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27 Cards in this Set
- Front
- Back
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Strabismus surgery |
* Associated with myopathy, epilepsy, MH * PONV risk * Oculocardiac reflex * Regional inappropriate in paeds * Requires good surgical conditions * Poor access to airway * Paediatric facility as per PS29 * ?Day case selection |
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Obesity |
* Anaesthetic factors: Airway, aspiration, poor gastric empyting, problems with ventilation/vascular access * Patient factors: CVS, resp, endocrine, GIT changes * Surgical factors: technical difficulty, DVT risk, positioning difficulty (risk to staff) |
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Obstetric viva |
* Two priorities: Maternal and foetal welfare * Always wedge/tilt! * Maternal ALS changes: early intubation, tilt in CPR, perimortem caesarean section * Personnel - senior obstetrician, paediatrician, midwives |
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Myasthenia gravis |
* Preassess for ocular, bulbar, musculoskeletal disease * Risk factors for post op ventilation (comorbid lung disease, FVC < 2.9L, pyridostigmine > 750mg/d, body cavity surgery, time sice diagnosis > 6 years, high grade disease) * Use of neuromuscular blocking agents (also including volatile, magnesium, aminoglycosides...) * In thymectomy - issues for anterior mediastinal mass |
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Preassessment of NOF |
I would perform a routine, thorough preassessment looking for co-existing disease. I Would pay specific attention to the mechanism of the fall, whether a trauma survey had been completed, and then risk factors unique to the elderly patient, i.e. frailty, DVTs, pressure cores and cognitive impairment. |
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Issues pertaining to the elderly |
Frailty, DVTS, pressure sores, dependence, and cognitive impairment including delirium. |
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Goals for NOF surgery |
* Clear communication with the patient and family regarding high risk nature of procedure * Haemodynamic stability (given co-morbidities...) * Anaesthesia and analgesia for a painful long bone operation * Attention to procedure-specific complications (eg. pressure sores, DVT etc...) |
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Preassessment of airway emergency |
I would perform a rapid assessment of: 1. The level and severity of obstruction 2. Work of breathing and signs of fatigue 3. Rate of progression of pathology |
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Management of impending airway disaster |
1. Ask re: postural symptoms 2. Nasendoscopy 3. Review imaging 4. Implement bridging techniques: glycopyrrolate, Heliox, optimal positioning, nebulized adrenaline and/or steroids. 5. Plan appraoach: Awake vs. asleep techniques Apnoeic vs. spontaneously ventilating Paralysed vs. non-paralysed |
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Issues re: microlaryngoscopy |
* Indication * Coexisting disease common (smokers, coronary artery disease, diabetic) * Degree of airway compression * Shared airway |
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Airway approach |
* Extrathoracic obstruction: Awake fibreoptic intubation (caution regarding cork-in-bottle phenomenon or a friable tumour) or other awake techniques * Intrathoracic obstruction: Gentle inhalational induction maintaining spopntaneous ventilation and avoiding paralysis, with either a rigid bronchoscope or cardiopulmonary bypass on standby |
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Jet ventilation technique |
* Rate: < 60/min conventional; >60/min high frequency jet ventilation * Jet only when cannula visible * Jet on lowest pressure possible * Maintain a patent airway for expiration and to avoid air trapping |
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Epilepsy issues with anaesthesia |
* Understanding aetiology (SOL, primary, etc) * Pharmacological interaction due to enzyme induction * Avoiding triggers |
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Nasal intubation - indications and contraindications |
Indications: * Surgical access to oropharynx, teeth, mandible * Anticipated difficult airway for AFOI (eg. masses, foreign body in mouth or airway) Contraindications: * BOS# * Coagulopathy/anticoagulation * Recent nasopharyngeal surgery * Nasal polyps * Midface trauma and instability |
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Difficult paediatric airways |
