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:
- Inhalational induction vs IV induction
- Spontaneous vs controlled ventilation (+/- muscle relaxant)
- Mask ventilation with guedel + two person technique
- Direct laryngoscopy
- Video laryngoscopy
- Asleep FOI
- Front of neck: surgical cricothyroidotomy by us vs ENT trache (awake?)
Catheter pack or Epidural pack
20ml of 0.25% l-bupivicaine for each side
Using US identify rectus muscle. Above umbilicus. Transverse plane if necessary.
Then view in longitudinal/sagittal plane
Enter as close to midline as possible, but alow enough clearance for dressing and wound.
Identify plane. Hydrodissect using saline and create space
Thread catheter as far as it goes
Then attach filter etc and inject remaining LA to see spread
Dressing pack – catheter to be exiting caudally. May use glue.
Attach infusion devise.
Sensory block of medial knee and distally.Motor sparing.
Can combine with popliteal nerve block for distal leg
Follow femoral artery into adductor canal
Between vastus medialis (above femur) and sartorius (medially)
To lower 1/3rd of thigh
If the nerve is not identified then field block of 10-20 ml
Take home messages:
In the elderly, hypotension is BAD. Keep MAP>55 and systolic no more than 10% less than baseline systolic. Consider running pressor infusion c.f. obstetric spinals
Always consider regional, BIS, no/less opioids (though not at expense of adequate analgesia)
Consider heavy prilocaine for hips & knee – if surgeon is experienced/quick
Oxycodone > morphine
Predict and treat delirium. HELP principles. Might be context specific therefore do better in own home. Involve geriatricians.
New anticoagulants – ideally need 73 hours but is balance of risk (given that mortality with #NOF increases per day)
Prehabilitation (exercise!). Not just walking. Remember strength training (stand from siting) and balance (stand on one leg with eyes closed)
EPOCH take home themes: data = power, engage and involve everybody, have a systems thinking approach, develop leadership & project management skills
Use frailty scoring systems e.g. Edmonton Frail Score
Compartment block, so volume important.
Provides post-op analgesia rather than surgical anaesthesia
For #NOF FICB>fem nerve block.
Transverse or longitudinal approach. Needle in plane.
1cm inf and lateral to junction of medial and lateral 1/3 of line connecting ASIS and pubic tubercle
Two ‘pops’ – fascia lata, fascia iliaca
Observe cephalad spread.
Looks cool but it is useful? Difficult to aspirate imagine.
Used for opioid sparing analgesia and enhanced recovery in colorectal , cystectomy…
Recipe for intra-op +/- post-op lidocaine infusion (aka lignocaine for us Brits!)
Loading dose: 1.5mg/kg over 10min
Maintenance intra-op and post-op: 1% in 50ml syringe at 1.5mg/kg/hr
Post-op use 0.4% lidocaine (in 250ml bag)
Dose range 0.5-2mg/kg/hr
MONITOR FOR LOCAL ANAESTHETIC TOXICITY SIDE EFFECTS!
Use IBW if BMI>30
Add 50mg ketamine to 50ml syringe. Run at 10mg per hour.
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)
1 part jelly
1 part lignocaine spray (10%)
= 5% lignocaine
Apply to inflated cuff, then deflate
extubate fully awake but ETT tolerant without coughing on ETT
intra-op can be less deep, epecially with good going regional e.g. caudal
EdM @ LRI