Acute Hemorrhage
Definition
Acute hemorrhage is the acute loss of a large volume of blood and can be either overt or covert.
Overt
Can be visualized in the surgical field, on sponges, or in the suction containers
Covert
No outward sign of bleeding (e.g., retroperitoneal or intrapleural hemorrhage, blood loss hidden in drapes)
Etiology
Bleeding from large blood vessel (artery or vein) secondary to surgical manipulation, trauma, or disease
May be related to disorders of coagulation or therapeutic anticoagulation
Typical Situations
Vascular, cardiac, thoracic, or hepatic surgery
Coagulopathy
Major trauma
Covert hemorrhage more likely when the surgical field is obscured by drapes or distant from the anesthesia professional, or during laparoscopic surgery
Delayed complication of earlier injury, surgery, or invasive procedure (e.g., surgical clip slipping off a vessel)
Occult blood loss (e.g., femoral fracture, gastrointestinal [GI] bleed)
Retroperitoneal surgery or injury
Obstetric emergencies
Prevention
Identify and correct coagulopathy early
Monitor prothrombin time (PT)/partial thromboplastin time (PTT) during warfarin or heparin therapy
Monitor activated clotting time (ACT) during intraoperative anticoagulation or after administration of protamine
Identify and institute prophylaxis for potential bleeding sites (e.g., GI tract ulcers in ICU patients)
Perform a focused assessment with sonography in trauma (FAST) examination in trauma cases to assess the presence of intraabdominal or pericardial fluid
Insert the largest possible IV catheter if you anticipate having to administer blood during a case
Insert arterial line if significant blood loss is anticipated
Establish an institutional massive transfusion protocol (MTP)
Manifestations
Overt
Blood in the surgical field
Blood on surgical sponges, drapes, and floor
Suction noise and accumulation of blood in suction containers
Fall in arterial pressure and filling pressures and increased HR
Increased pulse pressure variation during positive pressure ventilation
Hypovolemia assessed by transesophageal echocardiogram (TEE) or transthoracic echocardiogram (TTE)
Surgeon’s comments (e.g., “Have you given any blood yet?”)
Covert
Unexplained fall in arterial and filling pressures and/or increase in HR
Low filling pressures assessed by TEE or TTE
Fall in mixed venous O 2 (if monitored), especially in surgery where covert blood loss is possible
Increase in fluid requirements above what is expected
Little or transient BP response to administration of an IV fluid bolus or to vasopressor
Excessive response to vasodilator or anesthetic agents
Unexplained fall in urine output or hematocrit (a late sign)
Expanding abdomen or thigh, flank discoloration
Decreased oxygenation, increased peak inspiratory pressure (PIP) if hemothorax
Increased pulse pressure variation during positive-pressure ventilation
Similar Events
Hypotension (see Event 9, Hypotension )
Anesthetic or vasodilator overdose (see Event 72, Volatile Anesthetic Overdose )
Anaphylaxis (see Event 16, Anaphylactic and Anaphylactoid Reactions )
Progressively inadequate volume replacement
Occlusion of venous return by compression of the vena cava by the gravid uterus, surgical packing, pneumoperitoneum, or retraction
Pneumothorax (see Event 35, Pneumothorax )
Pulmonary embolism (PE) (see Event 21, Pulmonary Embolism )
Cardiac tamponade (see Event 18, Cardiac Tamponade )
Inappropriate diuretic therapy
Tachyarrhythmias
Management
Inform surgeons of the problem
Keep them informed of its severity
Options for surgeon to consider:
Convert from laparoscopic to open surgery
Clamp bleeding vessels, hold pressure on bleeding site, or pack to temporize bleeding
Clamp the aorta below the diaphragm (may be essential for resuscitation of the patient) (see Event 14, The Trauma Patient )
Apply hemostatic agents
Obtain expert surgical assistance
