Selik reception in anesthesiology. Ventilation of the lungs. Artificial ventilation of the lungs. In decurarization, atropine is used to
AIRWAY MANAGEMENT
A.V. Sitnikov
ANATOMY (SOME FEATURES)
The upper respiratory tract is the area of the oropharynx located above the vocal cords. It consists of nasal passages, oral cavity, pharynx.
The nasal passages are formed by the following anatomical structures:
nasal septum;
Nasal conchas;
Adenoids.
The pharynx includes tonsils, uvula and epiglottis.
Lower airway - all anatomical structures below the vocal cords (the narrowest section of the airway in adults, limiting the size of the endotracheal tube). The larynx is located at the level from IV to VI of the cervical vertebra, is a complex formation consisting of cartilage, ligaments and muscles.
The larynx is made up of 9 cartilages:
Unpaired: thyroid, cricoid and epiglottis;
Paired: arytenoid, horn-shaped and wedge-shaped.
Cricoid cartilage. The only complete cartilage ring in the respiratory system. Located under the thyroid cartilage. This is the narrowest part of the respiratory tract in children.
Cricothyroid membrane. Connects the thyroid and cricoid cartilages. Its size in adults is 0.9-3.0 cm. It is rather thin and does not contain large blood vessels along the midline.
Trachea. Fibromuscular tube, about 10-12 cm long and 20 mm in diameter (in adults). The backbone of the trachea are 20 arcuate cartilages. The trachea enters the chest cavity through the superior mediastinum and divides into the main bronchi at the level of the lower edge of the fourth thoracic vertebra (the level of the sternum angle).
Karina (keel of the trachea). The area where the trachea divides into the right and left main bronchi. The right one, about 2-5 cm long, departs from the trachea at an angle of 25°; left, about 5 cm, - at an angle of 45 °.
Respiratory protection.
INNERVATION
Touch.
The glossopharyngeal nerve (IX pair of cranial nerves) innervates the posterior third of the tongue and oropharynx from the border of the nasopharynx to the esophagus, including the soft palate, epiglottis, and pharynx.
The anterior laryngeal nerve (a branch of the vagus nerve) innervates the mucosa from the epiglottis to the vocal cords, including the latter.
The recurrent nerve (a branch of the vagus nerve) innervates the mucosa below the vocal cords to the trachea.
Motor.
The external branch of the anterior laryngeal nerve innervates the cricothyroid muscle.
The recurrent nerve innervates all the muscles of the larynx, except for the cricothyroid.
ASSESSMENT OF THE CONDITION OF THE AIRWAYS
Anamnesis
It is necessary to pay close attention to diseases that can affect the condition and patency of the respiratory tract.
Arthritis can significantly reduce the mobility of the cervical spine. Rheumatoid arthritis is characterized by instability of the cervical spine. Under these conditions, subluxation of the articulation between the I and II cervical vertebrae can lead to separation of the atlanto-dentate articulation and penetration of the odontoid process into the foramen magnum with compression of the spinal cord. Synovitis of the parietomandibular joint can significantly limit the movement of the mandible. At the same time, arytenoid cartilages are often involved in the inflammatory process.
Infectious and inflammatory processes of the floor of the mouth, salivary glands, tonsils, as well as pharyngeal abscess, causing pain, swelling or trismus, can limit the volume of mouth opening.
Tumors can block the airways and cause compression or displacement of the trachea.
In obese patients, it is necessary to find out the presence of "snoring" ("sleep apnea"), the cause of which may be hypertrophy of the tonsils and adenoids.
Injury. It is necessary to find out the nature of the injury and have an idea of its mechanism in connection with possible damage to the cervical spine, fracture of the base of the skull or intracranial pathology.
Trisomy on the 21st chromosome pair (Down's syndrome). Patients with this pathology may suffer from atlantoaxial articulation instability and macroglossia.
Scleroderma leads to a decrease in the mobility of the lower jaw and narrowing of the mouth opening by reducing the elasticity of the skin.
Acromegaly. Excess growth hormone causes hypertrophy of the mandible, tongue and epiglottis. The opening of the glottis may be limited due to hypertrophy of the vocal cords.
Nanism (dwarfism). In this pathology, instability of the atlantoaxial articulation occurs, as well as difficulties in ensuring airway patency due to hypoplasia of the lower jaw.
congenital anomalies. In a number of syndromes associated with congenital anomalies, there may be difficulties in securing the airway. In particular, patients with pathology of the facial skull.
If there are documents on previous interventions, it is necessary to pay attention to the facts of the complications that occurred during intubation and ventilation (the possibility of mask ventilation, the number of intubation attempts, the type of laryngoscope blade, the use of a guidewire, etc.).
Specific symptoms associated with impaired airway patency should be distinguished: dysphonia, stridor breathing, dysphagia, shortness of breath, positional obstruction.
Prior surgery and radiation therapy to the head or neck may complicate subsequent anesthetic procedures.
General inspection
Obvious, specific signs indicating the possibility of impaired airway patency:
Inability to open mouth.
Decreased mobility of the cervical spine.
A cut chin or an overly small upper jaw.
Protruding incisors.
Short, powerful neck.
pathological obesity.
Area damage assessment:
Face, neck, or chest in terms of their possible effect on airway patency.
Common signs of acute respiratory pathology:
Excitation, fear, significant changes in respiratory rate and spirometry, tachycardia.
Head and neck examination
Nose. The patency of the nasal passages and the possible curvature of the nasal septum are checked by alternately closing each nostril, asking the patient to breathe and say in which case breathing was freer. This procedure is especially important if nasotracheal intubation is required.
Mouth. Patients should open their mouths at least three fingers wide.
Teeth. A reduced number of teeth increases the risk of damage to the remaining teeth during anesthesia procedures. Before the operation, it is necessary to find out the presence of loose teeth, which either must be removed or protected with a special plastic.
Language. Macroglossia is considered as a congenital anomaly.
Neck. The distance from the lower edge of the lower jaw to the thyroid cartilage is less than the width of 3-4 fingers, indicating a possible difficulty in visualizing the trachea.
Mobility of the cervical spine. It is necessary to make sure that the patient can touch the chin of the chest and straighten the neck back.
The presence of scarring or tracheostomy indicates the possibility of subglottic stenosis.
Airway classification
The Mallampati classification is based on the position that if the root of the tongue is disproportionately large and obscures the entrance to the larynx, then during laryngoscopy it is very likely that it will be difficult to find out the location of the latter. The assessment is performed with the patient in a sitting position, head in the center, mouth as open as possible, tongue fully protruding.
Class I. Fully visible arches, soft palate and uvula.
Class II. The arches and soft palate are visible, and the uvula is covered by the root of the tongue.
Class III. Only the soft palate is visualized. In patients with this class of airways, intubation can be expected to be difficult.
Instrumental examination
In most patients, a thorough questioning and examination is sufficient to assess the condition of the respiratory tract. However, if necessary, they can be supplemented.
Laryngoscopy (indirect, direct, fiberoptic). Gives information about the state of the lower parts of the pharynx, glottis, the function of the vocal cords. It can be performed in conscious patients under local or conduction anesthesia.
Radiographic examination of the chest. Allows you to detect deviations or narrowing of the trachea.
Tomographic study of the trachea.
X-ray examination of the cervical spine. It is mandatory for injuries, especially for injuries above the level of the collarbone.
CT scan. May provide additional information when airways are obstructed by foreign bodies.
Pulmonary function tests and flow/volume curves. Allow to determine the degree and level of obstructive disorders.
Indicators of the gas composition of arterial blood. Help to identify patients with chronic hypoxia or hypercapnia.
MAIN TYPES OF VENTILATION
Mask ventilation
Indications
Conducting inhalation anesthesia for short operations in patients without the risk of regurgitation.
Preoxygenation (denitrogenation) in patients before tracheal intubation.
IVL in the complex of resuscitation measures.
Technique
Proper positioning of the face mask and airway management are essential.
The mask is chosen in such a size as to hermetically close the bridge of the nose, cheeks and mouth. It is preferable to use transparent masks that allow observation of the lips (color) and mouth (secretion, vomiting).
Location of the face mask. It is customary to hold the mask with the left hand, while the little finger is located on the corner of the lower jaw, the 3rd and 4th fingers hold the lower jaw, and the index and thumb hold the mask. The right hand is used to control the bag. If the patient is large, both hands may be needed to properly hold the mask. In this case, an assistant is needed to control the counterlung. For a snug and comfortable fit, the masks use special fasteners.
Patients without teeth present a serious problem due to the reduced distance between the jaws. In this case, an air duct should be used. To reduce leakage, it is necessary to press the mask tightly, so both hands are often occupied.
