Anesthesia and Pediatric Airway Management
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Questions and Answers

What is the percentage of anesthetic deaths in the U.S. attributed to difficult and failed airway management?

  • 3.5%
  • 2.3% (correct)
  • 4.7%
  • 1.5%

    • What is the narrowest portion of the adult airway?

  • Epiglottis
  • Trachea
  • Cricoid cartilage
  • Glottis (correct)

    • Why is it difficult to 'sweep' the tongue out of the way in children?

  • Because the tongue is very large compared to the oral cavity (correct)
  • Because the cricoid cartilage is narrower in children
  • Because the epiglottis is larger and stiffer in children
  • Because the tongue is smaller than the oral cavity

    • What is the age range during which the epiglottis is larger and stiffer in children?

    <p>Until about 2 years of age</p> Signup and view all the answers

    What is the significance of the ROM sign of retraction?

    <p>It is a sign of obstruction</p> Signup and view all the answers

    What is the primary objective of the LMA Fastrach?

    <p>To allow for blind intubation through LMA</p> Signup and view all the answers

    What is the maximum pressure recommended for LMA?

    <p>20 mmH20</p> Signup and view all the answers

    Which of the following is a complication associated with improper placement of LMA?

    <p>All of the above</p> Signup and view all the answers

    What is the size of the LMA mask for a normal adult weighing less than 70 kg?

    <p>Mask size 4</p> Signup and view all the answers

    What is the role of the second lumen in the LMA ProSeal?

    <p>It acts as an esophageal vent</p> Signup and view all the answers

    What is the primary indication for awake fiber optic intubation?

    <p>Anticipated difficult tracheal intubation/ventilation</p> Signup and view all the answers

    What is the purpose of the translaryngeal block?

    <p>It anesthetizes below the cords</p> Signup and view all the answers

    What is the use of the lighted stylet?

    <p>It visualizes the tracheal position through the skin of the neck</p> Signup and view all the answers

    What is the purpose of the bougie?

    <p>It helps in epiglottis-only view (grade 3)</p> Signup and view all the answers

    What is the advantage of the Glidescope?

    <p>It is useful in patients with limited neck extension or anterior airways</p> Signup and view all the answers

    What is the orientation of the probe/image in a long axis view?

    <p>Parallel to the desired structure</p> Signup and view all the answers

    What is the primary goal of hemodynamic monitoring?

    <p>To ensure adequate perfusion for delivery of O2 to tissues</p> Signup and view all the answers

    What is a limitation of noninvasive blood pressure (NIBP) measurement?

    <p>Improper cuff sizing</p> Signup and view all the answers

    What is the Penaz technique used for?

    <p>To analyze waveforms and provide dynamic vital signs</p> Signup and view all the answers

    What is the purpose of hydraulic coupling in the transducer system?

    <p>To create a voltage differential</p> Signup and view all the answers

    What is the effect of overdamping in a transducer system?

    <p>Loss of fine detail and underestimated SBP</p> Signup and view all the answers

    Why is proper leveling of the transducer important?

    <p>To negate the effects of hydrostatic pressure</p> Signup and view all the answers

    What is the conversion factor for 1 inch of height difference in hydrostatic pressure measurement?

    <p>0.74 mmHg</p> Signup and view all the answers

    What is the purpose of documenting blood pressure, heart rate, and respiration in anesthesia care?

    <p>To fulfill AANA standards of practice</p> Signup and view all the answers

    What is the consequence of a pinched phenomenon in a transducer system?

    <p>Loss of fine detail and absent dicrotic notch</p> Signup and view all the answers

    What is the primary advantage of using invasive monitoring in anesthesia care?

    <p>Continuous monitoring of vital signs</p> Signup and view all the answers

    What is the primary indication for performing a surgical cricothyrotomy?

    <p>Cannot intubate, cannot ventilate situation</p> Signup and view all the answers

    What is the advantage of surgical cricothyrotomy compared to tracheotomy?

    <p>The membrane is relatively avascular</p> Signup and view all the answers

    What is the purpose of the pressure valve in percutaneous translaryngeal jet ventilation (PTJV)?

    <p>To allow for passive egress of air</p> Signup and view all the answers

    What is the primary indication for using a double-lumen tube?

    <p>Prevention of damage to the healthy lung</p> Signup and view all the answers

    What is the correct technique for placing a left-sided double-lumen tube?

    <p>Pass the tube through the glottis with the distal curvature facing anteriorly</p> Signup and view all the answers

    What is the confirmation of a properly positioned left-sided double-lumen tube?

    <p>Visualization of the rim of the blue-bronchial cuff through the bronchoscope</p> Signup and view all the answers

    What is the management of a right-sided isolation scenario with a double-lumen tube?