If the abdomen is open, cannulate a large intraabdominal vein for rapid transfusion and cannulate the aorta directly for an arterial line
Consider surgical exploration (if postoperative hemorrhage is suspected)
Increase FiO 2 to 100% with high fresh gas flow
Replace volatile anesthetic as tolerated with opioids, midazolam
Check and verify BP and other vital signs
Treat severe hypotension with IV bolus of vasopressor
Ephedrine IV, 5 to 50 mg
Epinephrine, 10 to 100 μg
Phenylephrine, 50 to 200 μg
Repeat as necessary to maintain an acceptable BP
Activate local MTP to get emergency release of blood products
Rapidly restore circulating blood volume
Use crystalloid, colloid, or blood to replace circulating blood volume
For massive hemorrhage
Transfuse a balanced ratio (1:1) of red blood cells (RBCs) to fresh frozen plasma (FFP)
Transfuse 1 apheresis unit of platelets per 6 units of RBCs, until labs are available
If blood loss is sudden but may be controlled soon, delay giving blood and continue to give crystalloid as needed until bleeding is stopped
Depending on patient comorbidities and extent of hemorrhage, consider tolerating low-normal BP to decrease blood loss and hemodilution until bleeding is controlled
A pressurized bag of saline or colloid will run much faster than a unit of RBCs through a small peripheral IV
Dilute RBCs with saline to increase the speed with which they can be infused
Use an additional small-pore filter to avoid occluding the IV giving-set filter with debris
Warm IV fluids and use other patient warming devices to maintain body temperature (see Event 44, Hypothermia )
Call for Help if major fluid resuscitation is necessary
If possible, the primary anesthesiologist should monitor the patient and surgical status and direct activities of OR personnel
Additional help should
Check and transfuse blood products, and obtain and reorder blood products when necessary
Set up rapid transfusor device, if available
Set up cell saver unit for autotransfusion of RBCs if blood is not contaminated
Ensure adequate IV access; consider intraosseus (IO) line
Have a minimum of one 16-gauge or larger IV line, preferably more. In the case of severe blood loss, place at least one very large-bore IV line (such as 8.5 French catheter introducer) in a suitable peripheral or central vein. Use large-bore rapid transfusion IV tubing if available.
If IV access is difficult, change a small IV cannula to a large IV cannula by using the Seldinger technique
Use ultrasound guidance for more access
Check IV site to make sure IV line is not infiltrated
Consider IO line placement early in the resuscitation if IV access is difficult
Obtain adequate supplies of IV fluid (colloid or crystalloid)
Continue to NOTIFY BLOOD BANK of blood product needs, per local protocol
If emergency release blood products are administered (O-neg RBCs), send a new blood sample to blood bank for type and screen procedure as soon as possible and prior to transfusion of type-specific blood
Monitor hemodynamic status for adequacy of volume resuscitation
BP and HR
Central venous pressure (CVP) and/or pulmonary artery (PA) pressure
TEE or TTE
Monitor labs at regular intervals: hematocrit, electrolytes, arterial blood gas (ABG), PT/PTT, fibrinogen every 30 to 60 minutes
Further transfusion of blood and blood products should be guided by lab results
Keep track of surgical events and inform surgeon periodically about resuscitation efforts
Complications
Coagulopathy/disseminated intravascular coagulation (DIC)
Volume overload from overshoot of fluid resuscitation
Hypothermia
Hyperkalemia
Hypocalcemia
Irreversible shock
Acute respiratory distress syndrome (ARDS)/transfusion-related acute lung injury (TRALI)
Allergic/anaphylactic reaction to blood
Transfusion-related viral infection
Myocardial ischemia, arrhythmias
Renal failure
Neurologic injury
Cardiac arrest
Suggested Reading
Cardiac Arrest
Definition
Cardiac arrest is the absence of effective mechanical activity of the heart.