Ventilation can be assisted or forced.
Stridor breathing, high-pitched "cawing" sound, swing-like movements of the chest and abdomen indicate a violation of the airway. An additional sign may be the absence of fluctuations in the patient's bag.
Techniques for maintaining airway patency:
Overextension of the neck;
The extension of the lower jaw, placing the fingers under its angles and lifting it up;
The use of an air duct allows maintaining patency during obturation with a large tongue or soft palate. However, in the presence of a gag reflex, an air duct is not always appropriate. Complications when using the air duct: vomiting, laryngospasm, trauma to the teeth. Too short an airway due to pressure on the tongue can cause complete obstruction of the airways;
Nasal catheters are used with minimal airway obstruction, as well as in awakening and sedated patients with a preserved gag reflex. The use of a nasal catheter can cause bleeding, so their use should be avoided in patients receiving anticoagulants.
Complications
With mask ventilation, the risk of aspiration is high, since the airways remain unprotected, laryngospasm may develop. The inconvenience is the employment of both hands.
Laryngeal mask (LM)
There are four sizes of LM:
1st - for patients weighing less than 6.5 kg,
2nd - for patients weighing from 6.5 to 25 kg. Adults:
Rice. 8.1. Correct position of the laryngeal mask
The LM is inserted into the pharynx and advanced inward until it takes its "anatomical" position behind the larynx. In this case, the glottis remains uncovered by the epiglottis (Fig. 8.1). Ventilation is started after the cuff is inflated.
The correct standing of the LM is confirmed by the slight resistance of the tissues surrounding the larynx and the return movement of the LM connector (by a few millimeters) when the cuff is inflated. The LM allows mechanical ventilation, maintains airway patency when visualization and intubation of the trachea using the standard technique is not possible, and can also be used as a guide for an endotracheal tube (ETT) (ETT No. 6 can pass through LM Nos. 3 and 4). Cases of insufficient tightness are quite rare. LMA does not protect against regurgitation and aspiration. When installing the LM, local, regional or general anesthesia is required.
Tracheal intubation
Orotracheal intubation
Indications
Ensuring airway patency for anesthesia, the duration of which exceeds 1 hour, prolonged mechanical ventilation.
High risk of aspiration of gastric contents.
Inability to provide adequate ventilation with a mask.
Some types of surgical interventions (operations on the head or neck, cardiothoracic, intra-abdominal, etc.).
Technique
Typically, tracheal intubation is performed using laryngoscopes. The most commonly used blades are the Macintosh or Miller type (a modification of the Magill type blade).
The Macintosh type is a blade that has a certain curvature. The end of the blade during tracheal intubation is placed in the recess formed by the base of the tongue and the pharyngeal surface of the epiglottis. This provides a good view of the oropharynx and hypopharynx and creates a large enough space to advance the ETT with the least chance of damage to the epiglottis. There are four blade sizes: 1, 2, 3, 4. For adults, the 3rd size of the Macintosh blade is most often used.
The Miller (Magill) type is a straight blade. It is advanced during tracheal intubation so that its end is under the laryngeal surface of the epiglottis. In this position, the epiglottis rises, revealing a view of the vocal cords. The Miller blade leads to a better view of the larynx (vocal cords), but makes it difficult to pass the tube (due to reduced space) in the oropharynx and pharynx. There are also four blade sizes: 0, 1, 2, 3. For adults, the 2nd and 3rd Miller blade sizes are most often used.
The best position for intubation is for the patient to lie on their back with their head elevated 10 cm, with a pillow or double folded blanket placed under the back of the head. This provides flexion of the lower cervical spine. During extension in the atlantooccipital joint, the axes of the mouth, pharynx and larynx (trachea) are aligned in such a way that the distance from the lips to the larynx becomes the smallest, i.e. they lie on the same line. The position of "a person who inhales the morning air." The lower jaw should be brought forward.
The laryngoscope is held in the left hand, closer to the junction of the handle with the blade. The position for intubation is provided with the index finger of the right hand. With the middle finger of the right hand, pressing the lower jaw, open the mouth, and also exclude the infringement of the tongue and lips between the laryngoscope blade and the teeth or gums. After that, the laryngoscope is inserted into the oral cavity from the right corner of the mouth, protecting the incisors; the tongue is retracted to the left. Then the blade is advanced along the midline until the epiglottis appears in the field of view. The tongue and soft tissues of the pharynx are raised by the blade in order to see the entrance to the larynx. To this end, the laryngoscope must be lifted strictly up due to the strength of the whole arm, and not due to the brush, relying on the anterior teeth of the upper jaw. The latter can lead to trauma to the upper incisors or gums (intubation with a Mackintosh blade).
The size of the endotracheal tube depends on the type of surgery, age and anthropometric data of the patient. For most women, a 7.0 mm ETT is used, for most men, an 8.0 mm ETT. The ETT is held in the right hand like a pencil, inserted into the oral cavity from the right corner of the mouth, advanced through the oral cavity and then through the vocal cords. If the glottis is not visible, then the laryngeal surface of the epiglottis can be used as a guide for the intubation tube when passing it behind the glottis.
It is also possible to use a technique in which external pressure is applied to the cricoid cartilage to improve the view of the glottis (Selick technique).
In the case when the glottis is poorly visible or not visualized at all, it is recommended to use an ETT with a stylet (guide) inserted into it. When using a stylet (guide), it must be removed as soon as the end of the endotracheal tube has gone beyond the vocal cords. The ETT is placed so that the proximal end of the cuff of the endotracheal tube is just behind the vocal cords. The ETT marking is applied in relation to the incisors or lips. The cuff is inflated until the trachea is completely obstructed.
The correct placement of the endotracheal tube is determined by the concentration of carbon dioxide at the end of exhalation (EtCO 2) and auscultation of the lungs and stomach. If breath sounds are heard only on the right or left, then this means that the endotracheal tube is advanced into the right or left (very rarely) bronchus. In this case, the tube must be pulled back until the breath sounds are heard equally from both sides.
Auscultation of all parts of the lungs is necessary, since listening to only the tops can lead to an incorrect interpretation of the noise: they can be wired from another lung or stomach.
After tracheal intubation, the ETT should be securely fixed. They either fix it with a plaster to the cheek (two turns of the plaster around the tube are necessary), or tie the tube to the gag.
Complications
Damage to the lips, teeth, tongue, pharyngeal mucosa, larynx and trachea.
Tracheal rupture.
Dislocation of the arytenoid cartilages.
Nasotrachial intubation
Indications
Operations in the oral cavity.
The need for prolonged tracheal intubation in the postoperative period (since this type of intubation provides greater patient comfort and reduces the possibility of ETT kinking).
Such intubation also reduces the manipulation of the cervical spine, which is very important in patients with instability of this region.
Contraindications
Fracture of the base of the skull, especially the fracture of os. ethmoidalis (ethmoid bone).
Fracture of the bones of the nose, chronic nosebleeds (nasal polyps are a relative contraindication for intubation through the nose).
Technique
The nasal mucosa for anesthesia and vasoconstriction is treated with a lidocaine-adrenaline mixture. If both nasal passages are available, then the right one is usually chosen for intubation, because the bevel of most ETTs faces the nasal septum during the passage of the nasal passage, which reduces the likelihood of injury to the turbinates. The size of the ETT is limited due to the inferior turbinates. Typically, 6.0-6.5 mm ETT is used for women, and 7.0-7.5 mm ETT is used for men. After passing through the nasal passage and pharynx, the tube enters the glottis. For nasotracheal intubation, a laryngoscope and Magill forceps can be used to facilitate ETT.
Complications
Same as for orotracheal intubation.
Nosebleeds, submucosal tears, avulsion of tonsils and adenoids.
Infection of the maxillary and frontal sinuses, bacteremia.
Conscious intubation
Indications
Orotracheal or nasotracheal intubation is indicated in the following cases:
Expected difficult intubation in patients at high risk of gastric aspiration;
Doubts about the possibility of ventilation or intubation after induction (for example, a high degree of obesity);
Necessity to check neurologic status after intubation or positioning for surgery (eg, patients with instability (fracture) of the cervical spine).
Technique
To ensure awake tracheal intubation after rinsing with 4% lidocaine, a lidocaine spray or nebulizer should be used to desensitize the upper airways.
It is possible to use a conduction blockade of the following nerves:
superior laryngeal nerve. The blockade is performed from the projection of the horn of the hyoid bone or from the thyroid cartilage (Fig. 8.2).
A point on the skin is marked on 1 cm of the medial projection of the superior process of the hyoid bone. Slightly shifting a strip of skin, a 25G needle is passed until it comes into contact with the greater horn of the hyoid bone. The needle is then turned away from the bone in a caudal direction and passed through the thyroid-hyoid membrane.
