Tag Archives: clinical

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?)

Rectus Sheath Catheters

Equipment:

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.

Link:

http://e-safe-anaesthesia.org/e_library/09/Ultrasound_guided_rectus-sheath_block_Update_2010.pdf

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)

Saphenous nerve / adductor canal block

Indications:

Sensory block of medial knee and distally.Motor sparing.

Can combine with popliteal nerve block for distal leg

Method:

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

Links:

http://www.nysora.com/techniques/ultrasound-guided-techniques/lower-extremity/3059-ultrasound-guided-saphenous-nerve-block.html

Age Anaesthesia Meeting

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

Fascia Iliaca Compartment Block

For:

#NOF

hip surgery

Principles:

Compartment block, so volume important.

Provides post-op analgesia rather than surgical anaesthesia

For #NOF FICB>fem nerve block.

Approaches:

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

40ml.

Observe cephalad spread.

Links:

http://www.frca.co.uk/Documents/193%20Fascia%20Iliaca%20compartment%20block.pdf

http://www.nysora.com/updates/3107-ultrasound-guided-fascia-iliaca-block.html

http://www.ucl.ac.uk/anaesthesia/UCLHRegionalEducation/FemoralNerveEducation

http://neuraxiom.com/html/fascia_iliaca_block.html

 

Peri-op lidocaine infusion

Used for opioid sparing analgesia and enhanced recovery in colorectal , cystectomy…

Recipe for intra-op +/- post-op lidocaine infusion (aka lignocaine for us Brits!)

Lidocaine 1%

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

Optional extra:

Add 50mg ketamine to 50ml syringe. Run at 10mg per hour.

Ref: http://prc.coh.org/FF%20LidoIVPer12-10.pdf

 

RDH

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