Page 49 - TNFlipTest

Toronto Notes 2019
Induction
Anesthesia A15
Table 5. IV Fluid Solutions
mEq/L Na+ K+
Ca2+ Mg2+ Cl– HCO3–
ECF Ringer’s Lactate
142 130 4 4
4 3
3 - 103 109 27 28* 280-310 273 7.4 6.5
0.9% NS
154 -
-
- 154 - 308 5.0
0.45% NS in D5W
77 -
-
- 77 - 154 4.5
Duration (h)
4-6 18-24
D5W
-
-
-
-
-
- 252 4.0
2/3 D5W Plasmalyte + 1/3 NS
51 140
Calculating Acceptable Blood Losses (ABL)
• Blood volume terminfant 80mL/kg adult male 70 mL/kg adult female 60 mL/kg
• Calculate estimated blood volume (EBV) (e.g. in a 70 kg male, approx. 70 mL/kg) EBV=70kgx70mL/kg=4900mL
• Decide on a transfusion trigger, i.e. the Hb level at which you would begin transfusion, (e.g. 70 g/L for a person with Hb(i) = 150 g/L)
Hb(f) = 70 g/L • Calculate
mOsm/L pH
4.3
7.4
ABL
=Hb(Hi)–Hb(Hf) x EBV Hb(Hi)
=150–70 x 4900 150
-
-
-
51 98 - 27 269 294
5 - 3
*Converted from lactate
Table 6. Colloid HES Solutions
Voluven® Pentaspan®
Concentration
6% 10%
Plasma Volume Expansion
1:1 1:1.2-1.5
Maximum Daily Dose (mL/kg)
33-50 28
= 2613 mL
• Therefore in order to keep the Hb
level above 70 g/L, RBCs would have to be given after approximately 2.6 L of blood has been lost
Transfusion Infection Risks
Blood Products
• seeHematology,H52 Induction
Routine Induction vs. Rapid Sequence Induction
• routineinductionisthestandardingeneralanesthesia,howeveraRSIisindicatedinpatientsatriskof regurgitation/aspiration (see Aspiration, A5)
• RSI uses pre-determined doses of induction drugs given in rapid succession to minimize the time patient is at risk for aspiration (e.g. from the time when they are unconscious without an ETT until the time when the ETT is in and the cuff inflated)
Virus
HIV
Hepatitis C virus
Hepatitis B virus
HTLV
Symptomatic Bacterial Sepsis
West Nile virus
Risk per 1 unit pRBCs
1 in 21 million
1 in 13 million
1 in 7.5 million 1 in 1-1.3 million
1 in 40,000 from platelets and 1 in 250,000 from RBC
No cases since 2003
Table 7. Comparison of Routine Induction vs. RSI
Steps
1. Equipment Preparation
2. Pre-Oxygenation/ Denitrogenation
3. Pre-Treatment Agents
4. Induction Agents
5. Muscle Relaxants
6. Ventilation
7. Cricoid Pressure
8. Intubation
9. Secure Machines
Routine Induction
RSI
Check equipment, drugs, suction, and monitors; prepare an alternative laryngoscope blade and a second ETT tube one size smaller, suction on
100% O2 for 3 min or 4-8 vital capacity breaths; reduce risk of hypoxemia during apneic period following induction
Source: Callum JL, Pinkerton PH. Bloody Easy. Fourth Edition ed. Toronto: Sunnybrook and Women's College Health Science Centre; 2016
Use agent of choice to blunt physiologic responses to airway manipulation 3 min prior to laryngoscopy
Use IV or inhalation induction agent of choice
Muscle relaxant of choice given after the onset of the induction agent
Bag-mask ventilation
Posterior pressure on thyroid cartilage to improve view of vocal cords as indicated
Intubate, inflate cuff, confirm ETT position
Use agent of choice to blunt physiologic responses to airway manipulation; if possible, give 3 min prior to laryngoscopy, but can skip this step in an emergent situation
Use pre-determined dose of fast acting induction agent of choice
Pre-determined dose of fast acting muscle relaxant (most commonly SCh, occasionally high dose rocuronium) given IMMEDIATELY after induction agent
DO NOT bag ventilate – can increase risk of aspiration
Traditionally Sellick maneuver, also known as cricoid pressure, to prevent regurgitation and assist in visualization (2 kg pressure with drowsiness, 3 kg with loss of consciousness) but increasingly omitted
Intubate once paralyzed (~45 s after SCh given), inflate cuff, confirm ETT position; cricoid pressure maintained until ETT cuff inflated and placement confirmed
Secure ETT, and begin manual/machine ventilation