According to the second technique, after local anesthesia of the skin, the needle is inserted to the superior process of the thyroid cartilage, passing through the thyroid-sublingual membrane. After making sure that air enters the syringe, 2 ml of a 2% solution of lidocaine is injected. The procedure is performed on both sides.
The recurrent laryngeal nerve can be blocked by a transtracheal approach. A 25G needle is inserted midline through the cricothyroid membrane into the tracheal lumen, which must be confirmed by air aspiration. Then 2 ml of a 2% lidocaine solution is injected and the needle is immediately removed.
After the injection of the anesthetic, the patient begins to cough and the anesthetic spreads in the proximal direction. DanThis type of anesthesia is not recommended for patients with a full stomach due to the risk of aspiration.
For awake laryngoscopy, in addition to the conductive nerve block described above, sedatives such as midazolam, propofol, in combination with fentanide can be used.
Awakened nasal intubation can only be performed after adequate anesthesia with local anesthetics, either locally or regionally.
Before intubation it is necessary to use sedative drugs.
A well-moistened ETT is gently advanced into the nasopharynx.
Deep resonant breath sounds usually indicate that the ETT is over the tracheal inlet. An improved position for intubation ("a person breathing in the morning air") can be used.
Successful intubation is judged by the absence of phonation in the patient, the presence of breath sounds during ventilation, and the presence of a capnogram.
Complications
Same as for orotracheal intubation.
Luminous guidewire intubation
A special flexible fiber-optic conductor is used, through which the ETT can be blindly inserted into the trachea.
Intubation is performed in a darkened operating room. The ETT is placed over a guidewire, which is then inserted into the mouth, pharynx, and larynx. The correct positioning of the conductor is determined by a luminous spot on the front surface of the neck. If there is no spot, then the conductor is in the esophagus. The presence of a light spot on the anterior surface of the neck indicates that the conductor is in the trachea. After that, the endotracheal tube is shifted into the trachea, as with a conventional conductor.
Intubation with fiberoptic bronchoscope
A flexible fiber optic bronchoscope consists of special glass fibers through which light and images are transmitted. The working channel of the fiberoptic bronchoscope can be used to administer local anesthetics, supply oxygen, or to suction mucus, blood, etc. from the trachea. To ensure good visibility through the bronchoscope, the end of the brochoscope is placed in warm water or silicone before work. An oxygen flow of 10-15 l/min helps to protect the optics from mucus, secretion, etc. Standard equipment:
Mouthpiece.
Duct (Ovassapian).
local anesthetics.
Fiber bronchoscope with light source.
Indications
The flexible fiberoptic bronchoscope can be used in both conscious and anesthetized patients for diagnosis and tracheal intubation. Can be used for both nasal and oral intubation. Should be used first when difficult intubation is expected and not as a "last resort".
As a matter of choice, fibrooptic imaging should be used in patients with known or suspected damage to the cervical spine, in patients with head and neck tumors, in obese patients, or in cases of known or suspected difficulty in ventilation and intubation.
Technique
The ETT is put on the bronchoscope, oxygen is connected to the working channel, the position and advancement of the fiberscope is controlled with the right hand, and it is manipulated with the left hand. When advancing the fibrobronchoscope into the oral cavity, it is necessary to ensure that the bronchoscope goes strictly along the midline so as not to fall into the periformal fossa. The end of the bronchoscope after passing the lower part of the Schottky is transferred to the anterior position and advanced to the epiglottis.
If resistance is high, the intubation tube should be rotated 180° counterclockwise to facilitate passage through the vocal cords and contact with the anterior commissure.
Retrograde tracheal intubation
Indications
This technique is used in the event that the above methods were unsuccessful. This technique is applicable in patients who are conscious and spontaneously breathing.
Technique
After local and conduction anesthesia of the airways (as described above), the cricothyroid membrane is punctured by an 18G intravenous catheter in the midline. An 80 cm 0.025 inch metal wire or an epidural catheter is passed through the catheter into the oral cavity. The intravenous catheter is removed, the patient either spits out the metal conductor or the epidural catheter himself, or with the help of a laryngoscope it is removed from the oral cavity, and the endotracheal tube is advanced through it beyond the glottis.
Airway management in an emergency
Percutaneous needle cricothyroidotomy
It is performed by placing a 14G or 7.5F IV catheter through the cricothyroid membrane into the tracheal lumen. Oxygen is delivered through the connections of the 3 mm ETT adapter directly to the IV catheter or through the connection of the 8.5 mm ETT adapter to the body of the 2 ml syringe and then to the IV catheter. After the catheter has been placed, it must be monitored continuously, as catheter displacement can lead to barotrauma, extensive neck and anterior chest emphysema, and airway obstruction.
Through the catheter, oxygenation with a flow of 10-12 l / min can be carried out, but not ventilation. This is a temporary remedy and is absolutely contraindicated in complete obstruction of the upper airways, as it may lead to barotrauma.
Some semblance of jet ventilation can be carried out using the emergency oxygen supply button, when oxygen is supplied for 1 s, and spontaneous expiration for 2-3 s. With the appropriate equipment, it is possible to carry out high-frequency ventilation.
Complications
May include tissue enphysema, barotrauma, and pneumothorax. Since the upper respiratory tract is not "protected", aspiration of gastric contents is possible.
Cricothyrotomy
It is a fast, simple and safe method for upper airway obstruction. With the neck extended along the midline in the region of the cricothyroid membrane, a transverse incision is made with a scalpel. The scalpel handle is used for separating soft tissues and widening the gap before placing a tracheostomy or shpubation tube.
Rigid bronchoscopy
It is necessary to ensure the patency of the respiratory tract with foreign bodies of the trachea, with traumatic damage to the trachea, with stenosis. It is important to have all sizes of rigid bronchoscopes on hand (including for children). For induction on spontaneous breathing, it is recommended to use inhalation anesthetics.
Tracheostomy
It is performed under local anesthesia before induction of anesthesia in patients with known difficult tracheal intubation.
Technique
The incision is usually made along the third or fourth tracheal ring. This requires very careful dissection of the vessels, nerves and isthmus of the thyroid gland.
Complications
Include bleeding, false stroke, pneumothorax.
Special extras
Fast sequential induction
Indications
Patients who have recently taken food (full stomach), pregnant women, patients with severe intestinal obstruction, patients with a high degree of obesity or with symptomatic reflux.
Technique
Equipment needed for fast sequential induction:
Working suction;
Various types and sizes of laryngoscope blades (Mac and Miller);
Various ETTs on conductors, including one size smaller than normal.
An assistant (sister anaesthetist) who can perform the Selick maneuver (cricoid pressure).
The patient is preoxygenated with a large flow of 100% oxygen for 3-5 minutes (denitrogenation). If there is no time, then four breaths, equal in volume to the full vital capacity of the lungs, lead to the same result.
During the administration of a hypnotic (thiopental, propofol, ketamine) and a depolarizing muscle relaxant, the assistant performs the Selick maneuver. This technique prevents passive regurpation, reduces gastric ventilation during mask ventilation, and also improves the visibility of the vocal cords due to their displacement in the posterior direction. However, this technique does not prevent regurgitation during vomiting.
If possible, ventilate the patient with a mask. Tracheal intubation should be performed within 30-60 seconds. The Selick maneuver is performed until the correct placement of the endotracheal tube is verified.
If intubation is unsuccessful, then the Selick maneuver is performed throughout all subsequent intubation attempts and under ventilation with a mask of 100% oxygen.
Replacement of the endotracheal tube
Sometimes it is necessary to replace the endotracheal tube in patients whose intubation presented certain difficulties. As a rule, this is necessary because of damage to the cuff and the inability to perform oral tamponade.
The oral cavity and pharynx are sanitized. The patient is oxygenated with 100% oxygen.
A soft conductor is passed through the old endotracheal tube into the trachea. The old endotracheal tube is removed, and a new one is inserted into the trachea along the conductor. The conductor is removed. An alternative technique is isubation with a bronchoscope. A new endotracheal tube is put on a bronchoscope, which is then passed along the old endotracheal tube behind the vocal cords. The cuff on the old tube is deflated, and the bronchoscope is advanced into the trachea until the cartilage rings of the trachea are identified to verify the position. The old tube is removed and the new tube is inserted into the trachea in the same way as described earlier.
SOME COMPLICATIONS ASSOCIATED WITH AIRWAY MANAGEMENT
The key to success lies in a thorough preoperative examination, knowledge of the algorithm of action, the ability to resort to outside help and the availability of modern equipment.
