Tag Archives: airway

Anaesthesia for the obese patient

Beware of:

‘Apple’ fat distribution (central obesity)

Metabolic syndrome (3 of central obesity, hyper-tension, cholesterol, sugars, lipids)

 

Tips:

Pre-op: STOPBANG >5 = high risk of disordered breathing/OSA

AR: Consider test dose of 50mcg fentanyl pre-induction for sensitivity for opioids

RSI: No evidence

Drug dosing: Ideally use LBW. Practically IBW + few kg. For all drugs except suxamethonium and neostigmine

Position: Reverse trendelenburg with pillow under shoulders for tragus above sternum, rather than break in the bed

Extubation: consider NPA with lidocaine

Post-op: avoid ‘tying’ to the bed e.g. with a-line, infusions

 

Anticipated Difficult Airway

Remember to consider – to get an idea of what you are dealing with.

Thoughts. Which of the following are anticipated to be difficult and what is the plan for each:

  • Mask ventilation
  • LMA insertion/use
  • Endotracheal intubation
  • Front of neck access

 

Options to consider:

  • AFOI
  • Inhalational induction vs IV induction
  • Spontaneous vs controlled ventilation (+/- muscle relaxant)
  • Mask ventilation with guedel + two person technique
  • THRIVE
  • Direct laryngoscopy
  • Video laryngoscopy
  • Asleep FOI
  • Front of neck: surgical cricothyroidotomy by us vs ENT trache (awake?)

GAT conference take home messages

Tips:
Give IM atropine with IM sux
In obese O2 consumption is significantly greater during SV rather than IPPV
Epidural blood patch recommend 20ml
Dural puncture: inject 20ml normal saline down intrathecal catheter
NSAIDs may affect  platelets and clot strength of EBP
In difficult airway consider nasendoscopy.
AFOI topicalise. Reduce secretions by suction catheter or Yanker (also tests topicalisation)
Legal position: Prudent doctor  -> prudent patient
Coding – appropriately – gets the organisation appropriate money
Quality measures – e.g. length of stay
How to add value ? Outcome or quality / cost
In a report, if used a guideline say so
Detail discussions with patients, including apologies
References to read/watch/review:
‘Perfect storm NHS funding’
Cardiac arrest in neurosurgery patients

Cliff Reid YouTube videos
DOLS
NICE guidelines on trauma
BATLS, ATACC course
Kirkpatrick model (for simulation)

Unanticipated difficult intubation – DAS guidelines 2015

Updates & take-home messages:

  • Laryngoscopy -> SAD -> FM ventilation -> cricothyroidotomy
  • If poor view at laryngoscopy remove cricoid under direct vision + suction at hand
  • Use second generation SAD device
  • Removed cricoid for SAD insertion
  • Successful SAD = ‘stop and think’ moment
  • CICO -> paralyse, continue supraglottic O2 attempts -> front-of-neck
  • Laryngeal handshake
  • Front-of-neck = scalpel (No.10, broad blade), bougie, 6.0mm COETT

 

  • Limit the number of airway interventions
  • DO NOT REPEAT SAME TECHNIQUE
  • First attempt is the best. Make it so.
  • Use apnoeic oxygenation in high risk patients
  • Neuromuscular blockade (rocuronium)

https://www.das.uk.com/guidelines/das_intubation_guidelines

Paediatric foreign body aspiration – recipe for EUA

Gas induction. Maintain spontaneous ventilation. Adequate depth of anaesthesia

(+/- check ventilation – risk of pushing FB distally. Avoid insufflation of stomach)

Direct laryngoscopy

Spray cords with lignocaine

Insert uncuffed nasal (standard) ETT to level just above cords

+/- close mouth as required

Spontaneous ventilation of O2+anaesthetic vapour. PEEP on T-peice

Also see: https://anaesthesiaonreflection.wordpress.com/2014/12/05/paediatric-airway-surgery-recipe/

NB

Remember basic manoeuvres e.g. Abdominal thrusts, Heimlick Manoeuvre, back blows.
In the event of cardiac arrest CPR/chest compressions may dislodge the foreign body.

Airtraq tips

In a situation where the view is good but difficulty is encountered passed ETT between the cords consider the following:

Manoeuvring Airtraq (+/- head/airway) e.g. ‘drop’ it into pharynx to align angles better

Positioning of the glottis ‘target’ towards bottom right of screen

Use of bougie or wide bore NG tube (with ETT railroaded)

Alternative ETT e.g. standard instead of RAE