Etiology
Cardiovascular disease (e.g., myocardial infarction [MI], myocardial ischemia, cardiomyopathy, arrhythmia, valvular disease, aortic dissection)
Hypovolemia
Surgical maneuvers or positioning that causes decreased venous return
Hemorrhage
Hypoxemia
Failed airway management
Respiratory arrest
Shock (e.g., anaphylaxis, sepsis)
Bradycardia
After neuraxial blockade or any acute vagal reflex
After repeated doses of succinylcholine
Tension pneumothorax
Auto positive end-expiratory pressure (PEEP)
Pulmonary, venous air, or amniotic fluid embolism
Cardiac tamponade
Toxins (e.g., cocaine, methamphetamine)
Anesthetic drug-related complications (e.g., IV or anesthetic overdose, medication error, vasodilator bolus, local anesthetic systemic toxicity [LAST])
MH
Acidosis
Hypoglycemia
Electrolyte abnormalities (e.g., hyperkalemia, particularly in renal failure)
Hypothermia
Pulmonary hypertension
Transfusion reactions
Pacemaker failure
Typical Situations
ACS
Arrhythmias
Major trauma
Acute hemorrhage
Shock (e.g., anaphylaxis, sepsis)
Following a respiratory arrest
Difficult intubation or ventilation
Hypoxemia (e.g., unrecognized esophageal intubation)
Hypercarbia
PE
Bradycardia during neuraxial blockade
Acute vagal reflex
Drug toxicity (e.g., contraindications to succinylcholine, local anesthetic overdose)
Tension pneumothorax
Cardiac tamponade
Direct myocardial contact with the electrocautery
Pacemaker failure
Electrolyte abnormalities (e.g., hyperkalemia, hypocalcemia)
Obstetric complications
Prevention
Evaluate pacemaker function prior to surgery and manage appropriately
Place a transvenous or transcutaneous pacemaker prophylactically for patients with high-grade atrioventricular (AV) block or significant sinus bradycardia
Treat arrhythmias with appropriate antiarrhythmic therapy and continue through surgery
Aggressively treat bradycardia/hypotension following neuraxial blockade
Treat ACS to restore myocardial blood flow
Avoid surgery and anesthesia after recent MI
Administer vagolytic drug in patients or in procedures with a high risk of increased vagal tone (e.g., neuraxial blockade)
Drill and practice management of unstable patients (using simulation if available)
Administer vagolytic prior to, or mixed with, anticholinesterases that cause bradycardia
Manifestations
Unresponsive to verbal commands
Absence of pulse oximeter waveform
Loss of consciousness or seizure-like activity
No palpable carotid pulse (palpation of peripheral pulses unreliable)
Noninvasive blood pressure (NIBP) unmeasurable
Invasive arterial pressure without pulsations
Mean arterial pressure (MAP) less than 20 mm Hg without CPR
Absence of heart tones on auscultation
Apnea
Loss of, or decreased, ET CO 2
Arrhythmias (ventricular tachycardia [VT], ventricular fibrillation [VF], asystole)
Pulseless electrical activity (PEA) (rhythm in PEA may appear normal)
Cyanosis
Regurgitation and possible aspiration of gastric contents
Lack of ventricular contraction on TEE or TTE
Similar Events
Anaphylaxis (see Event 16, Anaphylactic and Anaphylactoid Reactions )
Pulmonary, venous air, or amniotic fluid embolism (see Event 21, Pulmonary Embolism , Event 24, Venous Gas Embolism , and Event 81, Amniotic Fluid Embolism )
Sepsis (see Event 13, The Septic Patient )
Acute hemorrhage (see Event 1, Acute Hemorrhage )
Medication reaction (see Event 63, Drug Administration Error )
Local anesthetic overdose (see Event 52, Local Anesthetic Systemic Toxicity )
Total spinal anesthesia (see Event 89, Total Spinal Anesthesia )
Cardiac disease (MI, ischemia [see Event 15, Acute Coronary Syndrome ], cardiomyopathy, aortic dissection)
Hypotension (see Event 9, Hypotension )
Seizures (see Event 57, Seizures )
Artifacts on monitoring devices
Electrocardiogram (ECG)
Pulse oximeter
Blood pressure measurement systems (NIBP or invasive)
Management
Treat the patient, not the monitor
Verify that there is no pulse (and that an “awake” patient has become unresponsive)
Check pulse oximeter and ET CO 2 waveforms
Palpate the carotid, femoral, or other pulse
Surgeon may have better access to palpable pulses
Check NIBP and ECG monitors and leads
Check arterial line waveform
Immediately notify surgeons and other OR personnel of the cardiac arrest
Call for help
Call OR or hospital “code”
Call for crash cart and defibrillator
Start CPR immediately (C-A-B: compressions, airway, breathing)
Apply defibrillation pads to chest
Turn off ALL anesthetics
Administer 100% O 2 at high flows to flush circuit of inhaled anesthetics and verify change
Begin basic life support (BLS)
Assign someone to start chest compressions
Compressions should be at least 100 per minute and at least 2 inches deep
Rotate compressors every 2 minutes and monitor for fatigue of the person performing chest compressions
Allow for complete recoil of the chest with each compression
Minimize interruptions in compressions and keep interruptions brief (less than 10 seconds)
Adequate compressions should generate an ET CO 2 of at least 10 mm Hg and a diastolic pressure of greater than 20 mm Hg (if an arterial line is in place). You MUST improve CPR quality and vascular tone if above conditions are not met.