Table 8.1
Algorithm of actions of the anesthesiologist in case of unsuccessful intubation
|
Problem |
Solution method |
|
First intubation attempt failed |
Continue mask ventilation until next intubation attempt (e.g. with a bronchoscope) |
|
All attempts fail |
The patient must be awakened |
|
The previous one is not possible due to the inability to cancel the surgery (emergency caesarean section) |
Mask ventilation should be continued using the Celica maneuver. |
|
Mask ventilation is difficult or impossible |
Provide oxygenation by placing a laryngeal mask. If, despite efforts, the patient's hemoglobin oxygen saturation decreases, then immediate percutaneous needle cricothyrotomy or surgical cricothyrotomy should be performed. |
laryngospasm
The most common cause of laryngospasm is irritation of the reflexogenic zones of the oropharynx, trachea or bronchi under conditions of surface anesthesia. This may be due to an attempted intubation or exposure to secretions, blood, gastric contents, or a foreign body. Contribute to the development of laryngospasm hypoxia, hypercapnia and acidosis. Reflex closure of the vocal cords causes the appearance of "strider" breathing. With complete obstruction, the anesthetist is unable to ventilate the patient.
Therapy
Switching to inhalation with 100% oxygen;
Introduction of depolarizing muscle relaxants;
Sanitation of the tracheobronchial tree;
Deepening anesthesia.
Bronchospasm
Bronchospasm can be either a manifestation of a generalized reaction of the body (bronchial asthma), or a local effect (such as: laryngospasm, reaction to intubation, etc.). Bronchospasm can also be a manifestation of an anaphylactic or anaphylactoid reaction of the body to the administration of a particular drug. In addition, a number of drugs (morphine, tubarine, trakrium) can provoke the development of bronchospasm due to their inherent histaminogenic effect.
Bronchospasm is characterized by tachypnea with labored expiration, with auscultation detecting hard breathing. When bronchospasm occurs in a patient under anesthesia, there is a sharp increase in inspiratory pressure, an increase in resistance and a sharp decrease in compliance.
Treatment
Verification of the position of the ingubation tube. Irritation of carina can be a provoking factor in the development of bronchospasm;
Deepening anesthesia. In this case, it is advisable to use halothane (halothane), since the latter is a very effective bronchodilator. During TBA, ketamine can be administered, as it also has a relaxing effect on the muscles of the bronchi due to the presence of sympathomimetic properties. However, barbiturates and propofol can be used. In case of hypoxia, it is necessary to increase the oxygen content in the inhaled mixture;
Inhalation of bronchodilators (insufflation into the breathing circuit). Insufflation of drugs allows minimizing the undesirable effects of drugs on the circulatory system (izadrin, steroid drugs);
IV drugs;
Sympathomimetics stimulate B 2-adrenergic receptors and activate adenylate cyclase in the lungs. The resulting cAMP causes relaxation of the smooth muscles of the bronchi:
Adrenaline, when administered in small doses (0.25-1.0 mcg / min), affects mainly ( B 2 receptors and thus is an effective bronchodilator;
Isoproterenol - non-specific B- agonist, causes tachycardia;
Methylxanthines (eufillin) - 5 mg / kg every 30 minutes, then 0.5-1.0 mg / (kg / h), but not more than 0.5 mg for 4 hours. Side effect - tachycardia.
Corticosteroids (prednisolone - 30-60 mg / kg; dexazone - 4- 8 mg/kg; - celeston - 1-2 mg/kg);
adequate humidification of the inhaled gas.
Bronchiospasm - extremely severe complication of the intraoperative period. It develops instantly, most often in the form of an allergic reaction during induction of anesthesia.
Symptoms:
- "stone" bag. The pressure on inhalation increases sharply, when you try to switch to manual ventilation - a feeling that the endotracheal tube is occluded;
Total cyanosis;
Breathing in the lungs is not audible.
With bronchiolospasm, the time from the onset of an attack to hypoxic cardiac arrest is very limited. As a rule, this happens in 2-5 minutes. Since the anesthesiologist rarely encounters such a complication, he begins to search for a place of occlusion, re-intubation of the trachea, which further reduces the time allotted to try to bring the patient out of this state.
The algorithm of action of the anesthesiologist in the event of bronchiolospasm:
Immediate percussion chest massage, rhythmic and deep compression of the chest in an attempt to imitate breathing;
In / in the introduction of high doses of steroids (celeston - 2.0-2.5 mg / kg);
The introduction of adrenaline;
Introduction to the endotracheal tube of mucolytic solutions.
Despite the timeliness and correctness of the measures taken, the mortality rate is extremely high and reaches 70-90%.
THE ROLE OF REGIONAL ANESTHESIA
Regional anesthesia may be the method of choice in patients with known difficult intubation. However, serious complications of the regional anesthesia itself (loss of consciousness, cardiac arrest due to intravenous administration of local anesthetics) may require tracheal intubation. Airway obstruction can also occur due to the use of sedatives and narcotic drugs. Successful use of regional anesthesia in patients with known difficult intubation can be achieved through the use of catheter techniques (prolonged regional anesthesia), test doses, and small increasing doses of anesthetic to prevent possible intoxication. The adequacy of the block should be checked before the start of the operation, and the plan for "retreat" (in case of development of inadequacy of the block during the operation, or if the patient can no longer be in a certain position, or if the operation is prolonged) should be discussed with the surgeon and the patient in advance. This may include local infiltration anesthesia, postponing the operation to another day, or using a conscious intubation technique for subsequent general anesthesia.
Latto I.P., Rosen M. Difficulties in tracheal intubation.-M.: Medicine.-1989.-303 p.
Mallampati S. et al. A clinical sign to predict difficult trachea! intubation: A prospective study//Can. Anaesth. soc. J.-1985.-V. 32.-No. 4.- R. 429.
Ventilation expiratory methods of breathing "from mouth to mouth" and "from mouth to nose" is the simplest and most affordable method of mechanical ventilation that does not require additional devices. For its implementation, first of all, free patency of the upper respiratory tract is necessary, which in any patient who is in an unconscious state is impaired as a result of retraction of the root of the tongue due to muscle relaxation and flexion of the neck.
Retraction of the root of the tongue is eliminated by maximum extension of the head in the atlanto-occiital joint. According to P. Safar, the reception is effective in 80% of patients, and in 20% of cases it is difficult (short neck, diseases of the cervical spine, etc.). In case of traumatic injuries of the cervical vertebrae, in order to avoid additional traumatization and damage to the spinal cord, it is necessary to use not extension of the head, but the extension of the lower jaw forward behind the chin. In most cases, the combination of these techniques is the most effective - the so-called "triple technique": extension of the head, extension of the lower jaw forward and opening of the mouth (head-tilt-chin-lift-method).
Obstruction of the oropharynx with sputum, blood, food masses is eliminated either by suction, or by a finger with a cloth or bandage wound around it after turning the patient's head to one side. The ingestion of the contents of the oropharynx into the lungs carries the threat of laryngo- and bronchospasm, hypoxia, and further developed Mendelssohn's syndrome.
"from mouth to mouth" The nose of the patient is closed with the first and second fingers of one hand and the ulnar side of the same brush exerts pressure on the forehead to hold the head in an unbent position. The second brush is placed under the neck or on the chin. With a tight pressing of the lips of the resuscitator's wide-open mouth to the patient's mouth, air is blown. The volume of one breath is usually 600-1200 ml, and the oxygen content in the exhaled air reaches 16-18%. Sufficient volume of one breath is more important than frequent ineffective breaths into the oral cavity. Evidence of the sufficiency of the breath produced is the raising and lowering of the chest, as well as the audible exhalation of the patient.
Mouth to mouth ventilation video
Lung ventilation breathing technique"mouth to nose". With four fingers of one hand, the patient's mouth is closed by pressing the lower jaw. The second hand is placed on the forehead and helps to extend and hold the head. After air is blown in, the patient's roses should be slightly opened, since exhalation through the nose is hampered by the retraction of the soft palate or the accumulation of mucus in the nasopharynx.
Breathing through the nose it can be difficult and even impossible with the curvature of the nasal septum, polyps, rhinitis. However, this method has several advantages over mouth-to-mouth breathing. Firstly, the airway at the level of the root of the tongue is better when the mouth is closed, and secondly, the pressure of the blown air is softened when passing through the nasopharynx, which prevents or reduces the entry of air into the stomach and the risk of regurgitation. This is especially important to consider when resuscitating pregnant women, who are always at risk of regurgitation and aspiration. Third, the method is more hygienic and safer for the reviver.
