SiTEL Airway Workshop

Transcription

1 SiTEL Airway Workshop Welcome to SiTEL. This site serves the education and simulation needs for Medstar South. This is one of two Medstar facilities designed to hone clinical and technical skills with the use of both immersive simulations and task training tools. It serves as a training ground for many different medical specialties including anesthesiology, OB/GYN, general surgery, orthopedic surgery, ENT, cardiology and gastroenterology. Today is an opportunity to practice some of the technical aspects of anesthesiology on task trainers. We will also review airway progression and intravenous access. Location The SiTEL center is located at 4000 Connecticut Ave NW, Washington DC The entrance is on the ground level, to the left of the main stairs leading into the building. This entrance is closest to the intersection of Van Ness and Connecticut(red dot on map). Once you enter the SiTEL center, ask the receptionist to call for me. Parking Parking is on the green lines in the map to the right. You can park on the east side of Connecticut for free after 10am. You can park on the west side of Connecticut at metered parking after 10am. Parking is available on Tilden St as well for 2 hours at a time. Zone 2 residents have no restrictions here. Non-zone 2 residents can and have been ticketed for parking for longer than 2 hours. Please make arrangements for 2 hours of parking time. Registration Please register at prior to coming to the session. It is as described in the additional packet. After the session, please fill out the post session review as well.

2 Learning Objectives - Airway progression - Vascular access and options Introduction Whatever field of medicine you end up in, you will share the clinical experiences of the latter two years of medical school and your intern year with your colleagues. Whether that intern year is a medical, surgical or transitional one, you will be expected to know some of the basics of being a physician. Two such responsibilities are airway distress and poor vascular access. Whether it is a 2am call regarding a postoperative patient with stridor or a MICU patient who requires four simultaneous infusions but now only has one 22G IV, you will be called upon to evaluate, temporize and intervene as needed. Focus Anesthesia has a hand in most aspects of hospital care, whether it is in the cath lab with cardiologists, the main ORs, the floor on acute pain service, the obstetric ward with OB/GYN or the endoscopy suite with gastroenterologists. As such, focus on the aspects of anesthesia that overlap with your chosen field. For example, if you are going into a surgical field, learn what an optimized patient is, what medical conditions are most concerning and likely to cancel your attendings cases, and a general feel for the flow of the OR. The same holds for medical subspecialties. Propofol isn t a panacea, sedation is a slippery spectrum, and a pre-procedural clearance is only an estimation of anesthetic risk, not a carte blanche to proceed.

3 For the rest of rotation, focus on intersections with whatever your chosen specialties are. For those of you going into medicine or medical subspecialties focus on the following among others: 1. Ventilator settings/management: your rotations in the ICU as medical students will be much more engaging if you have a concept of basic ventilator management. 2. Peripheral and central venous access: knowing when, where and how to get access is a basic but crucial skill set. 3. Preprocedural assessments of the level of sedation needed (moderate àà deep àà general). Sedation is a slippery slope, in which patients can easily slip from moderate to deep sedation. In unhealthy patients, this slope can be disastrous. 4. Optimization of the patient prior to procedures. Endoscopies, catheterizations, IR procedures are not benign procedures. They are often performed on patients who are at their sickest and cannot survive surgical interventions. These patients should be optimized. Figure out what that means for each physiologic system and which of those systems are most heavily weighted in a preprocedural assessment. 5. Basic information needed for emergent intubations in the ICU. Before intubating, what do you need at hand and why? 6. Understanding the pharmacology of the basic sedative medications that you may need in the ICU setting. Sedative medications have profound CV and Respiratory effects. Know them. 7. Invasive monitors and their utility intra- and postoperatively. 8. The ACC/AHA guidelines to preoperative cardiac workup is only one tool in planning a safe anesthetic management for a critically ill patient. The location of the procedure, the staff involved, and the backup resources available are all also factored into the assessment. For those of you going into surgery or surgical subspecialties focus on the following among others: 1. What is presurgical optimization? During your intern year and residency, being able to optimize the patients for surgery to avoid last minute delays/cancellations will ensure expeditious care for your patient. 2. What medical conditions should raise red flags and prompt further investigation with consulting services. Aortic Stenosis and Pulmonary Hypertension are critical conditions that require further investigation. 3. Predicting and preparing for potential blood loss. When do you transfuse? Are there different

4 guidelines with presence of high risk comorbidities? 4. Basic understanding of the anesthesia options available. What is MAC vs. Deep sedation vs. General Anesthesia with an LMA vs. GETA vs. Neuraxial techniques vs. Regional techniques. Their relevance to the surgeries you ll be involved with. 5. What are basic pain control options for the postoperative period. How do you prepare a patient with chronic pain for an invasive surgery. Patient pain scores are going to be part of overall satisfaction measure based endpoints in defining quality healthcare. You don t want to bring a chronic 10/10, lower back pain patient, on excessive narcotics, into the hospital for a major operation without planning for the inevitable exacerbation of that pain and limited response to further narcotics.

