10 cc syringes, 22 and 22 ga needles, 20 ga angiocatheter. alcohol swab, gauze, and Q-tip or pledgets with bayonette forceps, tongue depressor

Transcription

1 Local Anesthesia of the airway Collect equipment: (Drugs listed with each technique below.) Supplemental oxygen (if needed) Antisialogogue if oral topical planned Optimize position: 1) Nasal anesthesia :Nasal drugs Apply anesthetic bilaterally 2) Oral Topical anesthesia Drugs Glossopharyngeal nerve anesthesia : bilateral application Glossopharyngeal nerve block - Uncommon method - Painful, may result in hematoma, Highly vascular area with increased risk of toxicity Combined pharyngeal, periepiglottic, periglottic anesthesia but supplement may be needed anesthetizes trachea Superior laryngeal n block 10 cc syringes, 22 and 22 ga needles, 20 ga angiocatheter. alcohol swab, gauze, and Q-tip or pledgets with bayonette forceps, tongue depressor Nasal cannula or tubing Preop Glycopyrrolate 3-4 µg/kg if no medical concern (0.2mg IV/IM in adults) Patient supine; various degrees of sitting if dyspneic Extend neck for transtracheal (if no cervical concern) 3-4 cc 4% Cocaine ( 1.5 mg/kg) or 2-4 % lidocaine(3cc) with 0.5% Phenylephrine (1cc) or with Oxymetazoline (1cc) Apply anesthetic with Q-tips or pledgets leave for several minutes Apply viscious lido mixed with vasoconstrictor to nasal airway Advance Q 30 sec to post Nasopharynx (use progressively larger airways until approximates size of ETT Nasal atomizer 2-5% Lidocaine (liquid, viscous or ointment) Spray short bursts of local anesthetic to soft palate and posterior oropharynx, and peritonsillar pillars with the aid of tongue depressor. After each spray, ask patient to gargle and swallow Apply 4% lidocaine-soaked gauze attached to curved clamp, for 15 seconds to each pyriform fossa Ask assistant to pull tongue out of way with gauze-padded finger. Use light source to visualize anatomy Rub 4% lidocaine ointment on injection site. Use stoppered-22 ga needle or 25 ga spinal needle. After negative aspiration, inject posterior-inferior tonsillar pillars with 3 cc of 1% lidocaine and 1:200,000 epinephrine Place a glob of 5% lidocaine gel on both sides of one end of a tongue depressor toward the back of the pharynx in the midline and ask patient to bite on it. Let the gel melt for 5-10 minutes Atomize or squirt 2-4% lidocaine solution or gel (10ccc) on the palate tonsillar fossae,vallecula, epiglottis and larynx Instruct patient to gargle viscous lidocaine (4cc) intermittently for 5 min; then swallow or spit out. Instruct patient to inhale 5cc of nebulized 4% lidocaine for = 15 min. If not administered by mask, must inhale orally to prevent dilution of anesthetic, not nasally. Best method to avoid coughing? Identify hyoid cornu, keeping a finger nearby. Assistant pressure on opposite cornu feels impact. Use 10cc syringe (6cc 1% lidocaine) dart-like to hit hyoid cornu with 22 or 23-ga needle. Brace needle; after negative aspiration for blood; inject lidocaine (3cc).

2 Local Anesthesia of the airway Transtracheal anesthesia (Should cough with injection) Spray as you go anesthesia. Make sure no concurrent suction Aspiration-risk patients Test oral block/ clear airway Insert needle until it hits hyoid cornu. Pressure on opposite cornu aids to stabilize injection site. Walk off anteriorly and caudally ( cm) through the thyrohyoid membrane (feel click). Brace needle, and after negative aspiration for blood, inject lidocaine (2cc) Apply 4% lidocaine-soaked gauze attached on curved clamp to pyriform fossa for 1-2 min. 4% Lidocaine 3-4 cc Identify cricothyroid area. With 22 ga needle on 10 cc syringe, pierce cricothyroid membrane and after negative aspiration, inject. If angiocatheter inserted, pass the catheter a short distance and follow the same steps. Rapid injection via FOB working port 2-4% lidocaine (1cc) prn q 5-30 sec. for areas requiring anesthesia (whether as primary entire-airway technique or as supplement). Insert epidural catheter down working port, extending it 1 cm beyond FOB tip (tape it proximal) decreases visual disturbance of view, secondary to patient s reaction to spray. Avoid transtracheal and perhaps superior laryngeal block. Spray as you go may be safe Use Yankauer or soft suction to suction fluids toward the larynx and test the block

