Airway Management of the Parturient. Kevin C. Dennehy, MB, BCh, FFARCSI May C. M. Pian-Smith, MD

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Airway Management of the Parturient. Kevin C. Dennehy, MB, BCh, FFARCSI May C. M. Pian-Smith, MD"

Transcription

1 Airway Management of the Parturient Kevin C. Dennehy, MB, BCh, FFARCSI May C. M. Pian-Smith, MD Anesthesiologists involved in the care of the obstetric patient must consider airway management as an essential element. The importance of how well the airway is managed is emphasized in reports of the effect of anesthetic selection on maternal mortality, with a fourfold increase associated with general anesthesia versus regional anesthesia. Failure to achieve endotracheal intubation is one of the main causes of anesthesiarelated maternal mortality. 1 The present chapter reviews basic anatomy and physiology of the parturient s airway and the literature that is available to guide the clinician when deciding upon a particular technique of airway management. Anatomy and Physiology A broad spectrum of anatomical and physiological changes occurs in women during pregnancy. These changes will have effects on the airway and on the anesthesiologist s ability to rapidly provide a secure airway during general anesthesia. Average weight gain during pregnancy is 17% of prepregnant weight or approximately 12 kg. 2 This weight gain is made up of increases in blood volume and interstitial fluid, an increase in uterine size and contents, and deposition of new fat and protein throughout the body. Enlargement of the breasts may impact on the ability to place a laryngoscope blade into the mouth due to increased difficulty in navigating the blade handle. A laryngoscope with a short handle and optimal patient positioning (Fig. 1) have been utilized in this situation. Several factors increase the risk of aspiration in these patients. Lower esophageal sphincter tone is reduced during pregnancy. While gastric emptying has been reported to be normal during pregnancy and at term, 147

2 148 Dennehy and Pian-Smith Figure 1. A better alignment of the airway axis may be achieved by proper preinduction positioning of the parturient. (From Cohen. 23 With permission.) intestinal transit time is increased. 2 Gastric emptying is slowed during labor. Acid production is decreased during pregnancy and labor, but 80% of pregnant patients and 40% of patients in labor have a gastric ph equal to or less than Opioids administered during labor will further delay gastric emptying, but epidural analgesia using local anesthetics does not. If opioids are added to the epidural, they too will delay gastric emptying. 2 The combined effects of reduced lower esophageal sphincter tone and delayed gastric emptying place these patients at high risk of aspiration, particularly during labor if attempts to intubate are not immediately successful. Engorgement of the capillaries and mucosa of the nasal, oropharyngeal, and laryngeal structures occurs during the first trimester, continues throughout pregnancy, and results in an increased incidence of spontaneous epistaxis. The possibility of severe epistaxis secondary to trauma during attempted nasotracheal intubation has led to recommendations against this method of airway management. 2 Mucosal edema of the trachea has led to recommendations that a small diameter endotracheal tube (ETT) (e.g., 6.5 mm internal diameter) be placed during oral intubation. 3 Clinically, ETTs of larger diameter (e.g., 7.0 or 7.5 mm internal diameter) are inserted without complications, and the choice of ETT size should be dictated by clinical practice concerns. If endotracheal intubation is difficult, requiring multiple attempts at laryngoscopy with worsening of the already existing laryngeal edema, it may be necessary to select a smaller ETT for intubation and to allow sufficient time for resolution of the edema prior to extubation.

3 Airway Management of the Parturient 149 The Mallampati classification of mouth opening and the Samsoon and Young modified system (Fig. 2) have been reported to change during pregnancy. A prepregnancy classification of I II may advance one or two classes due to the changes discussed above. 4 There has also been a report of the classification changing during labor due to edema of the lower pharynx progressing while the patient was bearing down. The classification did not return to the prelabor assessment for a further 12 hours. 5 The clinical significance of these classification systems for predicting difficult intubation has been debated, but of 7 patients out of 1980 who had a failed intubation, 6 had a class IV airway assessment. 6 Oxygen consumption increases by 30% to 60% during pregnancy. 2 Functional residual capacity (FRC), which begins to decline by the fifth month of pregnancy, is reduced to 80% of the prepregnant state at term. If the patient is then placed supine, the FRC has been calculated to be 70% of the FRC in the upright position. These factors combine to result in rapid desaturation associated with apnea. 7 However, preoxygenation with the goal of denitrogenation will also take less time in the pregnant than in the nonpregnant patient (e.g., 55 seconds versus 111 seconds, respectively, to reach an end-tidal nitrogen level of 5%). 8 Two methods of preoxygenation, 3 minutes of tidal volume breathing or 4 vital capacity breath hyperventilation of 100% oxygen, produced similar levels of arterial oxygenation during rapid-sequence induction of anesthesia. 9 Cricoid pressure, applied by a trained assistant, is used during rapid-sequence induction of general anesthesia until no longer required by the anesthesiologist. The maneuver attempts to prevent regurgitation of gastric contents into the pharynx by pressing the cricoid cartilage against the sixth cervical vertebra thereby occluding the esophagus between these two structures. During the application of cricoid pressure, the assistant s hand may obstruct the placement of the laryngoscope, may cause flexion of the head at the atlanto-occipital joint making laryngoscopy and intubation difficult, or rarely, may result in complete occlusion of the airway that may Figure 2. Pictorial representation shows the Samsoon and Young modification of the Mallampati classification based on the ability to see oropharyngeal structures. (From Samsoon and Young. 6 With permission.)

4 150 Dennehy and Pian-Smith not resolve until cricoid pressure is removed. 10,11 Cricoid pressure may also make it difficult to perform other emergency maneuvers, such as properly placing a laryngeal mask airway (LMA). Positioning of the obstetric patient on the operating table is influenced by the anatomical and physiological changes associated with late pregnancy. Aortocaval compression occurs due to compression of the great vessels in the abdomen by the pregnant uterus, which results in maternal hypotension and uteroplacental insufficiency. The patient is therefore positioned with a wedge under the right hip to create left lateral displacement of the uterus away from the aorta and inferior vena cava. This left lateral displacement may also alter the position of the airway making laryngoscopy and intubation difficult. If an emergency tracheostomy is necessary, the left lateral positioning may make identification of landmarks difficult. Epidemiology Obstetric anesthesia has gone from being the third most common cause of maternal mortality to being the eighth. 1,12 The practice of obstetric anesthesia is continually evolving and at present is directed towards the safe provision of regional anesthesia. This practice has evolved due to evidence of increased mortality associated with general anesthesia. Hawkins and colleagues 13 determined that the case-fatality risk ratio was 16.7 times greater for general anesthesia versus regional anesthesia. This increased mortality is predominantly due to failure of tracheal intubation leading to cardiac arrest, anoxic cerebral injury, or aspiration of gastric contents. There is also increased awareness of the potential toxicity of local anesthetics and the possibility of excessively high blocks that has resulted in practices that reduce mortality associated with regional anesthesia. The evidence is available from numerous sources, and attempts have been made to identify explanations for changes in the trend of maternal mortality from anesthesia over the last approximately 25 years. 1,12 14 Although the incidence of difficult intubation is not precisely known, the incidence of failed intubation during obstetric general anesthesia has been calculated to range from 1 in to 1 in The latter figure was obtained from the results of a survey and a composite incidence of about 1 in 500 has been suggested as a reasonable estimate. 16 This compares with an incidence of failed intubation in the general surgical population of 1 in A report from Michigan determined that the inability to provide a secure airway was the predominant cause of the 15 anesthesiarelated maternal deaths, particularly during the latter part of the period The triennial reports on confidential enquiries into maternal deaths