    <p>Clamp the tracheal lumen and close the cap on the bronchial side</p> Signup and view all the answers

    What is a relative contraindication for using a double-lumen tube?

    <p>All of the above</p> Signup and view all the answers

    What is the threshold for expecting a difficult airway based on thyromental distance?

    <p>Less than 3 fingers (&lt; 6.5 cm)</p> Signup and view all the answers

    What is the goal of pre-oxygenation before intubation?

    <p>ETO2 &gt; 90</p> Signup and view all the answers

    What is the recommended angle for the needle during the infraclavicular approach for CVC placement?

    <p>10-15 degrees</p> Signup and view all the answers

    What is the approximate catheter length to the caval-atrial junction for a left SC insertion?

    <p>19 cm</p> Signup and view all the answers

    What is the waveform characteristic of atrial contraction in a CVP waveform?

    <p>A wave</p> Signup and view all the answers

    What is the concern if the catheter tip is too short during CVC placement?

    <p>Increased venous thrombosis risk</p> Signup and view all the answers

    What is the normal range for LVEDP?

    <p>4-12 mmHg</p> Signup and view all the answers

    What is the purpose of the NAVL pneumonic?

    <p>To remember the order of structures in the infraclavicular approach</p> Signup and view all the answers

    What is the significance of the X descent in a CVP waveform?

    <p>Systolic collapse in atrial pressure</p> Signup and view all the answers

    What is the recommended method for estimating catheter length?

    <p>Measuring the distance from the needle insertion point and the third rib</p> Signup and view all the answers

    What is the characteristic of the PA waveform in a PA catheter?

    <p>A diastolic step up from the RV waveform</p> Signup and view all the answers

    What is the purpose of the PAWP?

    <p>To assess LV preload indirectly</p> Signup and view all the answers

    What is the effect of a 10-inch difference in height between the external auditory canal and the blood pressure cuff on the arm?

    <p>MAP at EAC would be 20 mmHg lower than the MAP at the arm</p> Signup and view all the answers

    What is the significance of the damping coefficient in a transducer system?

    <p>It prevents the system from over-responding to changes in pressure</p> Signup and view all the answers

    What is the orientation of the probe/image in a short-axis view?

    <p>The probe/image is perpendicular to the desired structure</p> Signup and view all the answers

    What is the purpose of the Wheatstone bridge in a transducer system?

    <p>It undergoes hydraulic coupling to measure pressure changes</p> Signup and view all the answers

    What is the effect of an underdamped system on the waveform?

    <p>It appears as exaggerated peaks and troughs</p> Signup and view all the answers

    What is the characteristic of the korotkoff sounds used in sphygmomanometry?

    <p>They are created by turbulent flow due to partial collapse of the constricted artery</p> Signup and view all the answers

    What is the purpose of the oscillometry technique in non-invasive blood pressure measurement?

    <p>It measures the pressure fluctuations due to pulsations transmitted to solid-state transducers</p> Signup and view all the answers

    What is the effect of a 1-cm difference in height on the hydrostatic pressure measurement?

    <p>It increases the pressure by 0.74 mmHg</p> Signup and view all the answers

    What is the primary goal of hemodynamic monitoring in anesthesia care?

    <p>To ensure adequate perfusion for delivery of oxygen to tissues</p> Signup and view all the answers

    What is the limitation of non-invasive blood pressure measurement using the oscillometry technique?

    <p>It is affected by the cuff size and placement</p> Signup and view all the answers

    What is the estimated distance from the needle insertion point to the caval-atrial junction for a Right IJ approach?

    <p>16 cm</p> Signup and view all the answers

    Which of the following anatomical locations is associated with the highest risk of venous thrombosis if the catheter tip is too short?

    <p>Azygous vein</p> Signup and view all the answers

    What is the characteristic of the diastolic pressure in the pulmonary artery (PA) waveform?

    <p>Increased pressure during diastole</p> Signup and view all the answers

    What is the primary purpose of the NAVL pneumonic in the infraclavicular approach for CVC placement?

    <p>To preserve the anatomical order of nerves, arteries, veins, and lymphatics</p> Signup and view all the answers

    What is the significance of the X descent in a CVP waveform?

    <p>Systolic collapse in atrial pressure</p> Signup and view all the answers

    What is the estimated distance from the needle insertion point to the caval-atrial junction for a Left SC approach?

    <p>19 cm</p> Signup and view all the answers

    What is the characteristic of the PA waveform in a patient with mitral regurgitation?

    <p>Increased diastolic pressure</p> Signup and view all the answers

    What is the anatomical location of the caval-atrial junction in relation to the thoracic vertebrae?

    <p>At the level of the carina, at thoracic vertebrae 4-5</p> Signup and view all the answers

    What is the primary purpose of the CVP waveform analysis?