To avoid direct contact resuscitator always use a face mask, tissue or other cloth with the victim. It is more convenient if an S-shaped air duct, an anesthesia machine mask, a portable hand-held device such as the Ambu Bag are at hand. You can use an endotracheal tube by inserting it through the nose into the oropharynx under the root of the tongue, while covering the patient's mouth with his hand. Many companies produce devices for mechanical ventilation, such as a laryngeal mask, a double-lumen air duct, a Brook air duct, a face mask with a valve. It seems very convenient to use for IVL manufactured by the company "AMBU" "Life-key", which is a polyethylene sheet with a non-reversible unidirectional valve in the middle.
With all the above methods of breathing, it is advisable to use Sellick maneuver, which reduces the risk of air entering the stomach, and also prevents the aspiration of gastric contents in case of regurgitation (performed by an assistant).
reception, proposed by Sellick in 1961, consists in pressing the first and second fingers on the thyroid cartilage. Compression of the esophagus between the annulus of the cricoid cartilage and the sixth cervical ring prevents passive leakage of gastric contents. Holding the back of the neck with the second hand is an indispensable condition for the effectiveness of this technique.
Tracheal intubation- the most reliable way to ensure the conductivity of the upper respiratory tract, allowing you to achieve better oxygenation and hyperventilation (as a means of eliminating CO2 and correcting acidosis). Tracheal intubation reduces the risk of aspiration, facilitates the sanitation of the trachea and bronchi, provides a route for the administration of drugs (adrenaline, atropine, lidocaine) in cardiopulmonary resuscitation and other critical situations, in the recovery period after resuscitation (seduxen, naloxone). With the help of an endotracheal tube and a ventilation bag, you can use the reception of positive end-expiratory pressure (PEEP) up to 10 cm SHO, which reduces the loss of intrathoracic pressure during chest compressions and improves the effect of closed massage. The experiment showed that air insufflation with simultaneous compression of the chest increases cardiac output (the "thoracic pump" effect increases).
However, persistent attempts should be categorically abandoned. tracheal intubation by all means in unadapted conditions. Tracheal intubation, especially without the introduction of muscle relaxants, is not a simple procedure, and it should be performed by a doctor who is well versed in this technique. The manipulation time is limited to 20-25 seconds pi is practically determined by the duration of the inhalation delay of the intubator. Therefore, artificial ventilation with a well-fitting mask and debridement of the respiratory tract with suction may be much more appropriate than frantic attempts at repeated unsuccessful intubations, introducing the patient into even greater hypoxia due to the cessation of massage and ventilation.
... actions gastric lavage through the tube is carried out in the following terms:
a) up to 3 days after poisoning
b) up to 2 days after poisoning
c) up to 24 hours after poisoning
D) up to 12 hours after poisoning
123. Brain edema often develops when:
a) cardiopulmonary resuscitation
b) purulent-inflammatory processes
B) traumatic brain injury
d) spinal injury
Choose one correct answer
124. Anesthesia in an open circuit is carried out using:
A) Esmarch's masks
b) laryngotracheal mask
c) endotracheal tube
d) Carlens tubes
Choose one correct answer
125. An adsorber in an anesthesia machine is necessary for:
a) reduction of "dead" space
B) absorption of carbon dioxide
c) economical consumption of volatile anesthetics
d) enhancing the effect of narcotic substances
Choose one correct answer
126. During anesthesia, with preserved spontaneous breathing, the appearance of convulsions is associated with:
A) hypoxia
b) hypercapnia
c) hyperthermia
d) drug intolerance (narcotic analgesics)
Choose one correct answer
127. Drugs used forNLA(neuroleptanalgesia):
a) nitrous oxide + foran
b) ether + halothane
c) ketamine + seduxen
D) droperidol + fentanyl
Choose one correct answer
128. During decurarization, atropine is used to:
a) enhancing the analgesic effect of analgesics
B) reduce the vagotonic effect of proserin
c) normalization of possible water and electrolyte disorders
Choose one correct answer
129. During anesthesia, which of the following solutions should not be used:
a) saline solution NaCl 0.9%
b) reopoliglyukin
c) 5% glucose solution
D) 20% intralipid solution
Choose one correct answer
130. In what situations can a doctor instruct a nurse anesthetist to transfuse blood:
a) in emergency situations
b) a nurse of the highest category
c) in case of mass admission of patients
D) in any
Choose one correct answer
131. Preoperative preparation of children with peritonitis begins with transfusion:
a) fresh frozen plasma
b) whole blood
B) Ringer's solution
d) 20% glucose solution
Choose one correct answer
132. When performing endotracheal anesthesia with the use of halothane, the total dose of relaxants is advisable:
a) increase
B) reduce
c) leave it unchanged
Choose one correct answer
133. To prevent muscle fibrillation, apply:
a) short-acting relaxants (at the usual dosage)
b) long-acting relaxants (in the usual dosage)
C) test dose of long-acting relaxants
Choose one correct answer
134. Correction of metabolic acidosis is carried out by intravenous infusion:
a) 0.9% saline
b) 10% glucose solution
c) 5% glucose solution
D) 4% sodium bicarbonate solution
Choose one correct answer
135. The most severe transfusion reaction is observed in:
A) transfusion of blood of a different type
b) blood transfusion with a shelf life of 21 days
c) acute renal failure
d) violation of the patient's blood coagulation system
Choose one correct answer
136. Disinfectants must be stored:
a) in a cabinet for odorous and coloring substances
B) apart from drugs
c) in a cabinet for external preparations
Choose one correct answer
137. Treatment of apnea resulting from an overdose of depolarizing muscle relaxants should begin with the use of:
a) proserine
c) cordiamine
d) calcium chloride
Choose one correct answer
138. Nurse-anesthetist fixes indicators of the patient's condition in the anesthesia card:
A) every 5 minutes
b) at the beginning and at the end of anesthesia
c) as needed
d) every 15 minutes.
Choose one correct answer
139. What is not the cause of the terminal state:
a) severe blood loss
b) acute heart and respiratory failure
B) obesity
d) drowning
e) electrical injury
Choose one correct answer
140. When blood circulation stops, convulsions appear:
a) simultaneously with cardiac arrest
b) after 30 - 60 sec. after cardiac arrest
C) simultaneously with loss of consciousness or somewhat later
d) at the same time as breathing stops
Choose one correct answer
141. Termination of resuscitation measures is carried out through:
a) 2 hours after the start of resuscitation
b) 1 hour after the start of resuscitation
C) 30 min. with the ineffectiveness of resuscitation measures
Choose one correct answer
142. On an outpatient basis, general anesthesia can be performed by:
a) the surgeon performing the operation
b) a surgeon not involved in this operation
c) a trained nurse anesthetist
D) an anesthesiologist
Choose one correct answer
143. Respiratory disorders in anesthesia occur due to:
A) bending of the endotracheal tube
b) hypovolemia
c) hypertension
d) air embolism when the system is disconnected from the subclavian catheter
Choose one correct answer
144. What are the criteria for changing the carbon dioxide absorber in the adsorber:
a) according to the validity period specified in the instructions
b) by completely changing the color of the absorber in the adsorber
C) by changing the color of the absorber by 2/3 of the volume
Choose one correct answer
145. Circulatory disorders during anesthesia do not include:
a) hypovolemia and decrease in BCC with hypotension
b) heart rhythm disorder
B) prolonged sleep apnea
d) tachycardia
Choose one correct answer
146. The spinal cord is located:
a) between the dura mater and the arachnoid
B) in the spinal canal
c) between the yellow ligament and the dura mater
Choose one correct answer
147. Horse tail is:
A) splitting of the spinal cord into many branches
b) plexus of nerve endings in the pelvis
c) plexus of nerve endings in the epigastric region
Choose one correct answer
148. Caudal anesthesia is performed at the level of:
a) thoracic spine
b) cervical spine
B) sacral spine
d) lumbar spine
Choose one correct answer
149. For tracheal intubation, the patient is placed on the table in the position:
a) Trendelenburg
B) Jackson
c) Fowler
Choose one correct answer
150. Difficulties in conducting general anesthesia in emergency patients are due to:
a) progressive dehydration
b) toxemia
c) disorders of water and electrolyte metabolism
D) all of the above
Choose one correct answer
a) anticholinergics
b) antihistamines
B) narcotic analgesics
Choose one correct answer
152. Selick maneuver is used for:
a) facilitate tracheal intubation
B) preventing the development of regurgitation
c) preventing the development of vomiting
Choose one correct answer
153. Selick's maneuver is used for:
a) clamping of the trachea
B) constriction of the esophagus
d) clamping of the main bronchi
Choose one correct answer
154. Gas exchange in the lungs is disturbed when:
a) artificial lung ventilation
B) the position of the patient on a healthy side
c) the position of the patient on the back
Choose one correct answer
155. Complications of anesthesia are not considered:
a) an overdose of anesthetic
B) bleeding from a damaged vessel
c) violations of the respiratory circuit during mechanical ventilation
d) airway obstruction
Choose one correct answer
156. Features of anesthetic support for emergency operations:
a) the possibility of additional studies to clarify the diagnosis is limited
b) concomitant diseases worsen the patient's condition
c) there is a problem of a full stomach
D) all of the above
Choose one correct answer
157. In outpatient surgery, for the safety of the patient, it is not necessary:
a) the desire of the patient after general anesthesia to return home on the same day
b) the possibility of being accompanied by an adult
C) the financial condition of the patient
d) have a home phone
Choose one correct answer
158. Absolute contraindications to epidural anesthesia:
a) patient refusal
b) infection of the skin at the puncture site
c) bacteremia
d) severe hypovolemia (shock)
D) all of the above
Choose one correct answer
159. During anesthesia in patients in a state of shock:
a) the onset of general anesthesia must be very rapid
b) to prevent vagal disorders, premedication includes atropine
c) during the operation, the patient is given complex infusion-drug therapy
d) after the end of the operation, as a rule, an extended mechanical ventilation is performed
D) all of the above
Choose one correct answer
160. In patients in a state of shock, with existing hypotension, it is better to use for induction:
a) droperidol
b) barbiturates
D) ketamine
Choose one correct answer
161. Causes of blood pressure decrease during anesthesia:
a) full stomach before anesthesia
B) hypovolemia
c) antihypertensive effect of drugs
d) incorrectly selected ventilation parameters
Choose one correct answer
162. Indicators of the patient's condition are recorded in the intensive care card:
a) every 15 minutes
b) every hour
c) 2 times a day
d) every 2 hours
Choose one correct answer
163. Muscle relaxants are used for:
a) turning off consciousness
B) creating prolonged artificial myoplegia
c) ensuring neurovegetative inhibition
d) deep anesthesia
Choose one correct answer
164. Diffuse hypoxia during withdrawal from anesthesia is caused by:
A) rapid release of nitrous oxide into the alveolar system
b) breathing atmospheric air
c) breathing pure oxygen
Choose one correct answer
Choose one correct answer
166. External heart massage should not be performed if:
a) acute myocardial infarction
b) spinal deformities
B) multiple rib fractures
d) obesity
Choose one correct answer
167. When performing an external heart massage for a newborn, the number of compressions is equal to:
a) 60 - 70 per minute
b) 80 - 100 per min.