5 Airway Management of the Parturient 151 in the United Kingdom review every maternal death and attempt to determine the cause. For the triennium , anesthesia was the third leading cause of maternal deaths, responsible for 19 of 243 deaths. Fifteen of these deaths were attributed to problems with airway management during general anesthesia. 12 The most recent triennial report indicates anesthesia is the eighth leading cause of maternal mortality, with only one death directly related to anesthesia. 1 The quality of anesthesia care was considered to be substandard in this case and in 12 of 20 cases in which anesthesia was associated with maternal death, but the main cause was attributed to other pathology. 1 The perception of obstetric anesthesia as a high-risk specialty has led to significant improvements, with an overall reduction in the number of maternal deaths directly caused by anesthesia. Clinical Features The finding of a 16.7 times greater case-fatality risk ratio for general anesthesia versus regional anesthesia has resulted in the selection, whenever possible, of regional anesthesia for operative delivery of the newborn. Despite this emphasis, there will be some patients in whom regional anesthesia is contraindicated for various reasons, as detailed in Table 1. For patients in whom a general anesthetic is preferable or obstetrically necessary, various factors have been identified that when present may make intubation difficult. These coexisting factors may be divided into patient features, factors associated with the pregnant state, and factors associated with anesthesia. Patient Factors A high Mallampati or Samsoon and Young score has already been discussed above. A class IV airway (see Fig. 2) is associated with an 11.3 times greater chance of difficult intubation versus a class I airway. 17 Simple external examination of the head and neck can reveal a short neck, re- Table 1. Contraindications to Regional Anesthesia for Performance of Operative Delivery in the Obstetric Patient Absolute Relative Patient refusal Fetal distress Sepsis (local or systemic) Inadequate regional anesthesia Coagulopathy Maternal hemorrhage Thrombocytopenia Maternal cardiac disease (aortic stenosis, mitral stenosis)

6 152 Dennehy and Pian-Smith ceding mandible, or prominent upper incisors. These have been found to increase the difficulty of intubation 5-, 9.7-, and 8-fold, respectively (Table 2). A patient with all three features present has a greater than 90% chance of experiencing a difficult intubation based on the prediction method of Rocke and associates 17 shown in Figure 3. Morbid obesity (maternal weight > 136 kg) has been reported to result in difficult intubating conditions. Morbidly obese patients also have an increased incidence of operative delivery necessitating anesthetic intervention. 18 Twenty-four percent of obese patients and 29% of normal weight patients received general anesthesia for cesarean section, and 35% of the obese patients and 0% of controls were characterized as difficult to intubate. 19 Endler and coworkers 14 identified obesity as an associated factor in 80% of maternal deaths. Obstetric Factors Hypertensive disorders of pregnancy have been implicated as risk factors for difficult intubation. Elevated blood pressure in both pregnancy-induced hypertension and preeclampsia is thought to worsen mucosal and interstitial edema, which may make laryngoscopy difficult. 20 Thrombocytopenia may also be present, which will make the choice of general anesthesia more likely than a regional anesthetic should operative intervention be necessary. Emergency surgery has been implicated in 80% of maternal deaths, and 4 of 15 deaths were associated with general anesthesia and difficulty with, or failure of, intubation. 14 Anesthesia Factors First, equipment failure may, rarely, lead to inability to intubate. Second, previous reports have implicated operator inexperience and inad- Table 2. The Relative Risk of Factors Associated with Difficult Intubation as Compared with Samsoon and Young Airway Class I Risk Factor Relative Risk Samsoon and Young Classification Class I 1 Class II 3.2 Class III 7.6 Class IV 11.3 Short neck 5.0 Receding mandible 9.7 Protruding upper incisors 8.0 (Modified from Rocke et al. 17 With permission.)

7 Airway Management of the Parturient 153 Figure 3. The bar graph illustrates the probability of experiencing difficult intubation for varying combinations of airway risk factors and the observed incidence (%). SN = short neck; PI = protruding incisors; RM = receding mandible; Class I to IV = the Samsoon and Young airway classification. (From Rocke et al. 17 With permission.) equate supervision of trainees by experienced anesthesiologists as factors leading to failure to intubate. 12,17 In the report by Rocke and associates, 17 the presence of an experienced anesthesiologist led to rapid recognition of esophageal intubation and successful correction of the error. Airway Management Identification of those patients in whom intubation might be difficult is the ideal that we strive to achieve. Unfortunately, the methods of assessment we currently use clinically do not accurately predict which patients will be difficult to intubate. The sensitivity and specificity of oropharyngeal airway assessment using the Samsoon and Young classification have been reported to be 59% and 73%, respectively. 17 The positive predictive value of a patient with a class III or IV airway subsequently being difficult to intubate was only 4%. The negative predictive value, however,

8 154 Dennehy and Pian-Smith of a patient with a class I or II airway subsequently not representing difficulty at intubation was 99%. 17 Anesthesiologists must therefore use their clinical skills to determine which patients will present difficulty with airway management. This should be done as early during labor as possible to allow a management plan to be decided upon should it be necessary to administer an anesthetic. A plan should then be formulated that includes management of each patient s airway. Patients considered to be at low risk of failed intubation usually do not need any extra preparation. Patients considered to be at intermediate or high risk of failed intubation should have their options for analgesia during labor discussed with them and be encouraged to have an epidural placed. The requirement for general anesthesia, including awake intubation and/or having to allow the patient to awaken after failed intubation to proceed with an alternate plan, should also be discussed with them. Regional anesthesia, provided there are no contraindications, should be considered the safest method of providing anesthesia and should be chosen if possible. The maternal mortality figures from the United Kingdom bear this out, with a dramatic reduction in the number of deaths due to failed airway management over the last 40 years. However, the one death that was directly attributed to anesthesia during the most recent triennium occurred with a combined spinal/epidural anesthetic. 1 Once the decision has been made to proceed with general anesthesia, airway management begins with acid aspiration prophylaxis. It is not possible to eliminate the possibility of aspiration, so attempts are made to reduce the acidity and volume of gastric contents with either one or a combination of histamine-2-receptor antagonists, metoclopramide, 0.3 M sodium citrate, and proton pump inhibitors (omeprazole). No prophylaxis regimen has been found to adequately prepare the stomach of the laboring patient. Oral sodium citrate effectively raises the stomach ph but has a duration of action of approximately 1 hour. The administration of oral ranitidine the night before and IV ranitidine 90 minutes before elective cesarean section has been shown to be effective in reducing gastric volumes and increasing ph; however, some patients will still have a gastric ph less than Metoclopramide increases the lower esophageal tone in nonpregnant patients and decreases gastric volume. However, opioid administration offsets the effects of metoclopramide, which makes its use of questionable efficacy during balanced general anesthesia. Use of 40 mg of omeprazole the night before and the morning of surgery has been shown to be effective at reducing both gastric acidity and volume prior to elective cesarean delivery, but single-dose omeprazole has not. 21,22 Suitable equipment for airway management should be readily available with a minimum of time required to obtain and set up a fiberoptic intubating scope. A list of desirable equipment to have available is contained in Table 3. It is important to emphasize that in the case of an

9 Airway Management of the Parturient 155 Table 3. Airway Management Equipment Multiple mask and oral pharyngeal airways Multiple laryngoscope blades of various sizes (e.g., Macintosh, Miller, McCoy) Multiple laryngoscope handles, including a short one Multiple endotracheal tubes of various sizes Stylette and/or gum elastic bougie Size 3, 4, and 5 laryngeal mask airways Fiberoptic scope and light source Local anesthetic and antisialagogue to topicalize the airway Cricothyrotomy equipment based on institutional preference Other equipment based on preference of practitioner (e.g., Combitube, lighted stylette, Bullard laryngoscope (Circon ACMI, Stamford, CT), vasoconstrictor and nasopharyngeal airway for nasal intubation) expected or unexpected difficult or failed intubation, the clinician should employ the method of emergency airway management with which he or she is most familiar. Examples of emergency airway equipment available in our obstetric unit are shown in Figure 4. Figure 4. A photograph shows the selection of emergency airway equipment that is immediately available in our institution: laryngeal mask airway, intubating laryngeal mask airway (Fastrach; Intavent Research Ltd; Reading, UK), short-handle laryngoscope, lighted stylette, gum elastic bougie, and a jet ventilator.