Congenital * Midface hypoplasia (difficult BMV): Aperts, craniosynostosis * Macroglossia (difficult intubation): Down, Beckwith-Wiedemann syndrome * Mandibular hypoplasia (both difficult BMV and intubation): Pierre-Robin, Treacher Collins, Goldenhar syndrome Acquired * Acute: croup, epiglottitis, trauma, foreign body * Chronic: Asthma (polyps), adenotonsillar hypertrophy, OSA, glottic/subglottic lesions, glottic web * Poor MO/mobility: TMJ dysfunction, Still's disease, spinal fusion, burns |
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Obstetric GA |
* Prepare for difficult airway * RSI indicated after 12 weeks * Antacid prophylaxis * Steroids if pre-term * Left lateral tilt * Difficult airway - don't forget option to wake patient |
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Cerebral palsy |
* CNS - intellectual disability, spasticity, epilepsy * GIT/GUT - aspiration, bladder/bowel dysfunction * Altered thermoregulation * Paediatric patient with complex needs - ?appropriate time, place, surgical skill * Emergence delirium |
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Difficult Airway Society extubation guidelines |
Can I extubate this patient? * Tolerating FiO2 < 0.4 * Fully reversed * Breathing spontaneously, normal Vt * No pre-existing conditions Awake or deep? Have airway trolley present. |
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Increased end tidal CO2 |
* Increased production (MH, sepsis, thyrotoxicosis, NMS) * Decreased elimination (exhausted soda lime, hypoventilation, inadequate FGF, bronchospasm/obstruction, COPD, valve malfunction) * Other source (pneumoperitoneum, bicarbonate) |
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Hypotension |
Commence ALS guidelines if arrested. If not arrested, confirm BP reading/trace. Treat immediately with metaraminol 0.5mg and fluid bolus while scanning monitors for arrhythmia and decreased etCO2. Aim to establish the aetiology early: 1. Reduced preload 2. Reduced contractility 3. Reduced SVR Most common causes: Excessive anaesthesia, regional blockade, hypovolaemia, elevated intrathoracic pressure. |
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Awake fibreoptic intubation |
Indications: * Difficult airway * Unstable neck * After failed intubation Contraindications: * Uncooperative patient/refusal * Coagulopathy * Periglottic masses - cork in bottle phenomenon After gathering my equipment and personnel, I would: Explain procedure and obtain consent Secure IV access, monitoring and O2 via cut Hudson mask Premedicate with glycopyrrolate 200mcg IV Consider titrated remifentanil target controlled infusion for conscious sedation in non-critical airway Topicalise the airway: * Co-Phenylcaine two sprays to each nostril * Lignocaine 2% via mucosal atomisation device (max 8mg/kg) to nasopharynx and oropharynx Load scope with reinforced ETT 6.0 and advance through prepared nostril. * 16G epidural catheter down working channel of fibrescope and spray 1ml aliquots of lignocaine 4% to glottis and subglottic area Confirm placement of ETT visually; connect circuit; confirm placement with capnography. |
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DAS Extubation guidelines |
1. Plan - assess airway risk factors 2. Prepare - is it safe to remove tube? Optimise patient and environmental factors. 3. Perform * If SAFE to remove tube, consider either awake or advanced; i.e. LMA exchange, AEC * If NOT SAFE to remove tube, postpone OR arrange tracheostomy 4. Post-extubation care - safe transfer and handover to HDU/ICU/recovery |
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Aintree Intubation Catheter |
4.7mm ID, 6.5mm OD Smallest ETT able to be used 7.0 |
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CICO |
1 in 10 000 - 50 000 (ANZCA data) Most common RFs: * Trauma * Airway infection * Malignancy * Congenital abnormalities |
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NAP 3 findings: Neuraxial block complications |
* Death or paraplegia 1 in 50K-140K (obstets and paeds extremely low) * Permanent injury 1 in 24-54K |
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NAP 4 findings: Airway events |
* Aspiration commonest cause of airway deaths * 1/3 of events during emergence/recovery * Needle cricothyroidotomy failure rate 60% * Failures of assessment, planning and judgment were the strongest themes * Proportion of obese patients being reported double that of normal weight population * 1 in 4 events from ED or ICU * Most common cause of M&M in ICU was dislodged tracheostomy |
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NAP 5 findings: Accidental awareness under general anaesthesia |
AAGA rate 1 in 19 000 overall * Neuromuscular blockade 1 in 8000 * Without paralysis 1 in 136 000 * Cardiothoracic anaesthesia 1 in 8600 * Obstetric anaesthesia 1 in 670 Risk factors (in addition to above): * Induction phase accounted for 50% of cases * RSI, thio, TIVA * Female, younger adults, obesity, prev. AAGA * Emergency anaesthesia, junior trainee, out of hours. NOT RISK FACTORS: ASA, N2O, race |
