Typical Sequence of General Anesthesia

1
Typical Sequence of General Anesthesia

• Dr. Aidah Abu Elsoud Alkaissi
• An-Najah National University
• Faculty of Nursing

2
(No Transcript)
3
(No Transcript)
4
Size of the tubesplain and cuffed
5
(No Transcript)
6
(No Transcript)
7
Typical Sequence of General Anesthesia

• Pat is identified
• Checked for consent
• Result test Dx studies
• I.v infusion startedpreop. Or on arrival
• All drugs are given i.v.
• Intraoperative monitoring

8
Typical Sequence of General Anesthesia

• At induction- preoxygination with 100 O2, 3-5
  minutes through a mask- permits washout of most
  of the gaseous nitrogen from the body and
  provides a large reserve of oxygen in the lungs
• A test dose of the induction agent(50 mg
  thiopental) is given to check for exagerated
  response
• If succinylcholine will be used for intubation
  then a small pretreatment dose of a
  nondepolarizing muscle relaxant (0.5 mg of
  pancuronium) is given
• When given 5 min before succinylcholine, this
  small dose is sufficient to block most of the
  muscle fasciculations seen with succinylcholine
  and decrease post.op myalgias

9
Typical Sequence of General Anesthesia

• To induce anesthesia, and move pat rapidly to
  stage 3, a short acting barbiturate as thiopental
  (2-6 mg/kg) is given
• When pat becomes apneic and the eyelid reflex is
  gone, the airway is checked for patency by
  ventilating the pat with a mask
• Depending on several Factors such as an adequate
  airway and the type and duration of surgery,
  oxygen and anesthetic gases may be delivered to a
  spontaneously breathing pat via a mask that is
  held in place with a head strap
• Positioning of the head and oral or nasal airway
  used to maintain a patent airway
• If mask anesthesia is not suitable, then
  endotracheal tube may used to facilitate
  ventilation or to protect the airway from
  aspiration

10
Typical Sequence of General Anesthesia

• An intubating dose of a muscle relaxant such as
  succinylcholine (1-1.5 mg/kg) is given
• Muscle relaxant causes temporary paralysis of the
  jaw and diaphragmatic muscle as well as other
  skeletal muscles
• To facilitate intubation, a laryngoscope held in
  the left hand is inserted into the right side of
  the mouth and then moved to the midline
  sweeping (taking in or moving over) tounge to
  the left
• The endotracheal tube is introduced on the right
  side of the mouth and gently inserted into the
  trachea so that the cuff is a cm below the vocal
  cords
• The cuff is inflated just enough to occlude any
  air passage with the peak pressures used for
  ventilation

11
Typical Sequence of General Anesthesia

• Correct location of the endotracheal tube is
  verified by lisening for bilaterally equal breath
  sounds with a stethoscope,
• by absence of sounds over the stomach and by an
  appropriate level and waveform of ETCO2
• By symmetrical movement of the thorax with
  positive pressure ventilation. look at the chest
  for expansion with each breath
• By condensation of moisture from expired air in
  the endotracheal tube and breathing circuit
• ausculatate the chest for breath sounds
• An appropriate level and waveform of ETCO. check
  the capnoraphic tracing on the monitor to ensure
  end tidal CO2

12
Typical Sequence of General Anesthesia

• The vocal cords are the narrowest portion of n
  adult traches, the smallest portion of a childs
  airway is below the vacal cord
• Thereore uncuffed endotracheal tubes are used for
  children because the internal diameter of cuffed
  tubes in these small sizes would have too much
  resistance to ventilation and could easily
  become obstructed
• After the paralysis from the succinylchiline has
  worn off, the pat may be allowed to breath
  spontaneously with intermittent assistance, or
  additional muscle relaxant may be given and the
  ventilation controlled either manually or
  mechanically