10 156 Dennehy and Pian-Smith Proper positioning of the head and neck may convert an impossible intubation into an easy one. Obtaining the ideal position involves flexing the lower cervical spine and extending the upper cervical spine by extending the head on the atlanto-occipital joint. This position may be exaggerated for the obese patient to optimize the sniffing position : even large breasts will move away from the airway with padding or extra blankets placed behind the shoulders and head, as shown in Figure Following the induction of general anesthesia and a failed first attempt at intubation, a failed intubation drill needs to be instituted for subsequent airway management (Fig. 5). Help should be summoned. In certain circumstances, the clinician will realize immediately that the patient represents an impossible intubation and the safest course is to wake the patient up and reassess the anesthetic plan. If the clinician is able to ventilate the patient by mask and feels that endotracheal intubation is possible with different equipment (a lighted stylette, the Combitube [Kendall-Sheridan, Argyle, NY], or the intubating laryngeal mask airway [Fastrach, Intavent Research Ltd; Reading, UK] may be chosen based on clinician preference) or a change in position, he or she may elect to proceed with further attempts at intubation with the patient asleep. In general, each attempt should be preceded by significant changes in patient positioning or intubating strategy. During these attempts, it may be necessary to administer additional doses of induction agent and neuromuscular blocker. Cricoid pressure should be applied continuously throughout these airway manipulations. Eventually a point may be reached, if attempts at intubation have not been successful, when a decision is made to stop further attempts. This decision should be reached after relatively few attempts at intubation because each attempt will contribute to worsening laryngeal edema that may result in obstruction of the airway. Terminating attempts at intubation can be a difficult clinical and sometimes ethical decision to make. If general anesthesia was induced for an emergency cesarean section for fetal distress, then the time it will take to wake the mother and decide on a subsequent management plan may result in irreversible hypoxic damage to the fetus. If the decision is made to proceed with a bag/mask airway and deliver the baby, there is no guarantee that the airway will not be lost at any time during the operation, with the possibility that the mother will suffer irreversible hypoxic damage. Although the anesthesiologist s principal focus should be directed towards the safety of the mother, it is difficult to ignore the condition of the fetus in this situation. Each situation will have to be considered separately and a decision made to proceed with surgery or allow the patient to awaken based on the clinical conditions encountered at the time of the failed intubation. Despite our best efforts, including attempted utilization of the laryngeal mask airway (LMA insertion is more successful without cricoid pressure), 24 the can t ventilate/can t intubate scenario can occur. This is an indication for a surgical airway (see Fig. 5). A cricothyroidotomy with

11 Airway Management of the Parturient 157 Figure 5. Flow chart illustrates the failed intubation algorithm in the setting of an emergency delivery. F/M = face mask; CP = cricoid pressure; LMA = laryngeal mask airway; GA = general anesthesia (Combitube; Fastrach; Intavent Research Ltd; Reading, UK). (Modified from Suresh and Wali. 23 With permission.) transtracheal jet ventilation may be performed, but this method is associated with high morbidity (e.g., barotrauma) and is made particularly difficult by the emergency setting. If a difficult intubation is anticipated or subsequently encountered, a surgeon with experience in performing tracheostomies should be present.

12 158 Dennehy and Pian-Smith Conclusion There is an increased incidence of difficult/failed intubation during general anesthesia in the obstetric patient population compared with the general surgical population. Recognition of this fact has led to a decreased incidence of maternal deaths directly related to loss of the airway (i.e., anoxic brain injury), cardiac arrest, and aspiration-induced acute respiratory distress syndrome with multiorgan failure. Anesthesiologists must maintain a high index of suspicion for the parturient who may be at risk for a difficult/failed intubation and have a plan ready to deal with this situation. Continuing education of all those who care for the pregnant patient will allow potential problems to be addressed. References 1. Why mothers die. Report on confidential enquiries into maternal deaths in the United Kingdom London: Her Majesty s Stationery Office, Conklin KA. Physiologic changes of pregnancy. In: Chestnut DH, ed. Obstetric anesthesia. Principles and practice. St. Louis: Mosby, 1994: Leontic EA. Respiratory disease in pregnancy. Med Clin North Am 1977;61: Pilkington S, Carli F, Dakin MJ, et al. Increase in Mallampati score during pregnancy. Br J Anaesth 1995;74: Farcon EL, Kim MH, Marx GF. Changing Mallampati score during labour. Can J Anaesth 1994;41: Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987;42: Archer GW, Jr, Marx GF. Arterial oxygen tension during apnoea in parturient women. Br J Anaesth 1974;46: Norris MC, Kirkland R, Torjman MC, Goldberg ME. Denitrogenation in pregnancy. Can J Anaesth 1989;36: Norris MC, Dewan DM. Preoxygenation for cesarean section: a comparison of two techniques. Anesthesiology 1985;62: Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;2: Georgescu A, Miller JN, Lecklitner ML. The Sellick maneuver causing complete airway obstruction. Anesth Analg 1992;74: Report on confidential enquiries into maternal deaths in the United Kingdom London: Her Majesty s Stationery Office, Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, Anesthesiology 1997;86: Endler GC, Mariona FG, Sokol RJ, Stevenson LB. Anesthesia-related maternal mortality in Michigan, 1972 to Am J Obstet Gynecol 1988;159: Lyons G, MacDonald R. Difficult intubation in obstetrics. Anaesthesia 1985;40: Davies JM, Weeks S, Crone LA, Pavlin E. Difficult intubation in the parturient. Can J Anaesth 1989;36: Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992;77: Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult intubation: a prospective study. Can Anaesth Soc J 1985;32:

13 Airway Management of the Parturient Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993;79: Brock-Utne JG, Downing JW, Seedat F. Laryngeal oedema associated with pre-eclamptic toxaemia. Anaesthesia 1977;32: Ewart MC, Yau G, Gin T, et al. A comparison of the effects of omeprazole and ranitidine on gastric secretion in women undergoing elective caesarean section. Anaesthesia 1990; 45: Moore J, Flynn RJ, Sampaio M, et al. Effect of single-dose omeprazole on intragastric acidity and volume during obstetric anaesthesia. Anaesthesia 1989;44: Cohen SE. Anesthesia for the morbidly obese pregnant patient. In: Shnider SM, Levinson G, eds. Anesthesia for obstetrics. 3rd ed. Philadelphia: Williams & Wilkins, 1993: Suresh MS, Wali A. Failed intubation in obstetrics. Anesth Clin North Am 1998;16:

Master algorithm obstetric general anaesthesia and failed tracheal intubation

Master algorithm obstetric general anaesthesia and failed tracheal intubation Master algorithm obstetric general anaesthesia and failed tracheal intubation Algorithm 1 Safe obstetric general anaesthesia Pre-induction planning and preparation Team discussion Rapid sequence induction

More information

Perioperative Airway Management:

Perioperative Airway Management: Perioperative Airway Management: Update on Tools and Techniques Toni Felberg, M.D., FAAP Assistant Professor of Anesthesiology and Pediatrics Baylor College of Medicine Texas Children s Hospital Houston,

More information

FAILED INTUBATION IN OBSTETRIC PATIENTS - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline

FAILED INTUBATION IN OBSTETRIC PATIENTS - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline FAILED INTUBATION IN OBSTETRIC PATIENTS - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. To give guidance to obstetric anaesthetists in the management of a failed intubation in an obstetric patient.