C) 100 - 120 per min.
d) 120 - 150 per minute.
Choose one correct answer
Choose one correct answer
169. Criteria for stopping mechanical ventilation:
a) before the onset of spontaneous inspiration
b) until stabilization of hemodynamics
C) until complete restoration of spontaneous breathing
d) before the appearance of a cough reflex to the endotracheal tube
Choose one correct answer
170. Symptoms of cardiac asthma include:
a) chest pain when coughing
B) shortness of breath with difficulty breathing
c) persistent dry cough
d) secretion of viscous sputum
Choose one correct answer
171. In case of pulmonary edema, the following are used as emergency therapy:
a) nitroglycerin
b) sulfocamphocaine
c) atropine
D) lasix
Choose one correct answer
172. When carrying out infusion therapy in patients with cardiogenic shock, one should:
a) administer liquid based on the daily requirement
b) inject only colloidal solutions
c) administer liquid for 500-700 ml more than the daily requirement
D) limit the amount of fluid injected
Choose one correct answer
173. The main thing in emergency care for traumatic shock is:
a) the introduction of cardiac drugs
B) anesthesia
c) oxygen therapy
d) complete rest
Choose one correct answer
174. Start infusion therapy for massive blood loss with transfusion:
b) plasma
c) lipofundin
D) polyglucin
Choose one correct answer
175. In case of arterial bleeding, a tourniquet is applied:
a) below the wound
b) on the wound
B) above the wound
Choose one correct answer
176. In anaphylactic shock with collapse, emergency care should begin with the introduction of:
a) polyglucin
b) diphenhydramine
B) adrenaline
d) cordiamine
Choose one correct answer
177. To bring a patient out of a hypoglycemic coma, it is necessary to enter:
A) IV 40% glucose - 40 - 60 ml
b) insulin
c) IV NaCl 0.9% - 1000.0
d) antihistamines
e) s / c 0.5 adrenaline
Choose one correct answer
178. A victim with poisoning in a state of coma, gastric lavage is performed:
a) head down
b) with a raised head end
c) on the side
D) after tracheal intubation
Choose one correct answer
179. In case of enteral poisoning, it is necessary first of all:
a) keep calm
b) establish oxygen inhalation
B) gastric lavage
d) administer tonic drugs
Choose one correct answer
180. In case of parenteral poisoning, first of all it is necessary:
A) start fluid therapy
b) ensure complete peace
c) give activated charcoal
d) gastric lavage
Choose one correct answer
181. Antidote therapy is carried out:
a) at any time from the moment of poisoning
B) in the first hours after poisoning
c) within a day from the moment of poisoning
Choose one correct answer
182. Main symptom in preeclampsia:
a) nausea
B) headache
c) anemia
d) stool disorders
e) jaundice
Choose one correct answer
183. A newborn should take the first breath:
A) immediately after birth
b) within the first 8 seconds after birth
c) within the first 18 seconds after birth
d) within the first 25 seconds after birth
Choose one correct answer
184. After the end of anesthesia, the device should be processed:
a) during the day
B) no later than 30 minutes after anesthesia
c) no later than 2 hours after anesthesia
d) when you have free time
Choose one correct answer
185. The processing of medical instruments is regulated by orders of the Ministry of Health:
D) No. 408 and OST 42-21-2-85
Choose one correct answer
186. Stages of anesthesia for minor surgical manipulations:
a) stage of excitation
b) awakening stage
B) stage of analgesia
d) stage of anesthesia sleep
187. Liquid drugs:
A) sevoran
b) nitrous oxide
B) azeotropic mixture
d) xenon
Choose one correct answer
188. Necessary tool for the anesthesiologist's table:
a) Mikulich clamp
B) language holder
c) retractor
d) nippers
Choose one correct answer
189. Correct position of a patient after anesthesia:
a) lying face up on a pillow
b) lying on a pillow, head turned to one side
c) lying face down on a pillow
D) lying without a pillow, head turned to one side
Choose one correct answer
190. Risk factors in the development of complications during local anesthesia:
a) underweight
b) alcohol abuse
B) allergic to anesthetics
d) the nature of nutrition
Choose one correct answer
191. Premedication for planned operations is carried out:
a) 2 hours before surgery
b) immediately before the operation
c) 1 day before surgery
D) 30 minutes before surgery
Choose one correct answer
192. During conduction anesthesia, the anesthetic substance is administered:
a) intraosseously
B) in the tissues surrounding the nerve
c) infiltrate all tissues
Choose one correct answer
193. For intravenous anesthesia use:
a) lidocaine
b) owl
B) hexenal
d) isoflurane
Choose one correct answer
194. For inhalation anesthesia use:
A) halothane, nitrous oxide
b) novocaine, sodium thiopental
c) dikain, sovkain
d) calypsol, seduxen
Choose one correct answer
195. What is calledIIanesthesia stage:
a) surgical sleep
b) analgesia
B) arousal
d) awakening
Choose one correct answer
196. Ditilin during intubation anesthesia is used for:
a) induction of anesthesia
B) muscle relaxation
c) normalization of the activity of the cardiovascular system
d) prevention of bronchospasm
Choose one correct answer
197. Patient's problems after mask anesthesia:
a) acute urinary retention
B) vomiting
c) lack of personal hygiene
d) limitation of physical activity
Choose one correct answer
198. The plan of care for a patient after intubation anesthesia includes:
A) sanitation of the upper respiratory tract
b) tube feeding
c) siphon enema
d) drinking plenty of water
Choose one correct answer
199. To what depth should the sternum sag during chest compressions:
B) 4 - 5 cm
Choose one correct answer
200. To what depth should the chest sag during closed heart massage to a newborn:
A) 1.5 - 2 cm
b) 4 - 5 cm
c) 5 - 6 cm
d) 7 - 8 cm
Choose one correct answer
201. To ensure free patency of the patient's airways, it is necessary:
a) put on your back, turn your head to one side, push the lower jaw forward
B) put a roller under the shoulder blades, tilt the head back, push the lower jaw forward
c) put on your back, turn your head to one side, put a roller under your shoulder blades
Choose one correct answer
202. To prevent retraction of the root of the tongue during resuscitation, the head of the victim should be:
a) turned sideways
B) tilted back
c) bent forward
d) in normal position
203. Safety criteria for discharge in outpatient anesthesiology are:
a) no pain in the area of operation
B) stability of functions when observed for 1 hour
C) full restoration of the initial level of consciousness
D) fluid tolerance and ability to urinate
D) the presence of an adult escort
204. In the immediate postoperative period, circulatory disorders are associated with:
A) unreplenished blood loss
B) response to pain
c) residual effect of relaxants
D) rough shifting
Choose three correct answers
205. Reasons causing complications of anesthesia:
a) the temperature in the operating room
B) hardware malfunction
C) properties of pharmacological preparations or their incorrect use
D) little experience, insufficient knowledge
Choose three correct answers
206. What refers to the human factor:
A) performance of functional duties
B) observation of the patient using monitoring
C) ability to work with equipment
d) features of pharmacotherapy of drugs
Choose four correct answers
207. The main tasks of the ICU:
A) intensive care and resuscitation
b) organization of scientific and practical conferences
C) consultation of patients who are in other departments
D) maintaining medical records
D) advanced training of medical staff
Choose three correct answers
A) participation in the bypass of patients by the head
B) monitoring the workplace and maintaining it in constant readiness
c) confidential conversations with relatives
D) constant monitoring of the patient
Choose three correct answers
209. When taking up duty, a nurse must:
A) admit patients, their medical histories and cards
b) record an ECG for all patients
C) take medicines and all property according to the inventory
D) keep instruments and apparatus in constant readiness