Airway/Ventilation
If patient is not intubated, establish bag mask ventilation with 100% O 2 at a compression to ventilation ratio of 30:2 and prepare for definitive airway
Place a supraglottic airway (SGA) or endotracheal tube ( ETT) without stopping compressions and then ventilate at a rate of 10/minute with continuous compressions
Assign tasks to skilled responders
Ensure adequate IV access
If difficult IV access, place IO infusion line
Place arterial line
Call for TEE/TTE machine
Begin ACLS
Employ cognitive aids (ACLS algorithms) to help determine diagnosis and treatment
Diagnose and treat arrhythmias
Determine if patient is in a shockable rhythm
Analyze rhythm during very short breaks in CPR (e.g., during ventilation phase of the 30:2 compression-to-ventilation ratio or while rotating compressors)
CPR artifact can appear as a shockable rhythm
VT/VF (shockable pathway)
Continue high-quality CPR
Defibrillate as soon as possible with 200 J or follow manufacturer’s recommendations
Immediately resume chest compressions after each defibrillation
Do not check pulse or rhythm
If a shockable rhythm persists after the initial defibrillation, continue CPR and administer epinephrine IV, 1 mg every 3 to 5 minutes
Consider replacing 1 dose of epinephrine with vasopressin IV, 40 units
DEFIBRILLATE EVERY 2 MINUTES
Consider antiarrhythmics
Amiodarone IV, 300 mg
Lidocaine IV, 100 mg
Search for treatable causes for VT/VF
Torsades de pointes
Administer magnesium sulfate (MgSO 4 ) IV, 2 g
Hyperkalemia (see Event 40, Hyperkalemia )
Administer calcium chloride (CaCl 2 ) 10% IV, 500 to 1000 mg
Administer dextrose 50% IV, 50 g, and regular insulin IV, 10 units
Local anesthetic toxicity (see Event 52, Local Anesthetic Systemic Toxicity )
Administer 20% lipid emulsion (Intralipid)
MI (see Event 15, Acute Coronary Syndrome )
If rhythm changes to non-shockable rhythm, switch to PEA/asystole pathway
PEA/asystole (non-shockable pathway)
Continue high-quality CPR
Administer epinephrine IV, 1 mg every 3 to 5 minutes
Consider replacing 1 dose of epinephrine with vasopressin IV, 40 units
Search for treatable causes of PEA/asystole
Hypovolemia (see Event 1, Acute Hemorrhage , and Event 9, Hypotension )
Administer fluid bolus, rule out occult bleeding, administer sufficient blood products for massive hemorrhage or severe anemia
Evaluate fluid status with TEE or TTE
Inadequate preload from caval compression
Release pneumoperitoneum
Left uterine displacement for gravid uterus
Return prone patient with large abdomen to supine position
Release surgical retraction
Disconnect breathing circuit if breath stacking (auto-PEEP) and adjust ventilation appropriately
Hypoxemia (see Event 10, Hypoxemia )
Ventilate and oxygenate with 100% O 2
Auscultate breath sounds
Suction ETT
Reconfirm presence of ET CO 2
Tension pneumothorax (see Event 35, Pneumothorax )
Auscultate for unilateral breath sounds
Absence of sliding pleura sign on TTE
Distended neck veins or deviated trachea
Perform emergent needle decompression at 2nd intercostal space, mid-clavicular line
Patient will require pleural drainage after needle decompression
Coronary thrombosis (see Event 15, Acute Coronary Syndrome )
Unexplained cardiac arrest may be secondary to MI; consider TEE or TTE to evaluate global myocardial function and regional wall motion abnormalities
Toxins (including infusions)
Confirm that IV and volatile anesthetics are off
Check all infusions
Confirm they are the correct drug and rate of administration
Discontinue if they are not indicated
If the potential for LAST exists (see Event 52, Local Anesthetic Systemic Toxicity )
Administer 20% lipid emulsion (Intralipid)
Consider Intralipid for any overdose of a lipid-soluble drug
Send toxicology screen
Cardiac tamponade
Use TEE or TTE to rule out pericardial effusion
If present, perform emergent pericardiocentesis
Electrolyte and acid/base abnormalities
Send stat labs (ABG and metabolic panel)
Evaluate for acidosis, hyperkalemia, hypokalemia, hypoglycemia, hypocalcemia
VGE (see Event 24, Venous Gas Embolism )
Acute hypotension with drop in ET CO 2
Flood surgical field with saline