More information

AIRWAY MANAGEMENT. Angkana Lurngnateetape, MD. Department of Anesthesiology Siriraj Hospital

AIRWAY MANAGEMENT. Angkana Lurngnateetape, MD. Department of Anesthesiology Siriraj Hospital AIRWAY MANAGEMENT Angkana Lurngnateetape, MD. Department of Anesthesiology Siriraj Hospital Perhaps the most important responsibility of the anesthesiologist is management of the patient s airway Miller

More information

ANAESTHESIA FOR CAESARIAN SECTION PART 3 GENERAL ANAESTHESIA ANAESTHESIA TUTORIAL OF THE WEEK 97

ANAESTHESIA FOR CAESARIAN SECTION PART 3 GENERAL ANAESTHESIA ANAESTHESIA TUTORIAL OF THE WEEK 97 ANAESTHESIA FOR CAESARIAN SECTION PART 3 GENERAL ANAESTHESIA ANAESTHESIA TUTORIAL OF THE WEEK 97 16 th JUNE 2008 Dr James Brown. Royal Devon & Exeter Hospital, UK Correspondence to: jprb_brum@yahoo.com

More information

DIFFICULT AIRWAY MANAGEMENT

DIFFICULT AIRWAY MANAGEMENT DIFFICULT AIRWAY MANAGEMENT When you can t breath, nothing else matters Dr. J. Edward Johnson. M.D., D.C.H. Asst. Professor, Dept. of Anaesthesiology, KGMCH. 9/18/2015 1 IF YOU GET A CALL TO ATTEND THIS

More information

Difficult Airway Management and the Importance of the Introes Pocket Bougie

Difficult Airway Management and the Importance of the Introes Pocket Bougie A difficult airway is defined as the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal

More information

Head-Tilt Jaw-Thrust Thrust

Head-Tilt Jaw-Thrust Thrust Objectives EM Clerkship: Airways Explain anatomy and basic equipment used in airway management Describe proper p sizing and insertion of airway adjuncts Explain potential indications for endotracheal intubation

More information

COURSE OVERVIEW LEARNING OBJECTIVES Knowledge Knowledge Recall Knowledge Analysis Knowledge Synthesis Knowledge Application Skills Attitudes

COURSE OVERVIEW LEARNING OBJECTIVES Knowledge Knowledge Recall Knowledge Analysis Knowledge Synthesis Knowledge Application Skills Attitudes Rotation Director (email) Rotation Name Marc Hassid (hassid@musc.edu) Airway COURSE OVERVIEW Course Overview (75 100 words describing the course) The airway rotation is a CA-1 rotation that provides residents

More information

Difficult Airway. Predicting Difficult Mask Ventilation

Difficult Airway. Predicting Difficult Mask Ventilation Predicting Difficult Mask Ventilation Difficult mask ventilation can be a serious threat to a patient if difficult intubation occurs, and the patient cannot be properly ventilated by mask Five factors

More information

Miller, CG: Management of the Difficult Intubation in Closed Malpractice Claims. ASA Newsletter 64(6):13-16 & 19, 2000.

Miller, CG: Management of the Difficult Intubation in Closed Malpractice Claims. ASA Newsletter 64(6):13-16 & 19, 2000. Citation Miller, CG: Management of the Difficult Intubation in Closed Malpractice Claims. ASA Newsletter 64(6):13-16 & 19, 2000. Full Text In order to assess and minimize adverse outcomes related to airway

More information

Difficult Airway Management: Poor Decisions or Lack of Technical Knowledge?

Difficult Airway Management: Poor Decisions or Lack of Technical Knowledge? Difficult Airway Management: Poor Decisions or Lack of Technical Knowledge? Joseph L. Nates, MD MBA FCCM Professor, Vice Chair, ICUs Medical Director, Director of Research Critical Care Department, Division

More information

Rotation Specific Guidelines CCFP - EM Residency Program

Rotation Specific Guidelines CCFP - EM Residency Program Rotation Specific Guidelines CCFP - EM Residency Program ANAESTHESIA To utilize the relevant competencies contained within the CanMEDS-FM roles to develop anesthesia skills relevant to the emergency physician

More information

Pediatric Airway Management

Pediatric Airway Management Pediatric Airway Management Dec 2003 Dr. Shapiro I., PICU Adult Chain of Survival EMS CPR ALS Early Defibrillation Pediatric Chain of Survival Prevention CPR EMS ALS Out-of-Hospital Cardiac Arrest SIDS

More information

Trauma and Pregnancy. William Schecter, MD

Trauma and Pregnancy. William Schecter, MD Trauma and Pregnancy William Schecter, MD Trauma and Pregnancy ATLS Protocol the same Physiologic and Anatomic changes of pregnancy change the pattern of injury and the physiologic response to injury Two

More information

Cricoid Pressure: A Survey of Its Practice in India

Cricoid Pressure: A Survey of Its Practice in India Indian Journal of Anaesthesia 2007; 51 (6) : 505-509 Clinical Investigation Summary Cricoid Pressure: A Survey of Its Practice in India 505 B.S.Krishnan 1, D.A.Sanjib 2, D.Harikrishna 3, B.Rajlakshmi 4,

More information

Anatomical and Physiological Changes in Pregnancy Relevant to Anaesthesia

Anatomical and Physiological Changes in Pregnancy Relevant to Anaesthesia Anatomical and Physiological Changes in Pregnancy Relevant to Anaesthesia Dr. A. Calzolari Specialist Registrar in Anaesthesia Dr. D. J. Dalgleish Consultant Anaesthetist Royal Bournemouth Hospital Dorset,

More information

The Difficult Airway. The Difficult Airway. Difficult Airway Algorithms: ASA. Ectopic Anesthesia. Cancel Case. Awaken. airway. Defining ng the problem

The Difficult Airway. The Difficult Airway. Difficult Airway Algorithms: ASA. Ectopic Anesthesia. Cancel Case. Awaken. airway. Defining ng the problem The Difficult Airway The Difficult Airway Robert J. Vissers, MD FACEP Department of Emergency Medicine Legacy, Emanuel Hospital Defining ng the problem Defining ng the difficult d airway a Identifying

More information

A Difficult Airway Problem

A Difficult Airway Problem A Difficult Airway Problem Katie Cranfield & Rupert Gauntlett OAA Cases and Challenges 2 nd March 2016 Outline Case presentation What have we learnt? How has it changed our practice in Newcastle? Royal