13
Typical Sequence of General Anesthesia

• If the procedure is an emergency or the pat is at
  risk for aspiration (for example, in cases of
  intestinal obstruction, full stomach, hiatal
  hernia)
• The anesthesiologist may undertake rapid
  sequence induction
• Standing on the patients right side
• The perioperative nurse must be ready to assisst
  as necessary by applying downward pressures on
  the cricoid cartilage with the thumb and index
  finger of the right hand while the left hand is
  plaved under the patients neck for stability
• The cricoid cartilage is the only complete ring
  in the trachea, and downward pressure occludes
  the esophagus which lies immediately posterior

14
Typical Sequence of General Anesthesia

• If, after assessment of the patients airway, the
  anesthesiologist feels rapid intubation of
  trachea may be difficult, an awake intubation,
  using a fiber optic bronchoscope or other
  techniques, may be chosen
• Maintenance of anesthesia can be accomplished
  with either intravenous or inhalational
  anesthetic techniques or a combination of both
  with or without additional muscle relaxant
• The anesthesiologist suctions the oropharynx to
  decrease the risk of aspiration or laryngospasm
  following extuvbation, reverse any residual
  paralysis from the nondepolarizing muscle
  relaxant with an anticholinesterase such as
  neostigmine and an anticholinergic such as
  atropine and allows wash out of nitrous oxide and
  volatile anesthetic agents by giving 100 oxygen
  for several minutes before extubation
• The pat is then transported to the PACU to a
  waken from the anesthetic experience

15
Typical Sequence of General Anesthesia

• Untoward events that can occur with general
  anesthesia includehypoxia, respiratory,
  cardiovascular,renal dysfunction
• Hypotension
• Hypertension
• Imbalance of fluids or electrolytes
• Residual muscle paralysis
• Neurologic problems
• Malignant hyperthermia

16

• Prior to intubation,
• always check equipment and make sure everything
  you might need is not only within your reach, but
  also properly working.  
• If in the operating room, a complete check of
  the anesthesia equipment at the start of each day
  as well as a modified check before each new case
  is imperative. 
• If in the emergency room or the hospital wards,
  make sure you know where all of your equipment is
  and, also, that you have the necessary resources
  to support the patient once intubated.   

 
17

• Prior to positioning the patient
• Make sure that your laryngoscope is locked into
  position and that the incandescent light on the
  blade tip functions. 
• Also make sure that you have several alternate
  blades available in case the one you have chosen
  does not allow for visualization of the cords.
• Examine the endotracheal tube.  Make sure that
  the cuff inflates by using a 10-mL syringe to
  inflate the cuff and then detach the syringe to
  ensure that the cuff pressure is maintained.  Be
  sure to deflate deflate the cuff after testing
  it. 
• Attach the connector to the proximal end of the
  tube.  Push it in as far as possible to lessen
  the likelihood of disconnection.
• If you are going to use a stylet, it should be
  inserted into the ET tube and bent to resemble a
  hockey stic
• using a stylet, one should be within easy access
  in case the intubation proves to be more
  difficult than anticipated.
• Ensure a functioning suction unit to clear the
  airway in case of unexpected blood, emesis or
  secretions.
• Ensure that you have tape within your reach to
  secure the tube once it is in place

18
positioning

• Proper patient positioning can be the difference
  between a successful and failed intubation.
• The patients head should be level with the
  physicians xiphoid process.
• To achieve the sniff position (which allows for
  optimal visualization of the glottic opening),
  elevate the patients head and extend the
  atlanto-occipital joint.  This can be achieved by
  sliding your free hand (right hand if you are
  right handed, left hand if you are left handed)
  beneath the patients head and gently lifting it
  up and towards you.  Or, you can gently position
  the chin up and mouth open before attemting
  laryngoscopy.
• The "scissor technique" can also be used to
  further open the patients mouth.  Cross your
  right forefinger and thumb and insert into the
  right side of the patient's mouth.  Apply
  pressure to the upper teeth with your forefinger
  and  the lower teeth with your thumb to open the
  mouth.  Be sure to position your hands so as NOT
  to obstruct your view.