Choose three correct answers
210. What is the content of the work of an ICU nurse:
a) information to the patient about the operation performed
B) prevention of purulent-septic complications
C) providing general care and nutrition for patients
D) control of the work of the nurse
D) immediate report to the doctor about the deterioration of the patient's condition
Choose three correct answers
211. Before performing a puncture of the epidural space, the nurse anesthetist must prepare:
A) catheterization kit
B) local anesthetic
C) anesthetic for injection into the epidural space
d) depolarizing relaxants
Choose two correct answers
212. Marcain renders:
A) relatively strong and long-lasting effect
B) relatively low toxicity
c) improves heart function
d) induces deep sleep
Choose three correct answers
213. Adding adrenaline to a local anesthetic solution causes:
A) vasoconstriction at the injection site
B) increases the duration of action
C) reduces the severity of toxic side effects
d) increases BCC
Choose three correct answers
214. In case of overdose of local anesthetics:
A) automatism of the heart is inhibited
B) contractility and excitability are inhibited
B) bradycardia occurs
d) tachycardia occurs
Choose three correct answers
215. Early neurological symptoms in overdose of local anesthetics:
a) increase in blood pressure
B) numbness around the mouth
B) paresthesia of the tongue
D) dizziness
Choose three correct answers
216. The required intensity of epidural anesthesia depends on:
A) individual properties of the anesthetic
B) concentration of anesthetic
C) doses of anesthetic
d) individual tolerance to patients
Choose three correct answers
217. Safety measures for epidural anesthesia:
A) control of blood pressure
b) diuresis control
C) monitoring the general condition of the patient
D) the introduction of an anesthetic in fractional doses
Choose three correct answers
218. Preoperative preparation of emergency patients includes:
A) central venous catheterization
B) laboratory tests of blood and urine
B) preparation of the gastrointestinal tract
d) urine test according to Zimnitsky
Choose three correct answers
219. Advantages of endotracheal general anesthesia:
A) ensuring free airway patency
B) the possibility of aspiration of bronchial secretions
C) reliable isolation of the patient's gastrointestinal tract from the respiratory tract
d) the ability to perform the operation in secret from the patient
Choose three correct answers
220. Relative contraindications to endotracheal anesthesia:
a) the age of the patient
B) structural features of the facial skeleton
C) stenosing diseases of the larynx
D) in patients with an open form of tuberculosis
Choose four correct answers
221. Signs of clinical death:
a) convulsions
B) lack of consciousness
C) dilated pupils that do not react to light
D) no breathing
D) lack of cardiac activity
Choose three correct answers
222. Cardiac arrest during anesthesia is diagnosed by:
A) the appearance of a straight "isoline" on the monitor
B) lack of pulse and blood pressure
B) dilated pupils
d) lack of breath
Choose two correct answers
223. The criterion for evaluating infusion therapy in planned patients is carried out according to:
a) heart rate
B) hourly diuresis
c) blood glucose levels
D) central venous pressure
Choose two correct answers
224. During transfusion therapy in a burn patient, the following is administered:
a) whole blood
b) erythromass
B) plasma
D) saline solutions
Choose two correct answers
225. In traumatic brain injury, the state of coma develops when:
a) a fissure of the cranial vault
B) brain injury
c) concussion
D) compression of the brain
Choose three correct answers
226. Complications can be observed during mechanical ventilation using the “mouth-to-mouth” method:
A) dislocation of the mandible
b) ventricular fibrillation
B) regurgitation
D) rupture of the lungs, pneumothorax
Choose two correct answers
227. The main signs of cardiac arrest:
A) absence of a pulse in the carotid artery
b) lack of spontaneous breathing
c) narrow pupils
D) wide pupils
Choose three correct answers
228. Reliable signs of biological death:
a) cessation of cardiac activity
B) the appearance of cadaveric spots
C) the appearance of a symptom of "cat's eye"
D) the appearance of rigor mortis
229. Medicines required on the anesthetist's table:
A) barbiturates
B) muscle relaxants
B) atropine
D) prozerin
D) mezaton
G) hormones
Choose six correct answers
230. Instruments required on the anesthetist's table:
A) scissors
B) tonometer
B) laryngoscope
D) phonendoscope
D) endotracheal tubes
f) needle holder
G) mouth expander
Choose two correct answers
231. During nasotracheal intubation:
A) sanitation of the oropharynx improves
B) there is no symptom of the "root of the tongue"
c) dead space increases
d) the effect of the anesthetic is enhanced
Choose two correct answers
232. Indications for the use of depolarizing relaxants:
A) tracheal intubation
b) with anesthesia for more than 2 hours
C) with prolonged surgical intervention in children with renal insufficiency
Choose two correct answers
233. A sign of a burn of the upper respiratory tract in case of thermal injury is:
b) persistent cough
B) facial burns
d) hypersalivation
Choose two correct answers
234. With the introduction of atropine observed:
A) tachycardia
b) bradycardia
c) pupillary constriction
D) pupil dilation
Choose three correct answers
235. In acute blood loss observed:
A) fast and weak pulse
B) lowering blood pressure
c) intense excitement
D) pale skin
e) loss of consciousness
Choose four correct answers
236. The main signs of ODN:
A) cyanosis or other discoloration of the skin
B) shortness of breath, change in respiratory rate
c) a feeling of fear
D) changes in hemodynamics
D) participation in breathing of auxiliary muscles
Choose two correct answers
237. In order to maintain adequate gas exchange in the body, it is necessary:
a) replenish the BCC with infusion solutions
B) Maintain an open airway
C) restore adequate transport of oxygen and carbon dioxide
d) provide the optimal oxygen tension in the inhaled mixture
Choose three correct answers
238. When monitoring the effectiveness of mechanical ventilation, evaluate:
A) oxygenation
B) the presence or absence of respiratory discomfort
C) the amount of oxygen gas flow
d) hourly diuresis
Choose two correct answers
239. Transfer from mechanical ventilation to spontaneous breathing is carried out by:
A) restore neuromuscular conduction
b) control the volume of injected and excreted fluid
c) measure BCC
D) turn off nitrous oxide
Choose four correct answers
240. A nurse in the anesthesia team should know and be able to:
A) prepare for operation control and diagnostic equipment
b) decipher the cardiogram data
C) if a malfunction is found in the equipment, report it to the doctor
D) prepare the instruments necessary for tracheal intubation
E) carry out a set of measures for disinfection and sterilization of ventilators
Choose three correct answers
241. A nurse in the resuscitation team should know and be able to:
a) establish an infusion into the central vein
B) monitor the condition of the combatants and mark the parameters in the intensive care card
C) keep devices for the provision of resuscitation care in constant readiness
D) control the adequacy of spontaneous breathing or mechanical ventilation and mark the indicators in the map
Choose three correct answers
242. Factors that can cause cardiovascular disorders:
A) toxicity of pharmacological drugs
B) electrolyte disturbances
C) electrical instability of the myocardium
d) foreign body in the airways
Choose three correct answers
In 1961, Sellick described pressure on the cricoid cartilage to prevent regurgitation during anesthesia, and since then this method has become known as the Sellick maneuver (in English literature, more often cricoid pressure, cricoid force). An external force applied to the cricoid cartilage presses the esophagus against the cervical vertebrae. In theory, this technique should clamp the elastic esophagus while maintaining the airway lumen due to the rigidity of the cricoid cartilage.