More information

Case Study: General Anesthesia for acute appendectomy in a pregnant woman. David Roy Godden. Clinical Residency in Nurse Anesthesia II ANST 507

Case Study: General Anesthesia for acute appendectomy in a pregnant woman. David Roy Godden. Clinical Residency in Nurse Anesthesia II ANST 507 Case Study: General Anesthesia for acute appendectomy in a pregnant woman By David Roy Godden Clinical Residency in Nurse Anesthesia II ANST 507 Michele E. Gold, CRNA, PhD Associate Professor of Clinical

More information

What s New in Airway Management

What s New in Airway Management What s New in Airway Management Monday, Sept. 28th, 2015 Andreas Grabinsky, MD! Associate Professor, Department of Anesthesiology! Program Director and Section Head, Emergency & Trauma Anesthesia! Associate

More information

AIRWAY MANAGEMENT IN OBSTETRICS

AIRWAY MANAGEMENT IN OBSTETRICS 328 Indian J. PG Anaesth. ISSUE 2005; : AIRWAY 49 (4) : MANAGEMENT 328-335 INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005 328 AIRWAY MANAGEMENT IN OBSTETRICS Dr. Rudra A. Introduction Although the use of general

More information

NAP4. Major complications of airway management in the United Kingdom. Section 3. Appendices

NAP4. Major complications of airway management in the United Kingdom. Section 3. Appendices NAP4 Major complications of airway management in the United Kingdom Section 3 Appendices Appendix 1 Example intubation checklist for ICU and emergency department 204 NAP4 Report and findings of the 4th

More information

Paediatric airway management

Paediatric airway management Paediatric airway management Rigshospitalet, January 21 st 2010 Rolf Holm-Knudsen, M.D. Dep. of Anaesthesia, HOC Copenhagen University Hospital, Rigshospitalet DK-2100 Copenhagen, Denmark rhk@rh.dk The

More information

Airway Management for the Non-Anesthesiologist

Airway Management for the Non-Anesthesiologist Airway Management for the Non-Anesthesiologist Rondall K. Lane, M.D., M.P.H. Department of Anesthesia and Perioperative Care University of California, San Francisco Evaluating the Airway Predictors of

More information

Airway Management. William Schecter, MD Professor of Clinical Surgery University of California Chief of Surgery San Francisco General Hospital

Airway Management. William Schecter, MD Professor of Clinical Surgery University of California Chief of Surgery San Francisco General Hospital Airway Management William Schecter, MD Professor of Clinical Surgery University of California Chief of Surgery San Francisco General Hospital The most common cause of PREVENTABLE peri-operative death is

More information

Decision Making in Airway Management. Indications and Selection of Patients for Awake Intubation*

Decision Making in Airway Management. Indications and Selection of Patients for Awake Intubation* CHOOSE CONFIDENCE Decision Making in Airway Management Indications and Selection of Patients for Awake Intubation* William Rosenblatt, M.D. The induction of anesthesia, including the onset of apnea, takes

More information

Guideline Obs 122 Division of Surgery Directorate of Obstetrics and Gynaecology

Guideline Obs 122 Division of Surgery Directorate of Obstetrics and Gynaecology Guideline Obs 122 Division of Surgery Directorate of Obstetrics and Gynaecology Guidelines for the management of Peri-arrest or Peri-mortem Caesarean section Written by Hari Muppala and Apollo Meskhi,

More information

ASA closed claims in obstetrics: lessons learned

ASA closed claims in obstetrics: lessons learned Anesthesiology Clin N Am 21 (2003) 183 197 ASA closed claims in obstetrics: lessons learned Brian K. Ross, MD, PhD Department of Anesthesiology, University of Washington, Box 356540, University of Washington,

More information

Neonatal Intubation. Purpose. Scope. Indications. Equipment Cardiorespiratory monitor SaO 2 monitor. Anatomic Considerations.

Neonatal Intubation. Purpose. Scope. Indications. Equipment Cardiorespiratory monitor SaO 2 monitor. Anatomic Considerations. Page 1 of 5 Purpose Scope Indications Neonatal Intubation To assure proper placement of endotracheal tubes for maximum ventilation using proper intubation procedures. The policy applies to all Respiratory

More information

Geisinger Health System Anesthesiology Residency Program. Advanced Airway Management

Geisinger Health System Anesthesiology Residency Program. Advanced Airway Management Geisinger Health System Anesthesiology Residency Program Advanced Airway Management INTRODUCTION Airway management is part of everyday anesthesia practice. Major complications are frequently associated

More information

Geisinger Health System Anesthesiology Residency Program. Obstetric Anesthesia

Geisinger Health System Anesthesiology Residency Program. Obstetric Anesthesia Geisinger Health System Anesthesiology Residency Program Obstetric Anesthesia INTRODUCTION Education and training in obstetric anesthesia will consist of attending-supervised rotations for four weeks during

More information

Decision, Process, Management

Decision, Process, Management Decision, Process, Management Needle cricothyroidotomy involves passing an over-the-needle catheter through the cricothyroid membrane. This procedure provides a temporary secure airway to oxygenate and

More information

Extubation algorithm for major neck and upper airway surgery

Extubation algorithm for major neck and upper airway surgery Extubation algorithm for major neck and upper airway surgery Risk of airway swelling, bleeding and/or vocal cord paralysis No/low risk Verify full reversal of NMB and adequate spont breathing, stomach

More information

Anaesthesia tutorial of the week 112: Prone Positioning

Anaesthesia tutorial of the week 112: Prone Positioning Anaesthesia tutorial of the week 112: Prone Positioning Dr D G Hovord Specialist Trainee Registrar - Anaesthetics University Hospitals of Coventry and Warwick d_hovord@hotmail.com Self-assessment Before

More information

Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist

Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist American Association of Nurse Anesthetists 222 South Prospect Avenue Park Ridge, IL 60068 www.aana.com Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist

More information

AEROSPACE MEDICAL SERVICE SPECIALTY INDEPENDENT DUTY MEDICAL TECHNICIAN EMERGENCY MEDICINE PROCEDURES

AEROSPACE MEDICAL SERVICE SPECIALTY INDEPENDENT DUTY MEDICAL TECHNICIAN EMERGENCY MEDICINE PROCEDURES QTP4N0X1C-9 02 July 2015 AEROSPACE MEDICAL SERVICE SPECIALTY INDEPENDENT DUTY MEDICAL TECHNICIAN EMERGENCY MEDICINE PROCEDURES Volume 9 TOTAL FORCE, TOTAL CARE EVERYTIME, ANYWHERE 383d TRAINING SQUADRON/XUFB

More information

NEONATAL RESUSCITATION; THE USE OF LARYNGEAL MASK AIRWAY

NEONATAL RESUSCITATION; THE USE OF LARYNGEAL MASK AIRWAY NEONATAL RESUSCITATION 8 ORIGINAL PROF-1326 NEONATAL RESUSCITATION; THE USE OF LARYNGEAL MASK AIRWAY DR. FAHEEM FEROZE, MBBS, FCPS PAC Hospital Kamra DR. NAVEED MASOOD, MBBS, FCPS Classified Anaesthetist

More information

The unexpected difficult paediatric airway: Are you prepared?