    <p>To monitor the right atrial pressure</p> Signup and view all the answers

    What is the significance of the Y descent in a CVP waveform?

    <p>Diastolic collapse in atrial pressure</p> Signup and view all the answers

    Which artery is the primary source of hand blood flow?

    <p>Brachial artery</p> Signup and view all the answers

    What is the characteristic of the arterial pressure waveform in a patient with aortic stenosis?

    <p>Small amplitude and slow-rising systolic upstroke</p> Signup and view all the answers

    Which artery is preferred for arterial cannulation due to its easy access and compressibility in case of arterial puncture?

    <p>Femoral artery</p> Signup and view all the answers

    What is the significance of pulse pressure variation ≥ 13%?

    <p>The patient is likely to benefit from a fluid challenge</p> Signup and view all the answers

    Which vein is the first choice for central venous cannulation?

    <p>Internal jugular vein</p> Signup and view all the answers

    What is the Windkessel model used for?

    <p>To calculate stroke volume</p> Signup and view all the answers

    Which site is preferred for arterial cannulation due to its lack of collateral circulation?

    <p>Brachial artery</p> Signup and view all the answers

    What is the significance of a wide pulse pressure in a patient with aortic regurgitation?

    <p>Pulsus bisferiens</p> Signup and view all the answers

    Which artery has collateral circulation with the PT artery?

    <p>DP artery</p> Signup and view all the answers

    What is the goal of goal-directed fluid therapy?

    <p>To guide individualized patient fluid administration</p> Signup and view all the answers

    Study Notes

    Arterial Monitoring and Blood Pressure Measurement

    • Current gold standard for blood pressure (BP) monitoring includes arterial monitoring.
    • Indications: frequent arterial blood gas (ABG) tests, continuous real-time monitoring during expected rapid changes, failure of non-invasive BP monitoring, intra-aortic balloon pump (IABP) or left ventricular assist device (LVAD) use, deliberately induced hypo/hypertension, major surgeries, long-term vasoactive drug infusions.
    • Seldinger technique is utilized for arterial cannulation.
    • Preferred sites for cannulation include the radial artery (preferred), ulnar artery, brachial artery, axillary artery, and femoral artery.

    Arterial Cannulation Sites

    • Radial Artery: Preferred site with good collateral circulation; potential complications similar to ulnar artery.
    • Ulnar Artery: Primary source of hand blood flow, complications exist, generally safe.
    • Brachial Artery: Lack of collateral circulation increases risks; not often chosen.
    • Femoral Artery: Provides easy access but high potential for hemorrhage; longer catheters are preferred.
    • Dorsalis Pedis Artery: Has collateral circulation from posterior tibial artery; tends to estimate higher systolic pressure.

    Waveform Analysis and Cardiac Function

    • Arterial pressure waveform analysis aids understanding of cardiac function and correlates pressure waves with cardiac cycle phases.
    • Aortic Stenosis: Characterized by reduced stroke volume and a slow rising systolic upstroke on the waveform.
    • Aortic Regurgitation: Results in wide pulse pressure and may present as two systolic peaks (pulsus bisferiens).
    • Pulse pressure variation (PPV) >/= 13% indicates potential fluid responsiveness.

    Central Venous Catheters (CVC)

    • CVC should be inserted on the same side as the pathologic lung; right internal jugular is preferred.
    • Insertion risks: infection, arterial puncture, discomfort.
    • Catheter length estimates vary by site; average lengths include right SC (15 cm), right IJ (16 cm), and femoral (40 cm).

    Hemodynamic Monitoring

    • Goal is to ensure adequate tissue perfusion and oxygen delivery.
    • Measurement techniques include sphygmomanometry (auscultation) and oscillometry (automated).
    • Oscillometry limitations include proper cuff sizing for accurate readings.

    Damping and Calibration

    • Damping affects waveform responsiveness; overdamped systems yield minimal oscillations, while underdamped systems show exaggerated waves.
    • Proper calibration and zeroing are crucial for accurate pressure measurements, accounting for hydrostatic pressure differences based on patient position.

    Arterial Waveform and Catheter Placement

    • Confirmation of central line placement includes visual inspection, blood flow characteristics, and pressure measurement.
    • Abnormal waveforms: understand characteristics of A wave, C wave, X descent, V wave, and Y descent in central venous pressure (CVP) waveforms.

    Airway Management

    • Failed airway management accounts for a significant percentage of anesthetic deaths; non-invasive techniques should be prioritized.
    • Surgical and needle cricothyrotomy are options when traditional intubation fails.
    • Double lumen tubes allow for controlled ventilation distribution, particularly in severe lung disease.

