Induction Sequence Cheat Sheet by lkmaceac

Move patient to OR table and ensure safety strap is secured

usually placed across thighs 2 inches above the knees over the cover

Apply Monitors

record vital signs at least every 5 minutes

-BP

-Capno­graphy

Preoxy­gen­ation extends periods of safe apnea

 Below this level, oxygen saturation can decrease to critical levels <70% within moments.

 Denitr­ogenate the residual capacity of the lungs, maximizing oxygen storage

o Tidal volume breathing with 100% O2 for 3-5 minutes

o Sit up or reverse Trende­lenburg to increase FRC

• Obese
• Pregnant
• Pediatric
• Hyperm­eta­bolic pts

o FRC is the reservoir of oxygen that prevents hypoxemia during apnea

o FRC cannot be measured with spirometry because the residual volume cannot be exhaled and RV is a component of FRC

35 ml/kg

Helium wash in

o We can estimate how long a pt can remain apneic before desatu­ration if we know the patients FRC and oxygen consum­ption (VO2)

time until patient desats = FRC/VO2

Pregnancy
• Diaphragm shifts cephalad due to gravid uterus
• First give O2!!!
• Decreased chest wall compliance

Decrease
• Supine
• Trende­lenburg
• Lithotomy

o Egg allergy

 Patients with soy, peanut allergy or egg allergy can receive propofol without any special precau­tions. – Probably safe
 Most people with egg allergies are allergic to the albumin egg whites. Egg lecithin found in propofol is derived from the YOLK

o Peanut

 Like soy peanuts are a type of legume. Some have speculated the potential of cross sensit­ivity between peanuts and soy (and thus propofol) although there is no evidence to support this
 Prop is safe to use in pts with a peanut allergy

 Patients are sedated but conver­sat­ional
 Breathing is slow and regular
 Patient progresses from analgesia free of amnesia to analgesia with concurrent amnesia
 This stage comes to an end with the loss of consci­ous­ness.

 Tape eyes horizo­ntally after loss of consci­ousness
 Eyes should be protected before instru­menting the air way

o If you are using gas induction no muscle relaxa­tion- you can really see this
 Its really short with IV induction
 FOR KIDS
• Laryngospasm
• Don’t touch them too soon

 Plane 2, there are interm­ittent cessations of respir­ation along with the loss of corneal and laryngeal reflexes. Halted ocular movements and increased lacrim­ation may also occur.

 Plane 4 is marked by irregular respir­ation, parado­xical rib cage movement, and full diaphragm paralysis resulting in apnea.

Two hands

o Get it less than 20
o Two people approach

Placement of LMA if unable to ventilate

• LMA
• Difficult suprag­lottic airway placement
o Restricted mouth opening
o Obstru­ction
o Distorted airway
o Stiff lungs or C spine

During inspir­ation a negative gradient draws air into lungs

• Tendency to make airway collapse
• In awake state
o Counte­racted by three sets of dilator muscle

Contro­versy

• When placing an endotr­acheal tube after induction o Histor­ically been instructed to refrain from admini­stering muscle relaxation until adequate mask ventil­ation in the anesth­etized patient was confirmed in order to both avoid
 Critical hypoxemic event
 Ensure an attempt at an escape wake up.
o There is little published evidence to support this practice, and the admini­str­ation of muscle relaxation before ensuring adequate BVM ventil­ation remains contro­versial
o Neurom­uscular Blockade and the Airway
 Regarding Mask Ventilate- There is evidence that paralysis of the upper airway muscul­ature improves ability to ventilate
 A recent study published data indicating that NMB using rocuronium facili­tated bag-mask ventil­ation in anesth­etized patients

• What is the Neurom­uscular Junction? (NMJ)

o The neurom­uscular junction is a synapse that develops between a motor neuron and a muscle fiber o Made up of several compon­ents: the presyn­aptic nerve terminal, the postsy­naptic muscle membrane, and the interv­ening cleft (or gap)
o End Plate
 Acetyl­choline is hydrolyzed rapidly by the enzyme acetyl­cho­lin­est­erase in the synaptic cleft
 Not all acetyl­choline that is released reaches the endplate, some is hydrolyzed en route.

o Preoxy­gen­ation is critical
o Suction and airway altern­atives available
o Use adjuvant drugs to control BP, HR response: midazolam, narcotics, lidocaine, ketamine, etc
o Explain and rehearse use of cricoid pressure with the patient.
o Optimize position of upper airway.
o Identify person to do cricoid pressure
o Apply Cricoid while patient is awake
 Conscious 20N (2 kg)
 If you cant see they are pushing too hard
 Tell them to keep holding pressure until you them to let go
o Propofol 1.5-2.5 mg/kg
o asleep 40N (4 kg) of pressure
o Succin­ylc­holine 0.5 to 1.5 mg/kg or Rocuronium 1.2 mg/kg
o Loss of consciousness-fasciculations
o Eye Protection
o Intubate
o Hold cricoid until endotr­acheal tube cuff is inflated and placement is confirmed

 Aspiration risk
 Active bleeding in airway (risk of cough, laryng­ospasm)

 Prime circuit with N2O 70%,
 FGF at 8L/min
 Pop off valve open and patient end of circuit occluded.
 When patient is comfor­table with situation, begin volatile agent increasing vaporizer setting by 0.5% every 3 or 4 breaths
 Reassure patient with calm voice encour­aging a regular smooth breathing pattern.
 Use of a deep breathing pattern here may lead to premature onset of apnea with prolonged phase.
 Expect several minutes to fall asleep. Assist ventil­ation
 Don’t use N2O if you are trying to get pregnant- spont miscar­riage
 For adults or special needs

 Many anesthesia providers do not give fentanyl on induction
 Wait for return of sponta­neous respir­ation
 Others give small dose