The unexpected difficult paediatric airway: Are you prepared? The unexpected difficult paediatric airway: Are you prepared? Stephanie Bew Leeds Children s Hospital APA Linkman Meeting November 9 th 2015 What will this lecture cover? How often will I have to deal

More information

Pre-hospital Care Standard Operating Procedure. Rapid Sequence Intubation [RSI]

Pre-hospital Care Standard Operating Procedure. Rapid Sequence Intubation [RSI] Pre-hospital Care Standard Operating Procedure Rapid Sequence Intubation [RSI] REVIEW: May 2010 APPROVAL/ ADOPTED: PHC Policy Board DISTRIBUTION: PHC Doctors PHC Paramedics RELATED DOCUMENTS: THIS DOCUMENT

More information

Department of Veterans Affairs VHA DIRECTIVE 2012-032 Veterans Health Administration Washington, DC 20420 October 26, 2012

Department of Veterans Affairs VHA DIRECTIVE 2012-032 Veterans Health Administration Washington, DC 20420 October 26, 2012 Department of Veterans Affairs VHA DIRECTIVE 2012-032 Veterans Health Administration Washington, DC 20420 OUT OF OPERATING ROOM AIRWAY MANAGEMENT 1. PURPOSE: This Veterans Health Administration (VHA) Directive

More information

Pulmonary Complications after General Anesthesia

Pulmonary Complications after General Anesthesia Pulmonary Complications after General Anesthesia Brent Hadder, M. D. Assistant Professor Division of Surgical Intensive Care Palliative Care Service I have no financial support to disclose. 1 Pulmonary

More information

setting.

setting. 2.1 ANCC CONTACT HOURS By Linda Heltemes, CRNA, MS W While airway management is routinely performed in the surgical setting, it s never taken lightly. For patients with a difficult airway, the end result

More information

Airway assessment. Bran Retnasingham Andy McKechnie

Airway assessment. Bran Retnasingham Andy McKechnie Airway assessment Bran Retnasingham Andy McKechnie The average Camberwell patient? Airway assessment There is one skill above all else that an anaesthetist is expected to exhibit and that is to

More information

An Evaluation of the Rapid Airway Management Positioner in Obese Patients Undergoing Gastric Bypass or Laparoscopic Gastric Banding Surgery

An Evaluation of the Rapid Airway Management Positioner in Obese Patients Undergoing Gastric Bypass or Laparoscopic Gastric Banding Surgery OBES SURG (2010) 20:1436 1441 DOI 10.1007/s11695-009-9885-8 CASE REPORT An Evaluation of the Rapid Airway Management Positioner in Obese Patients Undergoing Gastric Bypass or Laparoscopic Gastric Banding

More information

Policies and Procedures. Number: 1162

Policies and Procedures. Number: 1162 Policies and Procedures Title: ENDOTRACHEAL TUBES (ADULT, PEDIATRIC) EXTUBATION Number: 1162 Authorization: [x] SHR Nursing Practice Committee Source: Nursing / Respiratory Therapy Cross Index: SHR Region-Wide

More information

Lesson 4: CHEST COMPRESSIONS

Lesson 4: CHEST COMPRESSIONS Lesson 4: CHEST COMPRESSIONS Neonatal Resuscitation Program Slide Presentation Kit The American Academy of Pediatrics is not responsible for any changes or modifications to this program made by the Neonatal

More information

IS A CHEST TUBE NECESSARY PRIOR TO AIR MEDICAL TRANSPORT OF PATIENTS WITH PNEUMOTHORAX?

IS A CHEST TUBE NECESSARY PRIOR TO AIR MEDICAL TRANSPORT OF PATIENTS WITH PNEUMOTHORAX? UNM School of Medicine IS A CHEST TUBE NECESSARY PRIOR TO AIR MEDICAL TRANSPORT OF PATIENTS WITH PNEUMOTHORAX? Principal Investigators: Gregory Pirkl Phase I-2, Medical Student Class of 2008 gpirkl@salud.unm.edu

More information

Contents. Cricoid Cartilage... Epiglottis... Trachea and Mainstem Bronchi... Summary... References... Suggested Reading...

Contents. Cricoid Cartilage... Epiglottis... Trachea and Mainstem Bronchi... Summary... References... Suggested Reading... 1 Anatomy of the Airway..... The Nose... Oral Cavity... Uvula... Tonsils... Tongue... Pharynx... Prevertebral Fascia... Retropharyngeal Space... Larynx... Laryngeal Cartilages... Laryngeal Cavity... Nerve

More information

TRAUMA IN PREGNANCY MODULE

TRAUMA IN PREGNANCY MODULE TRAUMA IN PREGNANCY MODULE INTRODUCTION Trauma affects approximately 7% of pregnancies which approaches rates in the general population. 1 Premature labour, placental abruption, foeto-maternal haemorrhage

More information

OET: Listening Part A: Influenza

OET: Listening Part A: Influenza Listening Test Part B Time allowed: 23 minutes In this part, you will hear a talk on critical illnesses due to A/H1N1 influenza in pregnant and postpartum women, given by a medical researcher. You will

More information

The American Society of Anesthesiologists (ASA) has defined MAC as:

The American Society of Anesthesiologists (ASA) has defined MAC as: Medical Coverage Policy Monitored Anesthesia Care (MAC) sad EFFECTIVE DATE: 09 01 2004 POLICY LAST UPDATED: 11 04 2014 OVERVIEW The intent of this policy is to address anesthesia services for diagnostic

More information

Michigan General Procedures EMERGENCY AIRWAY Date: May 31, 2012 Page 1 of 16

Michigan General Procedures EMERGENCY AIRWAY Date: May 31, 2012 Page 1 of 16 Date: May 31, 2012 Page 1 of 16 Emergency Airway Effective airway management and ventilation are important lifesaving interventions that all EMS providers must be able to perform. The approach to airway

More information

To outline nursing management of patients receiving epidural anesthesia during labor (Includes walking epidurals and combined spinal-epidurals).

To outline nursing management of patients receiving epidural anesthesia during labor (Includes walking epidurals and combined spinal-epidurals). HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER LABOR: EPIDURAL EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES

More information

Virginia Office of Emergency Medical Services Scope of Practice - Procedures for EMS Personnel

Virginia Office of Emergency Medical Services Scope of Practice - Procedures for EMS Personnel Specific tasks in this document shall refer to the Virginia Education Standards. AIRWAY TECHNIQUES Airway Adjuncts Airway Maneuvers Alternate Airway Devices Cricothyrotomy Obstructed Airway Clearance Intubation

More information

The Vortex Approach: Management of the Unanticipated Difficult Airway

The Vortex Approach: Management of the Unanticipated Difficult Airway The Vortex Approach: Management of the Unanticipated Difficult Airway By Nicholas Chrimes & Peter Fritz Smashwords Edition Copyright Nicholas Chrimes 2013. Smashwords Edition License Notes Although this

More information

Perioperative Management of Patients with Obstructive Sleep Apnea. Kalpesh Ganatra,MD Diplomate, American Board of Sleep Medicine

Perioperative Management of Patients with Obstructive Sleep Apnea. Kalpesh Ganatra,MD Diplomate, American Board of Sleep Medicine Perioperative Management of Patients with Obstructive Sleep Apnea Kalpesh Ganatra,MD Diplomate, American Board of Sleep Medicine Disclosures. This activity is supported by an education grant from Trivalley

More information

Out of the OR Airway Not Just for Anesthesia. T Fuhrman, MD, FCCP, RRT Chief, Anesthesia Bay Pines VAMC