Aspirate CVP catheter, if present
PE (see Event 21, Pulmonary Embolism )
Pulmonary hypertension
Use TTE or TEE to assess right ventricular (RV) function
Hyperthermia
Rule out MH (see Event 45, Malignant Hyperthermia )
Hypothermia (see Event 44, Hypothermia )
Continually reassess patient without interrupting chest compressions
Return of spontaneous circulation is indicated by
ECG and palpable pulse or BP
Pulse oximetry waveform
Increase in ET CO 2
Consider postresuscitation hypothermia for brain protection
Complications
Aspiration of gastric contents
Laceration of liver
Pneumothorax or hemothorax
Rib fracture
Hypoxic brain injury
Death
Suggested Reading
Difficult Tracheal Intubation
Definition
Difficult tracheal intubation occurs when successful intubation of the trachea is not accomplished within the first two attempts by an experienced anesthesia professional.
Etiology
Anatomical causes of a difficult airway
Full dentition
Obesity/short neck
Physician factors
Inexperience with airway management
Failure to respond effectively to a rapidly deteriorating situation
Equipment factors
Inexperience with equipment
Inadequate backup or alternative airway adjuncts or intubating devices
Typical Situations
Any patient with anatomy that makes direct laryngoscopy difficult
Short “bull” neck
Prominent maxillary incisors
Limited range of neck or jaw movement
Short thyromental distance
Late stages of pregnancy
Congenital syndromes associated with difficulty in endotracheal intubation
Infections of the airway
Acquired anatomic abnormalities
Intrinsic or extrinsic tumors of the airway
Following radiation therapy to the head and/or neck
Acromegaly
Morbid obesity
History of sleep apnea
Tracheal stenosis
Significant neck swelling or hematoma compressing the airway
Prevention
Carefully assess airway anatomy
Samsoon and Young modification of Mallampati classification
Class I: Visualize soft palate, uvula, tonsillar pillars, fauces (same as Mallampati class I)
Class II: Visualize soft palate, uvula, fauces
Class III: Visualize soft palate, base of uvula only
Class IV: Visualize hard palate only (same as Mallampati class III)
Class III and IV airways are associated with increased difficulty with tracheal intubation
Assess other patient factors
Patient’s ability to cooperate with airway management plan
Degree of difficulty with mask ventilation (e.g., facial hair, edentulous patients)
Degree of difficulty with SGA placement (e.g., limited mouth opening)
Degree of difficulty with surgical airway access (e.g., limited neck extension, goiter)
Create difficult airway cart with necessary supplies and equipment
Drill and practice management of difficult airway/failed intubation algorithm (using simulation if available)
Manifestations
Expected or known difficult tracheal intubation
Previous history of difficult airway or tracheal intubation
Airway examination classified as Samsoon and Young’s class III or IV
Presence of other anatomic features that make the patient difficult to intubate
Unexpected difficult tracheal intubation
Failure to intubate the trachea after two attempts by an experienced anesthesia professional
May be secondary to difficult laryngoscopy or difficulty passing the ETT into the trachea
Similar Events
Normal airway but unsuccessful intubation owing to inexperience of the laryngoscopist
Management
Expected Difficult Intubation
Err on the side of caution
Review previous anesthesia records, focusing on airway management
Perform a careful airway assessment; obtain a second opinion about the airway if you are still unsure of how to proceed
Consider alternatives to general anesthesia but remember that airway management will be difficult if a major complication or inadequate anesthesia occurs
If difficult airway is known or anticipated, consider performing an awake fiberoptic intubation
This will be the safest option in most cases
Awake intubation will be harder to perform if prior attempts at direct laryngoscopy have caused bleeding, secretions, or tissue edema
Administer glycopyrrolate IV, 0.4 mg as antisialagogue
Topicalize oropharynx
Lidocaine 4% nebulized and supplement if necessary
