1. volatile agents 2. IV anesthesia 3. premedication with anxiolytic 4. narcotics 5. pre operative sleep deprivation 6. drug ingestion, age 7. NMB recovery

patient loses consciousness but reflexes remain intact

excitement and delirium - most dangerous (do not manipulate airway)

medullary depression

airway manipulation possible

III

Minimum extubation item requirements: 1 2 3 4 5 6

1. oxygen 2. suction 3. oral nasal airway 4. tongue depressor 5. mask and syringe 6. succ 7. ability to give PPV 8. intubating stuff

deep extubation is during what stage:

Deep extubation: indications: 1 2 3 contraindications: 1 2

 Indications: • Severe asthma- bronchospasm • Specific procedure • Patient can’t tolerate hemodynamic instability  Contraindicated: • Difficult airway • High risk for aspiration

Extubation Criteria: 1 2 3 4 5 6 7

o Awake, return of airway reflex o Following command o Sustained head lift > 5 seconds = GOLD STANDARD o Hand grasp to command o Raise extremity for 45 seconds o Negative inspiratory force: >-25cm H2O o TOF= 4/4 with sustained tetanus >5sec  Adductor pollicis muscle innervated by ulnar nerve  Standard for extubation  TOF ratio > 0.7

gold standard for extubation criteria

sustained head lift 5 seconds

extubation procedure:

o 100% oxygen o Confirm recovery from NMB o Turn off volatile/nitrous o Turn oxygen flow meter to 6-10L/min o Patient must be spontaneously breathing  No tahcpynea/apnea  Tidal volume adequate >5ml/kg  ETCO2 less than 60mmHg  Oral airway in place  Suction oropharynx • If OG- suction stomach and remove o Deflate cute o Remove the tube as you squeeze the bag= positive pressure- so stuff doesn’t come back onto cords o Replace oxygen mask- may use positive pressure with first breath o Monitor until transferred to gurney o PACU

how to decrease bucking: 1 2 3 4

lidocaine 2-3 minutes prior to extubation: 1-1.5mg/kg propofol baby pushes judicious use of opioids suction in stage 3

mandatory in pediatric extubation:

precordial stethoscope

pediatric emergence, prior to turning anesthetic off: 1 2

1. empty stomach 2. suction oropharynx

Laryngospsm signs: 1 2 3 4 5 6 7

1. stridor 2. hypoxemia 3. tachpnea 4. tachycardia 5. retractions 6. no airflow despite effort 7. inability to phonate

prevention of laryngospasm: 1 2 3 4

 No airway manipulation during stage II  Extubation either deeply anesthetized or fully awake  Clear all secretions  Consider topical/IV local anesthetics

laryngospasm treatment: 1. a,b,c 2. 3. 4.

1. Positive pressure ventilation • CPAP with bag/mask • 100% oxygen • Head tilt, jaw thrust, oral/nasal airway 2. Succinylcholine • Adult: 20mg • Pediatric: 0.1-0.3mg/kg IV (or 0.2-0.6mg/kg IM) 3. Reintubate 4. Difficult airway algorithm

Bronchospasm signs: 1 2 3 4 5

1. audible wheezing 2. decrease pulm compliance 3. decreased tidal volume 4. ETCO2 may be absent 5. increased positive insirpatory pressure **** - differential diagnosis

increased positive inspiratory pressure: differential diagnosis: 1 2 3 4 5 6 7

1. analyphylaxis 2. aspiration 3. endobronchial intubation 4. kinked ETT 5. pulm edema 6. PE 7. tension pneumo

Mild bronchospasm treatment: 1. 2. 3. 4.

1. manually ventilate with 100% oxygen 2. increase anesthetic depth -volatile agent, propofol/ketamine, lidocaine 3. assess- what caused it? 4. beta agonist: Albuterol or atrovent via ETT

Severe bronchospasm treatment: (can’t ventilate) 1. 2. 3.

1. IV bronchodilator • Epinephrine= 0.5-1 mcg/kg • Terbutaline= 0.01mg/kg or 0.25mg SQ q20min • Ephedrine • Aminophylline • Isoproterenol 2. Corticosteroid • Methylprednisolone 1-2mg/kg 3. General anesthesia- inhaled agent- vasodilates

prevention of aspiration: 1 2 3 4 5 6

1. Preoperative give Bicitra 2. Suction stomach 3. Totally awake extubation and extra vigilance 4. Residual laryngeal nerve block- decreased ability to protect airway 5. Hemodynamic instability can cause N/V (hypotension, hypoxemia, acidemia) 6. Full reversal of NMB

Ventilated patient aspiration: 1 2 3 4

1. Place head down with right lateral tilt- keeps out of lungs the best 2. 100% oxygen 3. Suction ETT FIRST 4. Positive pressure ventilation and PEEP

extubated patient aspiration: 1 2 3

1. turn head to side 2. suction oropharynx 3. intubate if needed

treatment of apsiration pneumonitis: 1 2 3 4 5 NO- 6

o Bronchoscopy o Postop monitoring  Temperature  WBC, ABG  Chest Xray o Chest PT, IS o Antibiotics o NO STERIODS o Bronchodilators might help uninjured areas