Out of the OR Airway Not Just for Anesthesia. T Fuhrman, MD, FCCP, RRT Chief, Anesthesia Bay Pines VAMC Out of the OR Airway Not Just for Anesthesia T Fuhrman, MD, FCCP, RRT Chief, Anesthesia Bay Pines VAMC I have no COIs to report. This material is the result of work supported with resources and the use

More information

Trauma in Pregnancy. Julie Kruithof, MSN, RN, CCRN Adult Critical Care Nurse Educator April, 2014 No disclosures

Trauma in Pregnancy. Julie Kruithof, MSN, RN, CCRN Adult Critical Care Nurse Educator April, 2014 No disclosures Trauma in Pregnancy Julie Kruithof, MSN, RN, CCRN Adult Critical Care Nurse Educator April, 2014 No disclosures 2 Objectives Discuss epidemiologic and physiologic considerations related to trauma during

More information

ObLS INTEGRATING OB AND NRP TRAINING. J. Arafeh MSN, RN M. Druzin MD A. Puck MSN, RN

ObLS INTEGRATING OB AND NRP TRAINING. J. Arafeh MSN, RN M. Druzin MD A. Puck MSN, RN ObLS INTEGRATING OB AND NRP TRAINING J. Arafeh MSN, RN M. Druzin MD A. Puck MSN, RN Disclosures Julie Arafeh, Maurice Druzin and Andrea Puck do not have disclosures or conflict of interest to report Question

More information

Non invasive Positive Pressure Ventilation (NPPV) for Acute Exacerbations of COPD: Evidence Base & How to Set up a Service.

Non invasive Positive Pressure Ventilation (NPPV) for Acute Exacerbations of COPD: Evidence Base & How to Set up a Service. Non invasive Positive Pressure Ventilation (NPPV) for Acute Exacerbations of COPD: Evidence Base & How to Set up a Service Dr Karen Detering Why use ventilatory assistance? patients with COPD are prone

More information

Role of Bi-Pap in Acute Respiratory Failure due to Acute Exacerbation of COPD

Role of Bi-Pap in Acute Respiratory Failure due to Acute Exacerbation of COPD Role of Bi-Pap in Acute Respiratory Failure due to Acute Exacerbation of COPD N. Rizvi,N. Mehmood,N. Hussain ( Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi. ) Abstract Objective:

More information

Trauma during pregnancy : a situation pregnant with danger

Trauma during pregnancy : a situation pregnant with danger (Acta Anaesth. Belg., 2005, 56, 13-18) Trauma during pregnancy : a situation pregnant with danger K. M. KUCZKOWSKI Abstract : Trauma in pregnancy is currently a leading cause of non-pregnancy-related maternal

More information

Airway Management Apnea or Obstruction?

Airway Management Apnea or Obstruction? Airway Management Apnea or Obstruction? Florida Dental Society of Anesthesiology February 2016 H. William Gottschalk, D.D.S. Fellow, Academy of General Dentistry Fellow, American Dental Society of Anesthesiology

More information

POLICIES & PROCEDURES ENDOTRACHEAL TUBE (ADULT, PEDIATRIC) ASSISTING WITH INTUBATION. I.D. Number: Authorization

POLICIES & PROCEDURES ENDOTRACHEAL TUBE (ADULT, PEDIATRIC) ASSISTING WITH INTUBATION. I.D. Number: Authorization POLICIES & PROCEDURES Title: ENDOTRACHEAL TUBE (ADULT, PEDIATRIC) ASSISTING WITH INTUBATION I.D. Number: 1039 Authorization [X] SHR Nursing Practice Committee Source: Nursing/Respiratory Therapy Date Revised:

More information

Australian and New Zealand College of Anaesthetists (ANZCA)

Australian and New Zealand College of Anaesthetists (ANZCA) PS55 2012 Australian and New Zealand College of Anaesthetists (ANZCA) Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations

More information

HYPOPLASTIC LEFT HEART SYNDROME

HYPOPLASTIC LEFT HEART SYNDROME HYPOPLASTIC LEFT HEART SYNDROME What is HLHS? HLHS is the one of the most challenging and complex form of congenital heart diseases. Without treatment, this defect is usually fatal within the first weeks

More information

LMAs: Airway Management and Inhalant Anesthetics

LMAs: Airway Management and Inhalant Anesthetics LMAs: Airway Management and Inhalant Anesthetics Wanda O.Wilson, PhD, CRNA University of Cincinnati College of Nursing Nurse Anesthesia Major Brain AIJ: The Laryngeal Mask A New Concept in Airway Management.

More information

The 1st device. that allows simultaneous ventilation & intubation with continuous visualization. intubation. ventilation. continuous visualization

The 1st device. that allows simultaneous ventilation & intubation with continuous visualization. intubation. ventilation. continuous visualization The 1st device that allows simultaneous ventilation & intubation with continuous visualization ventilation intubation continuous visualization Patented worldwide by: THE TOTAL SOLUTION FOR AIRWAY MANAGEMENT:

More information

Liposuction GUIDELINE

Liposuction GUIDELINE .goo NON HOSPITAL MEDICAL AND SURGICAL FACILITIES PROGRAM College of Physicians and Surgeons of British Columbia Liposuction GUIDELINE You may download, print or make a copy of this material for your noncommercial

More information

Updates in the Management of the Difficult Airway

Updates in the Management of the Difficult Airway Disclaimer The views in the presentation are the author's, and do not reflect the views of the Department of Defence I am a full time Australian Defence Force Procedural Specialist (Anaesthetist) Updates

More information

Airway Management in the Obese Patient

Airway Management in the Obese Patient Airway Management in the Obese Patient Bradford L. Walters, M.D., FACEP Assistant Residency Director, Beaumont Health Systems Emergency Medicine Residency, Royal Oak, Michigan Associate Professor, Oakland

More information

Monitoring the condition of the mother during the first stage of labour

Monitoring the condition of the mother during the first stage of labour Before you begin this unit, please take the corresponding test at the end of the book to assess your knowledge of the subject matter. You should redo the test after you ve worked through the unit, to evaluate

More information

3. Place patient in a supine position and assure stable positioning of the neck and hyperextend the neck (unless cervical spine injury suspected).

3. Place patient in a supine position and assure stable positioning of the neck and hyperextend the neck (unless cervical spine injury suspected). 2917 Weck Drive Durham, NC 27709 USA Phone: 919-544-8000 www.teleflex.com Rusch QuickTrach Emergency Cricothyrotomy Kit Skill Competency The Rusch QuickTrach Emergency Cricothyrotomy Kit from Teleflex

More information

High Impact Intervention Care bundle to reduce ventilation-association pneumonia

High Impact Intervention Care bundle to reduce ventilation-association pneumonia High Impact Intervention Care bundle to reduce ventilation-association pneumonia Aim To reduce the incidence of ventilation-associated pneumonia (VAP). Context The aim of the care bundle, as set out in

More information

Laryngeal Mask Airways (LMA), Indications and Use for the Pre-Hospital Provider. www.umke.org

Laryngeal Mask Airways (LMA), Indications and Use for the Pre-Hospital Provider. www.umke.org Laryngeal Mask Airways (LMA), Indications and Use for the Pre-Hospital Provider Objectives: Identify the indications, contraindications and side effects of LMA use. Identify the equipment necessary for

