eye movement stopped, increase lacrimation

describe plane 3 of stage 3 of anesthesia

plane 3: complete relaxation of intercostal and ABD muscles, loss of pupillary light reflex
-most ideal plan (when NMB not used)

describe plane 4 of stage 3 of anesthesia

plane 4: irregular breathing, paradoxical rib movement, full diaphragm paralysis causing apnea

describe stage 4 of anesthesia

Overdose
-flaccid skeletal muscles
-fixed and dilated pupils
-hypotension
-weak and thready pulses

Steps to awake extubation

100% FiO2
Optimize position
adequate SPONT minute ventilation
follow commands
clear secretions with suction
insert oral airway
deep breath, deflate cuff, extubate on INSPIRATION with PEEP
-end of inspiration helps prevent atelectasis
-PEEP after helps prevent laryngospasm

what is Midazolam IV sedation dose

0.01-0.1 mg/kg

what is Midazolam PO sedation dose in children

0.5-1 mg/kg

what is Midazolam IV induction dose

0.1-0.4 mg/kg

what is Midazolam
onset IV
duration IV
half-life

onset: 30-60 seconds
duration: 20-60 minutes
half-line: 2 hours

Cardiovascular, respiratory, and cerebral effects of Midazolam for sedation dose

minimal effects

Cardiovascular, respiratory, and cerebral effects of Midazolam for induction dose

Cardio: dec BP, CO and PVR

Resp: resp depression

Cerebral: dec cerebral oxygen consumption, cerebral blood flow, and ICP

what is Fentanyl intraoperative anesthesia dose

2-50 mcg/kg

what is Fentanyl postoperative analgesia dose

0.5-1.5 mcg/kg

what can rapid opioid administration cause

skeletal muscle rigidity
-causes difficulty for pt to breathing so sedated, paralyze, and intubate

why is Lidocaine a part of the induction medications

blunts sympathetic response, blunts cough

what is Lidocaine pre-intubation dose

1.5 mg/kg

what is Propofol induction dose

1.5-2.5 mg/kg

what is Propofol infusion dose

25-200 mcg/kg/min

what is Propofol onset and duration

onset: 30-60 seconds
duration: 5-10 minutes

how is propofol metabolized

Liver (CYP 450)
Lungs (extrahepatic metabolism)

what allergies should you investigate reaction and do a test dose of propofol first

eggs, soy, and peanuts
-no evidence propofol has cross sensitivity

Cardiovascular, respiratory, and cerebral effects of Propofol

Cardio: dec BP, SVR, venous tone (preload), myocardial contractility

Resp: less sensitive to CO2 (resp depression/apnea) & inhibits hypoxic ventilatory drive

Cerebral: dec cerebral oxygen consumption, dec cerebral blood flow, dec ICP, dec intraoccular pressure, anticonvulsant

what is Succinylcholine (Anectine) dose for induction

1-1.5 mg/kg

what are side effects of Succinylcholine

increase potassium by 0.5 mEq/L (don't give to burn pts)
malignant hyperthermia
fasciculation

what is Rocuronium (Zemuron) defasciculating dose

0.06-0.1 mg/kg

what is Rocuronium (Zemuron) intubation dose

0.45-0.9 mg/kg

to have an onset of 60-90 sec what dose do you need for Rocuronium (Zemuron)

0.9-1.2 mg/kg

what is Rocuronium (Zemuron) maintenance bolus dose

0.15 mg/kg

what is Vecuronium (Norcuron) intubation dose

0.08-.12 mg/kg

what is Vecuronium (Norcuron) maintenance bolus dose

0.04 mg/kg followed by 0.01 mg/kg every 15-20 minutes

what is the dosing for Sugammadex

For Rocuronium and Vecuronium
-TOF 2/4 or better= 2 mg/kg
-TOF 0/4 + 2 post-tetanic count or better = 4 mg/kg

ONLY for Rocuronium
3 minutes after Roc dose of 1.2 mg/kg or less
-give 16 mg/kg of Sugammadex

what is a side effect of Sugammadex

unplanned pregnancy
-reduces effectiveness of hormonal contraceptive for up to 7 days

what is Neostigmine
onset
duration
metabolism

Onset: 5-15 minutes
Duration: 45-90 minutes
Metabolism: 50% renal, 50% hepatic

what is the dose for Neostigmine to reverse non-depolarizing NMB

0.02-0.07 mg/kg
-give Glycopyrrolate before or with

what is Glycopyrolate (Robinul) dose when given with Neostigmine

0.2mg of Glyco for every 1 mg of Neostigmine
-give before or with Neostigmine
-prevents bradycardia, excessive salivation, and other parasympathetic responses

what are the steps for RSI

preoxygenate to as close to 100% as possible
lidocaine, defasiculating dose of Roc
cricoid pressure- do not release pressure until airway verified
propofol immediately followed by succs
NO mask ventilation
intubate
verify correct placement--> if in airway then can release cricoid pressure
when twitches are back then can use a non-depolarize

why do RSI

full stomach
trauma
severe reflex
possible difficult airway (not always RSI though)