Be aware of total local anesthetic dose administered
Consider Williams airway in oropharynx and intubate over the fiberoptic bronchoscope with a 6.0 to 8.0 ETT
Do not oversedate the patient
Awake intubation can also be performed using video-assisted laryngoscopy with topical anesthesia
Prepare contingency plans and obtain appropriate equipment (difficult airway cart)
Multiple laryngoscope blades (different sizes of Miller and Macintosh blades)
Multiple ETT sizes (at least two sizes smaller than the expected size needed)
Bougie, airway introducers
SGA (e.g., LMA)
Intubating LMA
Video-assisted laryngoscope
Fiberoptic bronchoscope
A cricothyrotomy set (will require a trained person to perform)
If cricothyrotomy would be difficult or impossible, consider CPB standby
Unexpected Difficult Intubation
Call for help (e.g., anesthesia professional, anesthesia technician and surgeon capable of establishing surgical airway)
Call for difficult airway cart
Once help arrives, have them set up additional airway equipment
Mask ventilate with 100% O 2 ; consider using cricoid pressure but release if mask ventilation is difficult
Assess adequacy of ventilation and oxygenation
Place an oral or nasopharyngeal airway
Consider two-person mask ventilation technique
If mask ventilation is possible
Optimize patient’s position for intubation
Most experienced person should perform subsequent laryngoscopies
Limit intubation to three attempts
Consider intubation with video-assisted laryngoscopy
Use stylet or bougie
Use smaller ETT if difficulty in passing ETT through cords
Consider placing an SGA to be used as the primary airway device or to be used as a conduit for fiberoptic intubation with an Aintree exchange catheter
Consider an asleep fiberoptic intubation
Consider using an intubating LMA
Consider allowing spontaneous ventilation to return if possible and awaken the patient; convert to an awake intubation or cancel the case
If mask ventilation or intubation is impossible
Attempt to place an SGA
If successful, consider whether to wake the patient, continue the case with the SGA, or attempt to intubate the trachea through the device with an Aintree exchange catheter as outlined earlier
If SGA is unsuccessful, move early and aggressively to emergency cricothyrotomy or tracheostomy. DO NOT WAIT for the O 2 saturation to fall precipitously
Follow up
After an unexpected difficult intubation, ensure that the patient is informed of the complications and recommend that he or she obtain a MedicAlert bracelet ( http://www.medicalert.org ) to inform future anesthesia professionals about history of difficult intubation
Complications
Damage to airway structures
Bleeding in the airway
Airway obstruction from loss of airway reflexes or laryngospasm
Hypoxemia
Esophageal intubation
Gastric distention
Regurgitation and aspiration of gastric contents
Damage to the cervical spine during attempts at intubation
Suggested Reading
Emergent (Crash) Induction of Anesthesia
Definition
Emergent induction of anesthesia to facilitate an immediate lifesaving intervention
Etiology
Catastrophic event that results in the immediate need for life-saving surgical intervention
Typical Situations
Trauma
Stat cesarean section
Vascular catastrophes (e.g., ruptured aortic aneurysm)
Emergent surgical reexploration
Cardiac tamponade
Disruption of surgical anastomosis
Cath lab crash
Necrotizing fasciitis
Prevention
Resuscitate the patient prior to induction of anesthesia and surgical intervention
Have an OR and anesthesia workstation that is fully functional and ready for use
Have appropriate staff and equipment available
Drill and practice management of stat and urgent surgical cases (using simulation if available)
Manifestations
Stat call to the OR, ICU, emergency department (ED), cath lab, obstetrics (OB) suite, etc., for emergent case
Patient may arrive at the OR with little notice
Stat call to patient’s bedside with a decision to go emergently to the OR
Management
Do not transport the patient from an area where monitoring and resuscitation are occurring to the OR until it is set up and the anesthesia team and nursing staff are ready to care for the patient.