More information

FETAL CIRCULATION LEARNING OBJECTIVES

FETAL CIRCULATION LEARNING OBJECTIVES FETAL CIRCULATION LEARNING OBJECTIVES At the end the lecture the student should know the following: Components of fetal circulation Foramen ovale Ductusarteriosus Path of Fetal circulation Changes in circulation

More information

POLICY NAME: VANDERBILT UNIVERSITY HOSPITAL CHEST

POLICY NAME: VANDERBILT UNIVERSITY HOSPITAL CHEST POLICY NAME: VANDERBILT UNIVERSITY HOSPITAL CHEST PROTOCOL FOR BLUNT FORCE THORACIC TRAUMA Policy Description: Managing patients with multiple rib fractures or flail chest requires significant health care

More information

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

GASTROESOPHAGEAL REFLUX DISEASE (GERD) American College of Gastroenterology Digestive Disease Specialists Committed to Quality in Patient Care Common Gastrointestinal Problems A Consumer Health Guide GASTROESOPHAGEAL REFLUX DISEASE (GERD) What

More information

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

GASTROESOPHAGEAL REFLUX DISEASE (GERD) American College of Gastroenterology Digestive Disease Specialists Committed to Quality in Patient Care Common Gastrointestinal Problems A Consumer Health Guide GASTROESOPHAGEAL REFLUX DISEASE (GERD) What

More information

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

GASTROESOPHAGEAL REFLUX DISEASE (GERD) American College of Gastroenterology Digestive Disease Specialists Committed to Quality in Patient Care Common Gastrointestinal Problems A Consumer Health Guide GASTROESOPHAGEAL REFLUX DISEASE (GERD) What

More information

Conundrums in Ambulatory Anesthesia I

Conundrums in Ambulatory Anesthesia I THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER DALLAS Parkland Hospital, Dallas, Texas Conundrums in Ambulatory Anesthesia I Girish P. Joshi, MBBS, MD, FFARCSI Professor of Anesthesiology and Pain

More information

PRACTICE Guidelines are systematically developed

PRACTICE Guidelines are systematically developed Copyright by the American Society of Anesthesiologists. Unauthorized reproduction of this article is prohibited. Special Articles Practice Guidelines for Management

More information

The Expanding Role of the Obstetrical Anesthesiologist. Ob Anesthesia Update. Expanding Role of OB Anesthesiologist 8/31/12. Its not just epidurals

The Expanding Role of the Obstetrical Anesthesiologist. Ob Anesthesia Update. Expanding Role of OB Anesthesiologist 8/31/12. Its not just epidurals The Expanding Role of the Obstetrical Anesthesiologist Its not just epidurals Ob Anesthesia Update Expanding Role of OB Anesthesiologist Safety (Simulation and Team-training) Ultrasound Oxytocin for PPH

More information

Oxygen - update April 2009 OXG

Oxygen - update April 2009 OXG PRESENTATION Oxygen (O 2 ) is a gas provided in compressed form in a cylinder. It is also available in liquid form, in a system adapted for ambulance use. It is fed via a regulator and flow meter to the

More information

Medical Coverage Policy Monitored Anesthesia Care (MAC)

Medical Coverage Policy Monitored Anesthesia Care (MAC) Medical Coverage Policy Monitored Anesthesia Care (MAC) Device/Equipment Drug Medical Surgery Test Other Effective Date: 9/1/2004 Policy Last Updated: 1/8/2013 Prospective review is recommended/required.

More information

Difficult Pre-hospital Airway Management

Difficult Pre-hospital Airway Management Difficult Pre-hospital Airway Management Frans L. Rutten, MD, FDSA Elisabeth Hospital Tilburg, The Netherlands In management of patients with an emergency, airway management and ventilatory care are the

More information

International Training Program for Nurse Anesthetist The program: International training program for nurse anesthetist Name of certificate:

International Training Program for Nurse Anesthetist The program: International training program for nurse anesthetist Name of certificate: International Training Program for Nurse Anesthetist Department of Anesthesiology Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand The program: International training program

More information

GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline

GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. General anaesthesia for caesarean section carries considerable risk and is frequently performed out

More information

Trial of Labor After Cesarean Section

Trial of Labor After Cesarean Section Trial of Labor After Cesarean Section 1 After you have a baby by cesarean section, you can choose how to have your next baby. You can choose to schedule another cesarean section ( scheduled repeat cesarean

More information

Respiratory Services Policy and Procedure Manual

Respiratory Services Policy and Procedure Manual SUBJECT/TITLE: NUMBER: PAGE: CLIN -008 Page 1 of 6 AUTHORIZATION: Manager Respiratory Services Medical Advisor SITES FMC PLC RGH DATE ESTABLISHED DATE REVISED Jim Winnick ADDITIONAL AUTHORIZATIONS: Kristen

More information

Surface Echo for Vascular Access

Surface Echo for Vascular Access Surface Echo for Vascular Access Christopher A. Troianos, M.D. Professor and Chair, Department of Anesthesiology Western Pennsylvania Hospital West Penn Allegheny Health System Pittsburgh, PA Introduction:

More information

Obstetric Emergencies for Every Provider

Obstetric Emergencies for Every Provider Obstetric Emergencies for Every Provider James Bates, PhD, MD Associate Professor Director of the division of OB anesthesia Clinical coordinator MOR Department of Anesthesia University of Iowa College

More information

Guideline for the initial management of Severe Traumatic Brain injury in children (GCS 8 or less)

Guideline for the initial management of Severe Traumatic Brain injury in children (GCS 8 or less) Guideline for the initial management of Severe Traumatic Brain injury in children (GCS 8 or less) Guideline for the initial management of severe traumatic brain injury in children (GCS 8 or less) Introduction

More information

The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy

The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy Cindy Goodrich RN, MS, CCRN Content Description Sepsis is caused by widespread tissue injury and systemic inflammation resulting

More information

PRACTICE guidelines are systematically developed recommendations

PRACTICE guidelines are systematically developed recommendations Practice Parameters Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia

More information

AANA Journal Course 3

AANA Journal Course 3 AANA Journal Course 3 Update for nurse anesthetists Aspiration prophylaxis: Is it time for changes in our practice? *6 CE Credits John J. Nagelhout, CRNA, PhD Pasadena, California Pulmonary aspiration

More information

Goals and Objectives for the General Surgery Rotation Resident PGY1 Hamilton Health Sciences or St. Joseph Healthcare (2 four-week rotational blocks)

Goals and Objectives for the General Surgery Rotation Resident PGY1 Hamilton Health Sciences or St. Joseph Healthcare (2 four-week rotational blocks) Goals and Objectives for the General Surgery Rotation Resident PGY1 Hamilton Health Sciences or St. Joseph Healthcare (2 four-week rotational blocks) Overview During the first year of their residency training

More information

Schedule. BLS and Advanced Airway Management. Objectives. Airway Management. Review x. Ventilation Physiology. Ventilation

Schedule. BLS and Advanced Airway Management. Objectives. Airway Management. Review x. Ventilation Physiology. Ventilation BLS and Advanced Airway Management Districts 3 and 4 UVM, IREMS Winter, 2009 Schedule Basic Airway Review Practice Large Group Presentation Airway and Introduction to King KLTSD and Pediatric i Airway

More information

Continued on next page

Continued on next page Resident Journal Review An Update on Airway Management in Emergency Medicine Authors: Michael Allison, MD; Michael Scott, MD; Kami Hu, MD; David Bostick, MD; Daniel Boutsikaris, MD Edited by: Michael C.

More information