Airwayve

Check out this great video which summarizes the steps below: https://www.youtube.com/watch?v=8AOB2PtHfVM&ab_channel=InterAnest

Here are a few key steps in airway management: 

Ask yourself: 

• Will I be able to mask ventilate?
• Will I be able to perform laryngoscopy, directly or indirectly?
• Will I be able to intubate this patient?
• Is there a significant aspiration risk?

History and physical:

• Check your patients' anesthetic history for any record of a previously difficult airway.
• Difficult bag-mask - BONES: beard, obesity, no teeth, elderly, snoring (or OSA)
• Mouth opening & Mallampati score (high score = difficult laryngoscopy!)
• Thyromental distance (see below) and sternomental distance
• Mobility at the temporomandibular joint and prognathism 

Managing the airway:

• Pre-oxygenate patient to end-tidal O2 of >80%
• Align the oral/pharyngeal/laryngeal axes via the "sniffing position"
  • Helpful tip! Place folded sheets, rolled blankets or a foam headrest underneath patients' neck to help achieve this position. 
• Hold your Mac blade in your left hand; advance the blade to the vallecula while sweeping the tongue out of the way
• Apply pressure up to the corner of where the wall/ceiling meet to reveal the glottic opening and visualize the cords
• Describe the view of the cords using the Cormack-Lehane scale! If you can't see the cords, use the BURP maneuver
• Stop advancing the tube when you see the proximal end of the endotracheal tube is at 21-22 cm at the front teeth in an adult - then ask for the cuff to be inflated

Confirm tube placement:

• Auscultate for breath sounds
• Check capnography
• Look for symmetric rise and fall 
• Celebrate with a little happy dance (in your head)

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In this episode, we discuss induction, the stage of general anesthesia that encompasses the onset of sedation, amnesia, analgesia, and sometimes akinesia. The anesthesiologist’s goals are to achieve induction smoothly and safely, maintaining the patient’s hemodynamic stability throughout.

Step 1: Place monitors on patient (see Episode 2 show notes for a list of the CAS’ required monitors).

*Clinical tip: take a moment to double-check that all monitors are attached to the patient and showing up correctly on the screen. Run some fluids through the patient’s IV for a few seconds to check that it is functioning reliably.

Step 2: Surgical timeout.

*Clinical tip: The patient needs to be awake for this step, so hold off on giving any sedatives or psychoactive medications until after the timeout.

Step 3: Pre-oxygenation.

*Clinical tip: Aim for an end-tidal oxygen concentration (EtO2) of >0.8.

Step 4: Administer induction agents (intravenous or inhalational, depending on the type of induction). Typical IV induction agents may include an opioid, a benzodiazepine, an induction agent (sedative), and a neuromuscular blocker. 

*Clinical tip: propofol and some other induction agents can cause hypotension, so keep an eye on the patient's blood pressure readings after administering your medications. 

Step 5: Assess the depth of anesthesia before proceeding with airway management.

*Clinical tip: you can check the orbicularis oculi reflex by lightly brushing the patient's eyelashes with your finger.

Link to Canadian Anesthesiologists' Society (CAS) Guidelines (2020): https://bit.ly/34srKo8 

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In this episode, we discuss setting up the operating room for a general anesthetic. The mnemonic SOAP-IM(S) is a helpful checklist for organizing all of the necessary equipment. 

1. Suction

• Is the suction equipment (Yankauer/suction system) present and working?

2. Oxygen:

• Check circuit tubing, gas analyzer tubing, filter, face mask
• Check for availability of back-up O2 tank

3. Airway: 

• Have a plan for potentially difficult airways (stay tuned for the next episode!)
• Prepare an appropriately sized endotracheal tube (ETT), laryngoscope & oropharyngeal/nasopharyngeal airway
• Check ETT cuff for leaks 
• Have backup equipment ready
• Know where to access video-laryngoscope 

4. Pharmacy: 

• Check for commonly used medications and rescue medications
• Check the expiry dates of medications as you draw them up, and label each syringe with the medication and concentration

