The other day, a patient asked me: why is it necessary to repeat the regular vaccination for "Hepatitis B"? She said it was a pain in the ass.
I briefly explained to her:
Preventive vaccination: In the healthy population before the occurrence of infectious diseases, in order to prevent the occurrence of a certain infectious disease and epidemic, regular and systematic immunization of healthy people.
Theory of vaccination:
To give warning of an offense.
Give a feeble attack.
Inspire a strong defense.
After thinking about it, I realized that the inoculation theory of anesthesia can also be applied to prevent difficult or critical situations. From time to time, some "small difficulties", as "vaccination", can increase the individual and the organization of the "difficult or critical events" immunity and ability to fight.
It is wise to summarize our past experiences and lessons learned in order to prevent future risks in our work.
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900 Questions for Anesthesiologists
Dangdang
Today's Difficult Airway case we'd like to share with you:
Patient, female, 55kg, 163cm. Female, 55kg, 163cm, to be performed under static suction compound anesthesia "waist abdomen, double thighs liposuction". Routine preoperative examination showed no abnormalities.
Airway assessment: mouth opening two transverse fingers (predicted 3 cm); good head and neck mobility; laryngeal nodes appeared to be high; nail-chin distance three transverse fingers (predicted 5 cm); and, although there was no obvious small chin, he had undergone "chin augmentation" surgery and had a relatively large hypertrophied tongue.Mallanpati test: grade III.
Mallanpati test:
Grade 1 shows the pharyngeal isthmus, soft palate and uvula;
Grade 2 shows only the soft palate and uvula;
Grade 3 shows only the soft palate;
Grade 4 shows only the hard palate.
Preoperatively, the patient is informed of the "difficult intubation" situation, which requires appropriate cooperation in the awake "surface anesthesia" to probe the vocal folds, and if the intubation fails, the procedure is completed with intrathecal anesthesia.
For this difficult airway, I prepared the following preoperatively: different types of endotracheal tubes, laryngeal masks, plain laryngoscopes, visual laryngoscopes, and light rods. Of course, the laryngeal mask is certainly not suitable for the position change situation of this surgery, but it is one of the ways to deal with the difficult airway.
Admission: blood pressure 100/60 mmHg, sinus rhythm 70 beats per minute, oxygen saturation 95%, in the standing position for sterilization of the surgical area and then lying flat on the surgical bed.
Mask high-flow oxygen was administered for 5 minutes;
The following medications were administered during the oxygenation period:
Surface anesthesia was administered by spraying 1% lidocaine in the oropharynx, posterior pharyngeal wall, epiglottis, and vocal folds on two separate occasions.
Imidazole 1 mg was pushed static;
Sufen 20 micrograms was pushed in four times;
First attempt:
The patient was not asleep, and was asked to open his mouth widely, and a visual laryngoscope was placed in preparation for peeping at the vocal folds; the patient was able to tolerate the stimulation when it was placed into the mouth but was ready to continue to approach the direction of the epiglottis or to lift the laryngoscope. When the laryngoscope was placed in the mouth, the patient was able to tolerate the stimulus, but when he was ready to continue to approach the epiglottis or to lift the laryngoscope upward, the patient was unable to tolerate the stimulus, and the peeping failed.
? Second attempt:
Consider the possibility of an emergent difficult airway (i.e., simultaneous difficulty with mask ventilation and difficulty with intubation).
Continue high-flow mask oxygen and assisted ventilation ......
After the first attempt, sympathetic arousal resulted in increased oral secretions, and atropine 0.3 mg was administered IV.
Propofol 50 mg IV was given to test for tongue thrust and difficulty with mask ventilation?
If there is difficulty with mask ventilation, decisively discontinue further medications or make an immediate intubation attempt.
Clearly, in this case, the patient was well ventilated by mask, and after the patient's consciousness and respiration had disappeared, visual laryngoscopy was performed to peek at the glottis, but the glottic margins and epiglottic valleys could not be visualized, and the laryngoscopic exposure was graded at grade IV. The peeping maneuver lasted roughly 1 to 2 minutes, during which time the blood pressure and heart rate rose slightly.