5 Approach to Intubation 1. Pre-intubation patient assessment a. Basic airway assessment: i. Short neck? Beard? ii. Being bagged? On NRB face mask? iii. How many prior attempts? iv. Suctioning out a lot? v. Vitals? vi. Neck mobility vii. Dental condition b. Basic patient assessment: i. Responsive? Non-responsive? ii. Body habitus? iii. Labs: K, Creatinine, INR/LFTs, CBC c. History i. NPO status? ii. Cardiac history? Functional impairment? EF? Valvular disease? On pressors now? iii. History of muscular dystrophy? iv. Paralysis or prolonged weakness? v. Prolonged bed rest? vi. Renal/Liver impairment? vii. Pulmonary history? COPD? Asthma? 2. Pre-intubation equipment checklist a. Face mask with shield b. Appropriately sized ETT with appropriate stylet c. Laryngoscope with two blades that have intact lights d. Video laryngoscopy e. CO2 detector f. Suction g. Functioning IV h. Ventilator with respiratory therapist i. Meds j. AmbuBag 3. Meds a. Premeds: i. Fentanyl ii. Lidocaine b. Induction meds: i. Nothing ii. Etomidate iii. Propofol c. Paralytics: Nothing i. Short acting NDMR: Rocuronium ii. DMR: Succinylcholine

6 TALK Intubation - Describe everything you re doing. Vocalize what you see, what step of the intubation you are on, how you are trouble shooting if you re not seeing your ideal view. - Minor complications like a chipped tooth, or bloody lip can lead to patient dissatisfaction. It used to be that major complications happened frequently, but now with the improved safety profile of general anesthesia, small complications can be serious. As such we need to know that you have an idea of what you re doing. Positioning - Position patient at your umbilicus height - If obese place a ramp to align the neck and mouth opening in a more direct line. Preoxygenate - At least three FRC breaths with continued breathing at 100% - Longer preoxygenation if patient high risk for acute desaturations, morbidly obese, pregnant, underlying pulmonary disease. Induction - Premed + induction meds - Check breaths with a C ring grip on the mask o Middle finger pulls tip of chin towards you first o C grip with the index and thumb hold counter-traction against the middle finger o Do not exert too much force during ventilation - Good ventilation = o Chest rise o Condensation in mask during exhalation o etco2 on capnography - Paralytics based on PMH Intubation with a MAC blade - Place in sniff position if no neck mobility contraindications - Use right hand to scissor the mouth open o Middle finger is on the upper molars, pull the head towards you with the middle finger first o Once the mouth is slightly agape use the thumb the push the lower molars away - Open mouth wide enough that you can get blade by (make them yell not talk ) o You may feel a slight pop as the mouth opens wider o As long as they don t have a history of TMJ that is fine - Place the laryngoscope blade at the opening created by your right hand and sweep the tongue to the left. - Opening the mouth brings the head back into a more neutral position, take your right

7 hand out and reposition the head into sniff position once the blade is in. o Make sure to sweep the tongue to the left o Make sure the blade ends up in the middle: with the blade in line with the chin and nose. - You are going to be in one of three places once your blade is in o Too deep: going to see soft tissue, no epiglottis o Too shallow: going to see soft tissue, no epiglottis o Just right: visualize epiglottis, blade tip close to vallecula - Just right rarely happens o If so, advance to the vallecula and lift to visualize the cords - Too deep o Look at the patient s head, look at your blade. If your blade is mostly engaged in a small or regular sized head and all you see is tissue, you are probably deep. Slowly come out with the blade, following the midline until you see the epiglottis flop in to view o Once the epiglottis flops into view, advance until you meet the vallecula with the tip of your laryngoscope o Then lift - Too shallow o If blade is big for head, and very little of it is engaged, you re too shallow. o Slowly advance blade forward along the midline until you visualize the epiglottis o Advance to the vallecula then lift. Do you see the cords? No? o Take your right hand that had the patient in sniff position and reach out to the thyroid cartilage and adjust your view o Press down, cephalad and to the right and see if that improves your view o If there is a position that improves the view, ask your helper to replicate that pressure and call out directions for fine tuning - Once the cords are visualized describe them o Do you see just the base of the arytenoids o Do you see the vocal cords o Are they open? Are they closed? Or are they spasming? - KEEP YOUR EYES ON the CORDS o Reach out your hand and someone will put an ETT in it. o Approach the cords from a 1-2 o clock approach rather than a 12 o clock approach. o 12 obscures your view. 1 to 2 will allow you to visualize the ETT pass the cords. - ONCE the tip is past the cords, ask for the stylet to be removed o Advance slightly once the stylet is out to get the CUFF past the cords. ONLY LIFT when you re in the vallecula. Do NOT lift multiple times if not needed. When you lift, imagine that there is a pole that extends above and below the handle. Lift along that imaginary pole, do not crank back or shift forward the handle.