TEŠKA INTUBACIJA Priručnik za preživljavanje pacijenta (i anesteziologa)
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1 TEŠKA INTUBACIJA Priručnik za preživljavanje pacijenta (i anesteziologa) Dr Žika Petrović MD, FCARCSI, DEAA Consultant Anaesthetist Medway Hospital, UK
2 Težak airway ASA definicija teškog airway-a Klinička situacija u kojoj konvencionalno trenirani anesteziolog ima teškoće sa ventilacijom na masku, sa trahealnom intubacijom ili sa obe zajedno."
3 Teška ventilacija Nemogućnost treniranog anesteziologa da održi saturaciju kiseonika >90% koristeći masku za lice I 100% inspiratorni kiseonik, pod uslovom da je nivo saturacije kiseonika pre početka ventilacije bio u granicama normale
4 Teška intubacija Više od 3 pokušaja Duže od 10 minuta Neuspeh optimalnog najboljeg pokušaja
5 Predictors of difficulty to face mask ventilate (OBESE) 1.The Obese (body mass index >30kg/m2) 2.The Bearded 3.The Elderly (older than 55 y) 4.The Snorers 5.The Edentulous
6 Učestalost Teška ventilacija na masku 0.1% - 5% Teška LMA ventilacija 0.2% - 1% Teška intubacija 1-2% normalne hirurške populacije 50% pacijenata sa artritičnom vratnom kičmom
7 Causes of difficult airway Stiffness Arthritis of neck/jaw/larynx. Fixation devices Scleroderma Diabetes Deformity Cervical and craniofacial Burns/trauma/infection Swelling Infection/tumour/trauma/burns Anaphylaxis/haematoma/acromegaly Reflexes Cough/breathholding Laryngospasm/salivation/regurgitation Foreign body Other Pregnant/full stomach
8 Mallampati Score Sensitivity: 44% - 81% Specificity: 60% - 80% Roughly corresponds to Cormack and Lehane s laryngoscopy views Class I (easy) visualization of the soft palate, fauces, uvula, and both anterior and posterior pillars Class II visualization of the soft palate, fauces, and uvula Class III visualization of the soft palate and the base of the uvula Class IV (difficult) the soft palate is not visible at all
9 Airway assessment Thyromental Distance 6.5cm normal Sternomental Distance >12.5cm normal Protrusion of Mandible
10 LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility
11 Airway pomagala- stara I nova
12 Emergency Airway Trolley Rigid laryngoscope blades Tracheal tubes Tracheal tube guides Laryngeal Mask Airways Fibreoptic intubation equipment Non-invasive/minimally invasive airways Surgical Airway CO2 detectors
13 Alternative Airway Techniques LMA/Laryngeal Tube Transtracheal Jet Ventilation Retrograde Intubation Lightwand Combitube
14 Elastična bužija
15 Laryngeal Mask Lubricated LMA inserted into hypopharynx Tip in upper oesophogeal sphincter Inflate Cuff Muscle relaxants not necessary C/I: Need for high Peak Pressures Risk of Aspiration Pts with low lung compliance
16 Intubating LMA
17 Laryngeal Tube
18 Lightwand Flexible Inserted through ET tube Insert into larynx Light dims if entering oesophagus Limitations: Dark room
19 Combitube Double lumen tube Placed into hypopharynx blindly C/I Oesophageal pathology
20 Rigid Fiberoptic Scope Bullard Wu Scope
21 Rigid Fiberoptic Scope Upsher GlideScope
22 Rigid Fiberoptic Scope Levitan Scope
23 Fiberoptic intubation
24 Surgical Airway Cricothyroidotomy Complications: Bleeding Infection Vocal cord damage Tracheal stenosis C/I <12yrs Laryngotracheal Disruption Coagulopathy
25 Krikotiroidna punkcija
26 Bag Valve Mask
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29 Opšte preporuke Nemogućnost oksigenacije a ne intubacije usmrćuje pacijenta Nikad ne parališite pacijenta ako niste sigurni da mozete da intubirate Uvek razmotrite mogućnost awake fiberoptičke intubacije Ako intubacija nije neophodna razmotrite opciju regionalne anestezije ili neuraksijalnog bloka
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34 Moje iskustvo Brighton General Hospital, 4-ta godina specijalizacije 3:00 ujutro Pacijent, 40 god.,5 dana posle tonzilektomije pljuje krv, ne moze da legne, tahikardičan, ali nije dekompenzovan Anesteziolog mu je posle tonzilektomije rekao da ima usko grlo
35 Problemi Anksiozan pacijent Naginje hemodinamskom kolapsu Airway: edematozan, pun krvi I salive, evtl. primarno teška intubacija
36 Plan A: inhalaciona indukcija u polusedećem položaju, kada dovoljno duboka, pogled laringoskopom da se proceni situacija B: Krikotiroidni set spreman sa jet ventilatorom C: ORL hirurg opran i spreman da uradi hitnu traheostomu
37 A u praksi Direktna laringoskopija: uzak farinks pun krvi ali se vide mehurići vazduha iz dubine i naslućuju se glasne žice Da bih olakšao intubaciju dajem 50mg Skolina- GREŠKA gubim mehuriće kao vodič i posle 3 pokušaja ne uspevam da intubiram Krikotiroidna punkcija i jet ventilacija tokom hemostaze na kraju ipak traheostoma - intenzivna nega
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42 Plan A B C
43 H V A L A
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