1. Glycopyrolate 200-400mcg IV/IM ASAP
2. Sedation EARLY
Spray co-phenylcaine to nostrils
Gargle 4x5ml of Instilagel
Spray Xylocaine (10% lignocaine) to oropharynx -> distally
Spray-as-you-go with epidural catheter (2ml 1% lig)
Cricothyroid puncture (2ml 1%lig)
Instilagel+soft NPA to nostril NB risk of bleeding -> bad view/problems
4% lignocaine squirt to nostril using teat
4% lignocaine squirt to oropharynx
‘nebulised’ lignocaine using cannula + 1% lignocaine
Oral/pharnygeal surgery if surgeon agreeable, experienced, understanding of LMA issues
e.g. Adeno-tonsillectomy, Frenuloplasty, Dental extraction
0.2mg/kg = 1ml per 10kg of 2mg/ml
Sedation for AFOI
Minto/plasma target: 0.3-0.5 ng/ml
Without midazolam: Up to 1.5ng/ml
NB Anaesthesia, May 2011: Remi as sole agent (no LA), minto model, effect site concentration of 6-8 ng/ml.
– Early surgical haemostasis.
– 1:1:1 for any transfusion requirement anticipated to be >6 units.
– Fibrinogen >2g/l.
– Tranexamic acid.
– As near normothermia as possible.
– normal pH
Increase MV 12-18L/min (preemptively):
High RR (compared to Vt)
High I:E. Adv: reduced peak airway pressure for a given Vt, permits higher MV. (Improved oxygenation due to increased mean airway pressure.) Dis: reduced CO due to increased mean airway pressure, in obstructive airways can lead to gas trapping.
If oxygenation not a problem then reduce PEEP to increase MV for same peak airway pressure
Consider largest possible ETT.
Ask surgeons to deflate if necessary
Blood volume = 80ml/kg
If loss >= 10% then use colloid or blood
If it is down the right main bronchus (which it usually is)…
Cut off the distal connection of suction tubing and pass down the ETT/tracheostomy (size 8+)
Also a possibility is to connect to oral ETT and advance into right main bronchus
This gives wide bore suction.
To correct a metabolic acidosis when ventilating:
Target pCO2 (in kPa) = [HCO3]/5 + 1