Anesthesia Induction

Transition from Pre-Operative to Operating Room (OR)

  • Vital Signs Check

    • Establish baseline vital signs prior to disconnecting patient from pre-operative monitoring.

    • Important to verify that intraoperative vital signs remain within 20% to 30% of pre-operative baselines.

    • Assess heart rhythms alongside other vital signs.

    • Put on a set of gloves and add another glove to right hand

  • Medication Administration

    • Versed (Midazolam) may be administered pre-operatively under certain conditions:

    • Indicated if patient is young, highly anxious, or has high anesthetic tolerance.

    • Avoid giving Versed to patients aged 65 years or older or those with significant health issues.

    • Purpose of Versed:

    • Helps decrease anesthetic induction dose in the operating room.

Patient Interaction and Connection

  • Engaging the Patient

    • While transporting the patient to the OR, engage in casual conversation to lower anxiety:

    • Ask about their job, family, and personal interests.

    • Monitor patient's responsiveness:

    • If the patient is too quiet, it may indicate overdose of pre-operative medication.

    • If they respond well, dosage is likely appropriate or may require more.

Entering the Operating Room

  • Patient Sign-In and Preparations

    • Sign the patient into the OR and note the time of entry.

    • Adjust the head of the bed on the stretcher downward.

    • Transfer IV fluids to the OR pole along with antibiotics.

    • Connect necessary monitoring equipment, ensuring to check blood pressure first as it takes the longest.

  • Position Optimization

    • Confirm the patient's head is positioned properly at the top of the bed.

    • Use a doubled pillow underneath the shoulder to ensure optimal alignment.

    • Position the patient's head with foam pads to align the sternum and ear tragus:

    • Ensure proper airway positioning.

Preoxygenation Protocol

  • Optimize Ventilation

    • Ensure the APL (Adjustable Pressure Limiting) valve is open and set FiO2 (Fraction of Inspired Oxygen) to 100%.

    • Maximize gas flow before applying the mask.

    • Guide the patient to take deep, vital capacity breaths (approximately eight) for preoxygenation, extending intubation time to 7-9 minutes if done effectively.

    • Monitor end-tidal CO2 during preoxygenation:

    • Possible to have a nurse hold the mask or use a strap to free up hands for preparation.

Preparation for Intubation

  • Medication Setup

    • Arrange necessary medications and equipment at the head of the bed:

    • Eye tape, endotracheal tube, laryngoscope (McGrath or MAC blade).

  • Intubation Sequence

    • Administer drugs in the following order for normal intubation:

    1. Fentanyl

    2. Lidocaine

    3. Propofol

    • Wait until the patient is unconscious after administration:

    • Check for responsiveness by calling their name and performing an eyelash reflex test.

    • Eye Protection:

    • Tape the patient's eyes closed before securing the mask to prevent corneal damage.

    • Adjust APL valve to 20%:

    • Avoid higher settings to prevent opening the lower esophageal sphincter, reducing aspiration risk.

Bagging and Monitoring

  • Bagging Technique

    • If no chest rise is observed, insert an oral airway if necessary.

    • Administer Rocuronium (Rock) after initial bagging, set a timer for 1.5 minutes.

    • Optional: Administer gas while bagging if patient shows signs of coming to.

  • Defasciculating Dose Protocol

    • For a defasciculating dose:

    • Fentanyl followed by Rocuronium (0.06 to 0.12 mg/kg or 10% of the induction dose, typically 5 mg or 0.5 cc).

    • Administer Lidocaine and then Propofol, waiting for patient unconsciousness before taping eyes and proceeding with Succinylcholine and eventual intubation.

Rapid Sequence Induction (RSI) Protocol

  • RSI Drugs Sequence

    • Administer Lidocaine and Propofol, monitor for unconsciousness.

    • Check eyelash reflex.

    • Administer Succinylcholine (Sux) or a high dose of Rocuronium (1.2 mg/kg) if needed.

    • Note: Do not bag during RSI due to aspiration risks.

Intubation Procedure

  • Executing Intubation

    • Ensure gas is turned off before intubation to avoid compromising surrounding staff.

    • Use scissors to open the mouth, insert the laryngoscope, spreading lips with fingers for to prevent lip damage.

    • With the right hand, lift the patient’s head to enhance view of the vocal cords.

    • Engage the vallecula to help direct the tube.

    • Guide the endotracheal tube past the vocal cords:

      • If unable to pass the tube, ask the nurse to slightly pull the stylet to facilitate entry.

      • Inflate the cuff once in place, ensuring no herniation is observed.

Post-Intubation Protocol

  • Confirm Placement and Ventilation

    • Remove top glove on right and since it was in patient mouth before touching anything (don’t want to contaminate the area)

    • Connect the machine to the circuit, close APL valve to 20%, and bag.

    • Monitor for:

    • Chest rise

    • Condensation in tube

    • End-tidal CO2 readings

    • Bilateral breath sounds.

  • Final Adjustments

    • Transition machine to ventilation mode, adjust FiO2 to 60%, flow rates and gas concentrations as prescribed (2% to 2.6%).

Additional Preparations

  • Tube Security and Antimicrobial Administration

    • Tape the tube in place, noting the centimeter measurement either at the lips or teeth.

    • Ensure antibiotics are administered within one hour prior to incision, with a slow infusion rate to prevent adverse reactions (e.g., Red Man's syndrome from Vancomycin, ototoxicity for gentamicin, and anaphylaxis for Ancef).

  • Intraoperative Preparations

    • Insertion of temperature probe, OG tube, second IV if necessary, and application of a bear hugger.

    • Administer antiemetics:

    • Decadron and Zofran (with Zofran potentially given towards the end of surgery. Push slow to prevent prolong QT interval) and Benadryl at a dose of 12.5 mg.

Monitoring and Compliance

  • Final Checks

    • Perform a sweep of the room to confirm equipment readiness and monitor settings.

    • Monitor vital signs closely:

    • Adjust respiratory rates if end-tidal CO2 increases.

    • Manage blood pressure; if excessively high (e.g., readings of 190-200), consider administering blood pressure medications or additional fentanyl to mitigate risks of stroke.

  • Documentation

    • After confirming all protocols, complete the charting process to document the procedure and patient care steps followed during induction.

    • Continue to monitor patient while charting

      • Listening for alarms or the increase or decrease of the HR or pulse Ox beeping

      • If patient is moving or bucking

        • Give Prop, flip back to spontaneous if bucking, and/or increase gas

    • Lookout when surgeon wants to change position of bed or when he/she is going to cut so you can blunt the pain with prop or analgesics.