Laryngoscopic exposure grading:
This grading describes the laryngeal structures that can be visualized under laryngoscopic exposure and classifies them into four grades:
Grade I completely reveals the glottis;
Grade II visualizes the arytenoid cartilage (the posterior wall of the glottal inlet and posterior portion of the glottis);
Grade III visualizes the epiglottis only;
Grade IV does not see the epiglottis.
Third attempt:
Continued high-flow mask oxygen, positive-pressure ventilation ......
Pray tell:
If you think about it differently, the third attempt fails again! What should you do?
Omit the follow-up.
Timing of extubation: the patient is fully conscious.
Due to the limited capacity and equipment, some of the methods and medications used in this case, although there are deficiencies or differences, but I still want to give the majority of grass-roots anesthesiologists a few suggestions:
1. The patient is often rarely killed by "failure of intubation" and "failure of ventilation"; The patient is not only a patient of the hospital, but also a patient of the hospital. Failure of intubation"; Always be alert to the emergence of "acute difficult airway". Anesthesiologists' nightmare ...... " 2. It is important to make the necessary assessments and preparations in advance for a difficult airway! Don't be unprepared. 3. Whenever possible, seek any help you can get. 4. Repeated attempts at tracheal intubation are contraindicated to avoid unnecessary tissue loss, bleeding, and peripheral edema, which can make an already difficult problem even more severe. 5. It is best to try a particular method of intubation, whoever it may be, only once, and if it fails, switch to a different principle of intubation if possible. 6. For "difficult airway", more tools, more hope for success. Without the right tools, no one is likely to be able to do it. 7. Some details are really important: for example, surface anesthesia can be done more carefully and patiently, perhaps the effect of surface anesthesia will be better; another example, give atropine in advance to make the oropharynx drier, perhaps the effect of surface anesthesia will be better... 8. Appropriate understanding and learning of the "blind intubation through the nose" is also one of the ways to solve the difficult airway. 9. Prepare for the management of an acute difficult airway, such as emergency cricothyrotomy needles or other equipment, and the necessary preparations for a rapid tracheotomy. (But to ensure effective connection with the respiratory circuit.) I personally make a simple cricothyroid puncture needle (first picture), theoretically can do the effect of immediate ventilation after puncture (have not practiced, just for reference), of course, only suitable for a short period of time, to establish a more effective and more stable airway to buy time. (Second image) A foreign disposable rapid cricothyrotomy device seen online. 10. Before you give anesthetic drugs, any decision you make, there can be room for communication and negotiation. If the existing conditions are not conducive to "medical safety," don't get hung up on it! Wait until the patient is stable, then return to the hospital room, and then schedule the surgery if you have the manpower and equipment to do so. ...... It's like the following book, which I don't know if you've read? Most of the time, it's not the "technical skills" that make the difference between success and failure. Advertisement Non-Technical Skills for Anesthesiologists Dangdang To summarize: The patient's "medical treatment" is used to satisfy his or her "medical needs".
Summary:
Patients use "medical" means to satisfy their own "desire for beauty" ;?
The surgeon achieves the vision of an "aesthetic" result through "technical" means;
The anesthesiologist achieves the vision of an "aesthetic" result through "management" and "skill";
The anesthesiologist achieves the vision of an "aesthetic" result through "management" and "skill"; and The anesthesiologist uses "management" and "skills" to achieve the goal of medical safety.
......?
We can only use reflexive thinking to go beyond what is expressed above, and compare more "methods and tools" with "crisis awareness", which I personally believe is more important than the former.
Only remind yourself: Even if you think that a very common surgical anesthesia, there may be very unexpected situations; therefore, we have to treat each case of surgical anesthesia with care.
The essence of medicine is: safety.
Of course, everyone's attitudes and perceptions of medical safety are very different.
In my case, I was lucky.
For "lucky", I found a few words to share with you:
Luck is always supported by your own efforts. But when you let yourself down, luck slips away. -- Roland
Luck is an accessory to effort.
You can't catch luck even if it's given to you without a primitive accumulation of strength.
The sky gives everyone the same, but everyone's preparation is not the same.
Don't envy those who always get lucky, you have to work very hard to meet the good luck.
Don't envy those who always get lucky.