19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
OTHER WAYS TO INTUBATE

• Nasotracheal Intubation Nasal intubation is
  similar to oral intubation except that the ETT is
  advanced through the nose into the oropharynx
  before laryngoscopy. 
• If the patient is awake, local anesthetic drops
  and nerve blocks can be used. 
• A lubricated ETT is introduced along the floor of
  the nose, below the inferior nasal turbinate,
  perpendicular to the face. 
• Often, a nasopharyngeal airway can be used.  The
  tube is advanced until it can be visualized in
  the oropharynx. Via laryngoscopy, the tube is
  then advanced in between the abducted vocal
  cords.
• Nasal instrumentation (with ETTs, NPOs, or nasal
  catheters) is contraindicated in all patients
  with severe midfacial trauma.

23
Flexible Fiberoptic Bronchoscopy

• Laryngoscopy may be contraindicated in a patient
  who requires intubation and mechanical
  ventilation.  This is often the case in trauma
  patients who may have an unstable cervical spine
  or in patients with poor range of motion of the
  temporo-mandibular joint.  In such patients,
  flexible fiberoptic bronchoscopy allows for
  indirect visualization of the larynx.  The
  endoscope is introduced through the mouth or
  nose.  Once anatomic structures are recognized,
  and the larynx or trachea are entered under
  direct visualization

24
COMPLICATIONS OF INTUBATION

• Complications of laryngoscopy and intubation are
  most frequently secondary to airway trauma, tube
  malpositioning, tube malfunction or physiologic
  responses to airway instrumentation.  
• Trauma such as tooth damage, lip/tongue/mucosal
  laceration, sore throat, dislocated mandible,
  retropharyngeal dissection can occur during
  laryngoscopy and intubation. 
• Mucosal inflammation and ulceration and
  excoriation of nose can occur while the tube is
  in place. 
• Laryngeal malfunction and aspiration, glottic,
  subglottic or tracheal edema and stenosis, vocal
  cord granuloma or paralysis during extubation. 

25
COMPLICATIONS OF INTUBATION

• Malpositioning of the endotracheal tube can
  result in esophageal intubation and unintentional
  extubation.
• Physiologic responses to intubation include
  hypertension, tachycardia, intracranial
  hypertension, and laryngospasm.  Laryngospasm,
  which occurs during induction and recovery from
  anesthesia or, rarely, in an awake patient, is a
  forceful involuntary spasm of the laryngeal
  musculature caused by sensory stimulation of the
  superior laryngeal nerve.   Treatment includes
  positive pressure ventilation via a bag-mask
  device using 100 oxygen or administration of IV
  lidocaine.

26
HOW TO EXTUBATE

• Knowing when to extubate is also an important
  knowledge set.  In general, it is best to
  extubate when a patient is still deeply
  anesthetized (but with adequate spontaneous
  respirations)
• or when the patient is awake and responsive with
  stable vital signs, good grip and sustained head
  lift. 
• Adequate reversal of neuromuscular blockade must
  be established. 
• A patient must also demonstrate adequate
  spontaneous respiratory function with a vital
  capacity of greater than 15 mL/kg and a negative
  inspiratory force of greater than 20 mm Hg. 
• Extubation while the patient is in a light plane
  of anesthesia or still emerging from anesthesia
  is avoided because of an increased risk of
  laryngospasm, the most dreaded complication of
  extubation.

27
HOW TO EXTUBATE

• Regardless of whether a patient is extubated
  while deeply anesthetized or awake, begin by
  thoroughly suctioning the patients pharynx and
  mouth in order to decrease the risk of aspiration
  or laryngospasm.  
• Also, preoxygenate the patient with 100 oxygen
  in case it becomes difficult to establish an
  airway after the ETT is removed. 
• Untape the ETT and deflate its cuff.  Apply a
  small degree of positive pressure on the air bag
  to help blow out any secretions you may have
  missed on first suctioning and suction again. 
• Withdraw the tube on end-inspiration or
  end-expiration in a single, smooth motion.  Apply
  a face mask to deliver 100 oxygen.

28
Anesthesia machine