Call for additional help
Anesthesia professionals
Nursing staff (scrub nurse[s] and circulating nurse)
Technical support (anesthesia and surgical support technicians)
Surgical assistants
Prepare anesthesia equipment
If patient is already in the OR, assign someone to monitor the patient as you set up
Turn on anesthesia machine and monitors
If time allows, perform full machine check
At minimum, confirm that you are able to provide positive pressure ventilation with machine and circuit
Confirm suction is functional
Confirm presence of self-inflating bag/mask
Confirm airway equipment, including oral airway, ETT, functional laryngoscope blades and handles
Confirm presence of SGA (e.g., LMA) and bougie for possible difficult airway
Confirm that video-assisted laryngoscope is present
Prepare medications
Induction agent as indicated (ketamine, etomidate, propofol)
Neuromuscular blocker (succinylcholine unless contraindicated)
Emergency medications (ephedrine, phenylephrine, and/or epinephrine)
Obtain brief history and physical
Information can come from patient, medical record, or caregivers
Check critical lab values
Check whether sample has been sent to blood bank for type and cross
Reassess and confirm it is a life-threatening emergency
Avoid crash induction if not medically necessary
Assess whether the patient has allergies to any medications
Assess for major cardiopulmonary disease (e.g., valvular heart disease, low ejection fraction, asthma, chronic obstructive pulmonary disease [COPD])
Perform airway examination
Monitoring
Determine what IV access and lines are functional
Place additional IV access as indicated
Consider IO line if unable to quickly achieve vascular access
Connect ECG, NIBP, pulse oximeter, and all invasive monitoring lines that are present
Consider placement of arterial line preinduction if not already present in situ
Assign this task to skilled help
Induction
Preoxygenate while setting up and placing monitors
Confirm left uterine displacement for OB patient
Assume full stomach
Consider administration of Bicitra (PO), 30 mL
Modify induction dose of anesthetic based on hemodynamic parameters and patient comorbidities
Consider using ketamine or etomidate as an induction agent if hemodynamically unstable
Consider IV fluid bolus while preoxygenating patient
Consider video-assisted laryngoscopy as first choice for intubation
Turn device on
ETT with appropriate stylet
Laryngoscope, ETT, suction on and ready at head of bed
Perform RSI with cricoid pressure
Release or manipulate cricoid pressure if unable to visualize the vocal cords or to intubate the trachea
Ensure correct placement of ETT via ET CO 2 and auscultation
If unable to intubate, move to video-assisted laryngoscope (see Event 3, Difficult Tracheal Intubation )
Postinduction
Monitor patient
Expect instability and search for treatable causes
Support as needed with vasopressors and fluid
Consider placement of TEE to monitor myocardial filling and function
Establish additional IV access as indicated
Provide anesthesia as tolerated
Balance risk of awareness with hemodynamic stability
Obtain RBCs and other blood products as indicated
Send labs for ABG, blood glucose, and lactate as indicated
Administer appropriate antibiotics
Complications
Aspiration of gastric contents
Difficult intubation
Awareness under anesthesia
Cardiac arrest
Suggested Reading
Esophageal Intubation
Definition
Esophageal intubation is the placement of the ETT in the esophagus at the time of intubation or the subsequent displacement of the ETT from the trachea into the esophagus.