3 Fiberoptic Intubation (FOI) Unique to awake FOI = colored If FOI-inexperienced: Practice on a simple 5-minute dexterity model for 10 minutes beforehand. Antisialogogue Glycopyrrolate 0.2 mg or atropine 0.4 mg - intravenous =20 minutes pre-foi. Request assistant Enlist knowledgeable help, able to hold face mask on asleep patients correctly Pre-check equipment Gather FOI cart: Plug light source to electrical outlet. Choose FB with diameter as close as possible to endotracheal tube (ETT). Plug FB into light source, turn on, and follow adjustment instructions. Test controls. Very clear focus on written object. Black 12 o clock. Use defogger or put FB-ETT in warm irrigation bottle. Check patient status IV, EKG, BP, RR, Sp02 Assistant keeps track of time spent during FB use. Optimize Position Bed-low as possible +/- neutral head position. Supine if ø respiratory distress. Sitting if indicated (e.g. respiratory distress) facing patient.inverts FB view. Administer Sedation Choices: Midazolam, Fentanyl, Dexmedetomidine, Ketamine, Remifentanil. Goal: Respiratory rate > 9/ min, Sp02 = 92%, patient cooperation as needed. If Sp02 < ~92-93%: Give 02. Otherwise, use Sp02 drops to 93-95% as indicator of sedation level. Anesthetize Airway See Local Anesthesia (LA) Section. Spray-as-you-go won t need testing. Injecting LA via mm diameter working port or epidural passed through working port, sprays jet ahead & causes less reactive movement next to FB tip. Test local anesthetic: Insert Yankauer or soft suction midline toward glottis clears secretions/ blood Assistant holds tongue out gently, with one gauze. Insert IOA (If awake use lidocaine paste on the ventral side) or bite guard. If patient reacts, supplement with local anesthetic (+/- add minimal sedatives). ETT on FB Place lubricated endotracheal tube (ETT) high up on insertion tube. FB handling Keep scope straight Rest control hand on shoulder Attach suction to FB. If time allows, be diagnostic, not just technically skilled. If needed, assistant gives jaw thrust or chin lift while keeping IOA midline. Non-dominant hand has FB controls by shoulder. Thumb controls angulation lever with index finger ready for suction valve. Dominant hand holds distal FB insertion tip between thumb and two fingers.

4 Always keep FB straight (shoulder to hand), even if stepstool is needed. Keep hand braced, Small, slow movement, Black Avoid pink-out & getting lost Insert distal tip of FB through IOA or in center of mouth. Brace on cheek/ioa Advance FB very slowly, while keeping recognized objects in middle of view. Use lever to look up/down, turn BOTH hands and use level to look sideways. Keep centered in FB view: IOA/pink tissue juncture, uvula, epiglottis, etc. Intubation Find carina Advance FB to 3 rings above carina. NB: touching carina provokes coughing. Position ETT correctly Hold FB immobile. Keep ETT bevel posterior or anterior (less preferred). Look at ETT cm length Advance ETT. When near larynx, ask patient to inhale deeply; insert quickly. Use FB to see ETT pass Advance ETT until 2-3 cm above carina under visual control of the FB. Inflate ETT Cuff Stabilize ETT with one hand and inflate cuff. Remove FB Remove FB while holding ETT immobile and hand FB to assistant. Attach ETT to 100% O2 Attach ETT to Ambu-bag or Ventilator. Check PetCO2 Observe PetCO2 waveforms while hand ventilating. Trouble-shooting Plan A: If ETT meets resistance near larynx, withdraw 1-2 cm, rotate 90 degrees counter-clockwise and advance (if awake-on deep inhalation). Repeat prn. Plan B: cricoid pressure, jaw thrust, flex neck, sometimes: release jaw thrust. Plan C: tapered tip/flexible ETT, laryngoscope aid, FOI in Aintree in ETT. Fiberoptic Intubation (FOI) All purpose Tips If awake, inform patient - Increases cooperation, decreases sedative need, decreases psychic trauma. Indications: Any intubation/airway insertion, difficult airway, cervical spine risk, one-lung isolation, Aintree placement for postop, ETT exchange, tracheo-bronchoscopy Contraindications: Lack of training, (if awake) lack of patient cooperation, any significantly distorted airway anatomy, secretions, or blood making success very unlikely Fiberoptic cart: Should contain: FB, light source, video, power cord, intubating oral airways (IOA), bite guards, FB swivel adapter, local anesthetic paste, etc. Treat FB like a baby: expensive & delicate 1000s of 8-25 µm diameter glass fibers (human hair is 20 µm)

5 To clean tip: brace it very near its end and wipe gently in air with alcohol pad. No bending, No tossing, No poking or brushing tip on linens, sponges. No turning one hand in one direction unless the other moves similarly. Good care = minor repair costs (< $ ) in a five-year period. Lubricant Viscous lidocaine gel, Lubricate ETT/FB when going through devices. Secretions Preemptive suctioning down toward glottis is important before FB insertion. Technique - New School Dominant hand performs finer, complex movement of aiming tip in correct direction, rotating tip, and moving FB-insertion tube deeper or backing it out. Moving control lever up or down and depressing suction valve is not complex. Old School Controls were taught to be in dominant hand. OK if one is used to this. Trouble shooting Tips Insertion Length Before insertion of the FB, measure the distance from the corner of the mouth to the ear = distance from the mouth opening to the glottis. After 5-10 attempts, you should be able to insert the FB into the trachea within seconds Keep straight and follow the midline of the hard palate, past the uvula, while inserting FB to the measured length. Then search for epiglottis, etc. Centered Avoid hazard Keep desired objects in center of view. Go around obstacles e.g. secretions. Secretions or blood During FB viewing can use FB suction and/or insert Yankauer. Clean tip prn. Fogging in patient Touch buccal or other mucosa to clear it. Combos If needed, second operator move tissues with DL, videolaryngoscope, etc. Unable to intubate? Alternate plan: mask ventilate and try again or use other technique -DL Be wary of 02 via FB High 02 flow in small airway or if FB tip is in unknown body area can result in pneumothorax or gastric rupture. Know what you see and where you are! Be encouraged!!! Most likely success wasn t 100% during one s first 50 DL intubation attempts. Every FB use (even hard ones) is experience that helps one become an expert.