    Difficult Airway Factors

    • Indicators of a difficult airway include thyromental distance < 6.5 cm, mouth opening < 4-5 cm, and BMI > 30 with neck circumference > 40 cm.
    • Pre-oxygenation aims for end-tidal oxygen concentration > 90% or three minutes of 100% O2.

    Additional Notes

    • Use the Windkessel model for understanding arterial behavior during systole and diastole.
    • Dynamic monitoring facilitates individualized patient fluid therapy and replaces traditional methods.### Supraglottic Airways
    • Supraglottic means “above the glottis” or “above the larynx.”
    • Types include LMA Classic, Unique, Fastrach, ProSeal, and Supreme, which feature a mask, airway tube, and inflation line.

    Advantages of Supraglottic Airways

    • Offers hands-free operation and better seal for patients with beards.
    • More manageable for ENT surgery and easier maintenance of airway compared to facemask.
    • Minimizes facial nerve/eye trauma and operating room pollution.

    Disadvantages of Supraglottic Airways

    • Considered more invasive with an increased risk of airway trauma.
    • Requires additional skills, deeper anesthesia, and some TMJ mobility.
    • Risks include N2O diffusion into the cuff and multiple contraindications.

    Comparison with Endotracheal Tube (ETT)

    • Advantages: Less invasive, suitable for difficult intubations, lower likelihood of tooth/laryngeal trauma, reduced laryngospasm/bronchospasm, and no need for muscle relaxation or neck mobility.
    • Disadvantages: Higher risk of gastric aspiration, less secure airway, limited maximum positive pressure ventilation (PPV), and potential for gastric distention.

    Contraindications of LMA

    • Absolute: Unable to open mouth or complete upper airway obstruction in all settings.
    • Relative: Increased aspiration risk, prolonged bag-valve-mask ventilation, morbid obesity, second or third trimester pregnancy, full stomach, upper GI bleed, abnormalities in supraglottic anatomy, and need for high airway pressures (should be ≤20 mmH2O).

    LMA Size Selection

    • LMA Classic: Size 4 for adults <70 kg; Size 5 for adults >70 kg, both with a cuff volume up to 30 mL.

    LMA Variants

    • LMA Fastrach: Designed for blind intubation with an anatomically curved tube that aids in ETT insertion.
    • LMA ProSeal: Features a second lumen for esophageal venting, providing some aspiration protection if optimally seated.
    • LMA Supreme: Single-use design includes a gastric port/tube that minimizes gastric insufflation but offers no aspiration guarantee.

    LMA Insertion Technique

    • Deflate the cuff and insert while advancing along the palate and posterior pharyngeal wall until resistance is met; then inflate the cuff.

    Complications Associated with LMA

    • Risks include aspiration of gastric contents, local irritation, airway trauma, pressure-induced lesions, and mild sympathetic responses.
    • Improper placement may lead to obstruction, laryngospasm, or bronchoconstriction.

    Advanced Airway Management

    • Fiberoptic Intubation: Used for anticipated difficult tracheal intubation, confirm ETT position, and evaluate airway swelling or trauma.
    • Translaryngeal Block: Anesthetizes below the cords using a small catheter and lidocaine.

    Monitoring and Hemodynamic Assessment

    • Goal is to ensure adequate perfusion for oxygen delivery; blood pressure measurement has poor correlation with tissue oxygenation.
    • Monitor HR and cardiovascular status, with noninvasive blood pressure measurements using sphygmomanometry and oscillometry.

    Central Venous Catheter (CVC) Placement

    • Average catheter lengths to caval-atrial junction vary by insertion site (Right SC: 15 cm; Left IJ: 21 cm; etc.).
    • CVC tip should be positioned properly to avoid complications like thrombosis or arrhythmias.

    Pressure Waveforms and Catheter Placement Confirmation

    • Confirm placement through color of aspirated blood, pressure measurements, and imaging (e.g., chest x-ray).
    • Right atrial, right ventricular, and pulmonary artery pressures change as the catheter is advanced through the heart.

    Waveform Abnormalities and Interpretation

    • A wave corresponds with atrial contraction; C wave indicates tricuspid closure; V wave reflects filling of the atrium.
    • PAWP provides assessment of left ventricular preload with normal values ranging from 4-12 mmHg.

    Summary of Key Concepts

    • Understanding the proper use, insertion techniques, and potential complications of supraglottic airways and advanced airway management techniques is critical in anesthetic practice.
    • Continuous hemodynamic monitoring aids in assessing tissue perfusion and responding to physiological changes during procedures involving airway management.

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    Related Documents

    Essentials Final.docx

    Description

    Learn about the unique challenges of managing pediatric airways, including congenital disorders that increase difficulty. Understand the importance of a comprehensive history and physical examination in identifying potential airway problems. Discover the anatomical differences in pediatric airways, such as a larger and stiffer epiglottis and a relatively large tongue.

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