Etiology
Difficulty in visualizing the larynx at the time of intubation
Difficulty in passing the ETT
Change in position of the ETT after correct placement
Dislodgement by objects placed into, or removed from, the oropharyngeal cavity
Typical Situations
After a difficult or “blind” intubation
During intubation by an inexperienced laryngoscopist
After manipulation of the patient’s head or neck
After placing or removing devices from the esophagus (e.g., TEE probe or nasogastric tube [NGT])
Nasotracheal intubations
Prevention
Use proper intubation technique for optimal visualization of the larynx
Observe the ETT passing between the vocal cords
Secure the ETT carefully before allowing movement or positioning of the patient’s head
Check the position of the ETT after each change of the patient’s position or manipulation of the ETT
Visualize the carina during fiberoptic intubation
Use video-assisted laryngoscopy for difficult intubations or as a confirmation of proper ETT placement
Manifestations
Abnormally low or absent ET CO 2 waveform after the first few breaths
Equivocal or absent thoracic breath sounds
Breath sounds or gurgling heard over the epigastrium
Abnormal compliance during hand or mechanical ventilation
Leakage around the ETT with a normal ETT cuff volume
In the awake patient, continued vocalization after the cuff of the ETT is inflated
Visualization of the ETT in the esophagus on direct or video-assisted laryngoscopy
Inability to palpate the cuff of the ETT in the sternal notch
Regurgitation of gastric contents up the ETT
Late signs
Decreasing O 2 saturation and cyanosis
Hypotension
Bradycardia, premature ventricular contractions (PVCs), tachyarrhythmias, asystole
VT/VF
Similar Events
Malfunction or disconnection of capnograph
Breath sounds that are difficult to hear
Complete or partial extubation (see Event 37, Unplanned Extubation )
Endobronchial intubation (see Event 30, Endobronchial Intubation )
Severe bronchospasm (see Event 29, Bronchospasm )
Kinked ETT (see Event 7, High Peak Inspiratory Pressure )
Rupture of, or failure to inflate, the ETT cuff
Management
Development of hypoxemia within 10 minutes of intubation must be assumed to be due to esophageal intubation unless capnography demonstrates a sustained normal CO 2 waveform or video-assisted laryngoscopy clearly shows ETT passing through the vocal cords.
Preoxygenate the patient before induction; check ET O 2
Administer 100% O 2 until ETT placement is verified
Verify position of the ETT after intubation
Inflate ETT cuff and check for leak
Check for a normal ET CO 2 waveform on the capnograph
Listen for breath sounds in both axillae and over the stomach
Look for bilateral chest expansion
Manually ventilate the patient; assess the compliance of the reservoir bag
Perform direct or video-assisted laryngoscopy to visualize the position of the ETT relative to the vocal cords
Get help if there are problems determining the position of the ETT
Have assistant prepare fiberoptic bronchoscope to assist with ETT verification and placement
If the patient desaturates and you are unable to verify ETT placement
Remove ETT and ventilate with 100% O 2 by mask or SGA
If esophageal intubation is confirmed
Remove the misplaced ETT
Ventilate with 100% O 2 by mask or SGA if O 2 saturation is < 95%
Reintubate the trachea with a clean ETT using video-assisted laryngoscope
If intubation was difficult on the first attempt or reintubation fails (see Event 3, Difficult Tracheal Intubation )
Ventilate with 100% O 2 by mask if O 2 saturation is < 95%
Call for help and for difficult airway equipment
Prepare to place an SGA (e.g., LMA)
Consider waking the patient for possible awake intubation
Prepare for possible fiberoptic intubation
Prepare for surgical airway
After tracheal intubation, place an orogastric tube to empty the stomach
Complications
Hypoxemia
Hypercarbia
Cardiac arrest
Airway, pharyngeal, or dental trauma from repeated laryngoscopy
Aspiration of gastric contents
Hypertension, tachycardia
Myocardial ischemia/infarction
Suggested Reading
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