Rice. 1 - The general principle of operation of the Sellick technique
Sellick originally suggested using pressure on the cricoid cartilage to prevent gastric distention during mask ventilation. It should be noted that the American Heart Association (AHA) does not recommend performing the Sellick maneuver with bag and mask ventilation during cardiopulmonary resuscitation. During resuscitation, to prevent gastric distention, ventilation with a small volume (6 - 8 ml / kg) and a long time of artificial inspiration (1 second) are used.
Currently, the Sellick technique is used to protect the airways from gastric contents during the time period from turning off the patient's consciousness to inflating the cuff of the endotracheal tube. The Difficult Airway Society (DAS) guidelines list the Sellick maneuver as a required component of rapid sequence induction in the United Kingdom.
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The Sellick maneuver is commonly taught as a component of emergency intubation in emergency medicine training programs in the Russian Federation. At the same time, it should be noted that drugs used during rapid sequential induction are not included in the general profile for emergency medical care.
Sellick technique
The assistant anesthesiologist performing intubation finds the cricoid cartilage (palpates the thyroid cartilage, below it in the recess - the cricoid membrane, even lower - the cricoid cartilage) and places the index finger in its center, the thumb and middle finger laterally.
Rice. 2. Cartilages of the larynx 
Rice. 3. The position of the fingers when performing the Sellick maneuver While the patient is conscious, a force of 10 Newtons is applied, which is equivalent to the impact on the support of a body at rest with a mass of 1 kilogram. After the onset of sedation, the force is increased to 30 Newton (3 kg). The cricoid pressure is believed to improve visualization of the vocal cords during direct laryngoscopy, but in some cases, the pressure on the cricoid cartilage must be relieved in order for the anesthetist to see the vocal cords. The pressure can be relieved only if the laryngoscopy is continued so as not to miss the regurgitation. If you “let go” of the cartilage, then be prepared to apply an aspirator (there is evidence that pressure on the cricoid cartilage weakens the tone of the esophageal sphincter). If regurgitation has begun, pressure on the cricoid cartilage should be resumed.
You can understand what a force of 30 Newtons is by training.
We take a syringe with a volume of 50 ml. We collect 40 ml of air, block Luer Lock. Install the syringe vertically with the piston up. With fingers I, II and III, we lower the piston to 33 ml, overcoming the pressure of the air compressed in the syringe.
It is also believed that 40 Newton is the threshold of pain when pressing on the back of the nose (that is, we press a little weaker on the cricoid cartilage).
Some experts both abroad and in Russia question the effectiveness of the Sellick method for protection against aspiration during tracheal intubation, since there is no convincing scientific data in its favor. Sufficiently detailed criticism of Sellick's reception in Russian.
A group of French researchers attempted to demonstrate the value of the Sellick technique in a fairly large sample of patients. Their results are published in October 2018 in JAMA Surgery. Let's try to figure out what they did:
IRIS - Sellick Interest in Rapid Sequence Induction
The purpose of the study is to test the hypothesis “the incidence of pulmonary aspiration does not increase when there is no pressure on the cricoid cartilage”.
The study was conducted from February 2014 to February 2017 at 10 academic medical centers. The control group used a placebo procedure, simulating pressure on the cricoid cartilage without applying force. To disguise intervention from the doctor, an opaque screen was used to cover the assistant's hands. The study is organized as a noninferiority trial, meaning the researchers are trying to prove that the new intervention (Sellick's rejection) is NOT WORSE than the old one (Sellick's performance).
The study included patients aged 18 years and older who underwent surgery under general anesthesia with rapid sequential induction. The inclusion criteria were quite broad:
- less than 6 hours since the last meal,
- OR at least 1 of the following:
- emergency conditions;
- body mass index over 30;
- transferred intervention on the stomach;
- intestinal obstruction;
- early postpartum period (less than 48 hours);
- diabetic gastroparesis;
- gastroesophageal reflux;
- diaphragmatic hernia;
- preoperative nausea and vomiting;
- pain syndrome.
It should be emphasized here that these are not patients of the emergency department, but of the intensive care unit.
Pregnancy, Sellick contraindications, succinylcholine contraindications, pneumonia, pulmonary contusion, upper airway anomalies, mental disorders, and patients who were considering alternative airway management were excluded from the study.
Anesthesia and intubation were standardized according to French guidelines. Pre-oxygenation was followed by induction with a fast-acting hypnotic (propofol, thiopental, etomidate, or ketamine of choice) and succinylcholine (1 mg/kg). Rocuronium was not approved for use in this study. Intubation was performed in the “sniffing position” (improved Jackson position) using a Macintosh-type metal blade. The position of the tube was confirmed by capnometry. The decision to prescribe opioids was made by the anesthesiologist independently.
The Sellick maneuver was performed by specially trained assistants trained in the 50-ml syringe technique.
To calculate the sample size, the investigators used a predicted aspiration rate of 2.8% based on prior studies. However, this figure turned out to be incorrect, because this frequency of aspiration occurred in a more “emergency” patient population.
Results of the IRIS study
A total of 3472 patients were randomized.
Tab. 1. Distribution of patients into groups. The primary endpoint is pulmonary aspiration:
- in the Sellick group in 10 patients (0.6%);
- in the sham procedure group, 9 patients (0.5%).
Relative risk 0.90; 95% CI, 0.33 - 2.38.
The upper bound of the one-sided 95% confidence interval exceeded the non-worse performance limit set at 1.5. Thus, non-inferiority has not been demonstrated.
The rate of difficult intubation was higher in the Sellick group but did not reach statistical significance. Comparison of the Cormack and Lehane score and the extended intubation time suggests increased difficulty of intubation in the Sellick group.
In the Sellick group, the anesthesiologist more frequently instructed to relieve pressure on the cricoid cartilage, with the Cormack and Lehane score generally improving.
Tab. 2. Comparison of results by groups. The authors of the study conclude that they failed to show “no worse effectiveness” of the sham procedure compared to the Sellick technique, that is, there is no reason to refuse pressure on the cricoid cartilage.
The FOAMed blogs discussed this study and noted that misprediction of pulmonary aspiration rates resulted in a sample size that was too small. The design of the “non-inferior performance” study did not allow for a result that could somehow be interpreted in practice.
Sources
1. James R. Roberts, Catherine B. Custalow, Todd W. Thomsen: Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier, 2019.
2. C. Frerk et al.: Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. BJA: British Journal of Anaesthesia, Volume 115, Issue 6, 1 December 2015, Pages 827–848, https://doi.org/10.1093/bja/aev371
available via link
3. American Heart Association Guidelines for CPR & Emergency Cardiovascular Care available via link
4. Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia. The IRIS Randomized Clinical Trial.
Aurelie Birenbaum, MD; David Hajage, MD, PhD; Sabine Roche, MD; Alexandre Ntouba, MD; Mathilde Eurin, MD; Philippe Cuvillon, MD, PhD; Aurelien Rohn, MD; Vincent Compere, MD, PhD; Dan Benhamou, MD; Matthieu Biais, MD, PhD; Remy Menut, MD; Sabiha Benachi, MD; François Lenfant, MD, PhD; Bruno Riou, MD, PhD
JAMA Surg. doi:10.1001/jamasurg.2018.3577
Published online October 17, 2018
available via link
5. Life in the Fast Lane - Cricoid Pressure available via link
6. E. M. Nerd - The Case of the Inferior Superiority available via link
7.St. Emlyn's blog JC: Cricoid Pressure and RSI, do we still need it? available via link
8. Website of the Volyn hospital - The Sellick maneuver - a ritual or an effective measure? available via link
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SELIC reception, what is it? procedure, indications. and got the best answer
Answer from Vaal[guru]
The Sellick maneuver is used by emergency anesthesiologists during direct laryngoscopy in patients with a "full stomach". The assistant presses down on the cricothyroid cartilage. Thus, it compresses the area of the entrance to the esophagus and prevents the contents of the stomach from entering the oral cavity and trachea. A very simple and effective remedy for the prevention of regurgitation and aspiration pneumonitis.
Answer from 2 answers[guru]
Hello! Here is a selection of topics with answers to your question: SELIC reception, what is it? procedure, indications.
Answer from Azize Reshitova[newbie]
The technique, proposed by Sellick in 1961, is to press the first and second fingers on the thyroid cartilage. Compression of the esophagus between the annulus of the cricoid cartilage and the sixth cervical vertebra prevents passive leakage of stomach contents (this is called regurgitation). Holding the back of the neck with the second hand is an indispensable condition for the effectiveness of this technique.
Used in artificial lung ventilation
Answer from Fanatalex[newbie]
You confused Vladimir with Safar.