5. IV: equipment for placing an IV, fluids, IV tubing.

6. Machine: anesthetic machine check.

• Check for leaks 
• Ensure circuit can supply positive pressure 

7. Monitors: refer to the CAS requirements 

• Standard required monitors for every patient: 
  • Pulse oximeter
  • Blood pressure (NIBP)
  • 3-lead or 5-lead ECG
  • ETCO2 gas analyzer - measure of ventilation
• Other equipment you will commonly use:
  • Capnography
  • Temp monitor
  • Stethoscope
  • Peripheral nerve stimulator

8. Special equipment + Seat: any extra case-specific equipment, and chairs for you and your staff!

• Consider special equipment such as blood products as needed

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This is the first episode in series #2 (approach to general anesthesia). In this episode, we break down the pre-operative evaluation.  

Step 1: Confirm patient identifiers and NPO status
Step 2: Focused anesthetic history

• Review of systems: CV, resp, GI, GU, neuro (Bonus: endo)
• PmHx/PsHx with previous surgical complications - always ask about pseudocholinesterase deficiency and malignant hyperthermia
• Meds/allergies and compliance to medication

Step 3: Focused physical exam

1. Airway assessment
   1. BONES mnemonic + Mallampati score
   2. Mouth open
   3. Thyromental distance
   4. Protrude mandible and bite upper lip
   5. Neck extension/flexion 
2. CV exam
3. Resp exam
4. (Neuro exam if indicated)
5. ASA status

Step 4: Discuss risks and obtain informed consent

• Risk to teeth: 1/1000
• Typical risks: postoperative pain, postoperative nausea/vomiting, sore throat

For a more detailed description of the modalities of anesthesia and their indications, refer to Chapter 3 of the Ottawa Anesthesia Primer

Patterson L. Ottawa Anesthesia Primer: Patrick Sullivan. University of Ottawa, Faculty of Medicine. ECHO Book Publishing, 2012. ISBN 978-0-9918009-0-2. Can J Anesth Can d’anesthésie 2013. https://doi.org/10.1007/s12630-013-9997-4

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Dr. John Centofanti is an Assistant Professor in the Department of Anesthesia and Program Director of the Critical Care Residency Program McMaster University. He is also a critical care physician and anesthesiologist in Hamilton, Ontario. Join us as we ask about his unique experiences in training and his insights into a career in anesthesiology. 

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In this episode, we discuss the diverse roles that anesthesiologists have in the hospital and outpatient settings and tackle some stereotypes and myths about the specialty. 

Anesthesiologists can be seen in:  

• The operating room and pre-op clinics
• ICU
• ER
• Labour and delivery
• On the wards as part of the Acute Pain Service (APS) 
• In chronic pain clinics

Common myths:

• Anesthesiologists do the same things each day
• Anesthesia is only about putting people to sleep
• It’s “boring” work
• Anesthesiologists don’t diagnose conditions

Check out this article written by a McMaster Med student which discusses how anesthesia is portrayed on TV: https://rb.gy/91afx9

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In this episode, we provide a brief overview of our podcast, and the general modalities of anesthesia. These encompass: 

General Anesthesia:  Provides analgesia and amnesia, with or without muscle relaxation depending on the surgical indications. The goal is to maintain normal physiological function during the operative period.

Regional Anesthesia: Application of a local anesthetic to the nerves supplying the surgical site to provide analgesia. It encompasses both neuraxial (spinals, epidurals) and peripheral (regional nerve block) techniques. 

Monitored Anesthesia Care: Anesthetic monitoring with or without the administration of intravenous sedation. This modality if used for procedural sedation such as during a colonoscopy. 

For a more detailed description of the modalities of anesthesia and their indications, refer to chapter 2 of the Ottawa anesthesia Primer

Patterson L. Ottawa Anesthesia Primer: Patrick Sullivan. University of Ottawa, Faculty of Medicine. ECHO Book Publishing, 2012. ISBN 978-0-9918009-0-2. Can J Anesth Can d’anesthésie 2013. https://doi.org/10.1007/s12630-013-9997-4

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