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DAS Guidelines update April 2015 In this presentation are 3 draft algorithms and highlights of things that are new or considered particularly important.

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Presentation on theme: "DAS Guidelines update April 2015 In this presentation are 3 draft algorithms and highlights of things that are new or considered particularly important."— Presentation transcript:

1 DAS Guidelines update April 2015 In this presentation are 3 draft algorithms and highlights of things that are new or considered particularly important emerging as themes in the new guidelines. Any / all comments would be welcomed by the Guidelines group by to

2 Plan A: Mask ventilation and tracheal intubation failed intubation succeed Laryngoscopy Tracheal intubation Plan B: Airway management using SAD, maintenance of oxygenation and review Supraglottic Airway Device succeed Plan C: Attempt oxygenation, & ventilation Revert to face mask ventilation Plan D: Rescue techniques for "can't intubate, can't ventilate” situation Cricothyroidotomy failed oxygenation STOP AND THINK Assess risks and benefits of: a.awakening the patient and postponing surgery b.tracheal intubation through the supraglottic airway device c.proceeding without intubating the trachea CICO Postpone surgery Awaken patient succeed 2015 Basic Structure of DAS Guidelines flow chart* *Includes RSI DRAFT

3 Management of unanticipated difficult tracheal intubation-during induction of anaesthesia in an adult patient (includes RSI) Any problems call for help Plan A: Facemask ventilation & tracheal intubation Optimise head and neck position Preoxygenate Adequate neuromuscular blockade Direct / Video Laryngoscopy (no more than 4 attempts in total) External laryngeal manipulation (BURP) Bougie Remove cricoid pressure Maintain oxygenation and anaesthesia Succeed Failed intubation Plan B: SAD Insertion Insert Supraglottic Airway Device No more than 4 attempts in total 2 nd generation device preferred Oxygenate and ventilate Surgical Cricothyroidotomy (alternative techniques only if skilled) Plan D: Emergency Front of Neck Access Plan C: Maintain oyxgenation Fail Succeed Failed Oxygenation Postpone surgery Awaken patient Verify tracheal intubation with capnography STOP AND THINK Assess risks and benefits of: a.awakening the patient and postponing surgery b.tracheal intubation through the supraglottic airway device c.proceeding without intubating the trachea Revert to facemask ventilation Use 2 person technique +/- adjuncts Review neuromuscular blockade 2015 Succeed Plan for post-operative care DRAFT

4 Failed intubation, failed oxygenation in the paralysed, anaesthetised patient. Cannula cricothyroidotomy (only if skilled) Plan D: Emergency Front of Neck Access 2015 Surgical cricothyroidotomy Laryngeal handshake Vertical skin incision Locate Cricothyroid membrane Horizontal incision through Cricothyroid membrane Turn blade through 90 0 Slide Bougie along blade into trachea Remove blade Railroad tube Inflate cuff Ventilate Verify with capnography Exclude endobronchial intubation Secure Equipment: 1. Scalpel (no 10 or 20 blade) 2. Bougie 3. Tube (cuffed 6mm ID) Fail Ensure help is coming DRAFT

5 Highlights Importance of planning to reduce risk is emphasised Importance of “anaesthesia team” is recognised Expanded section around new techniques for preoxygenation and maintenance of oxygenation (including nasal O2) Videolaryngoscopy is explicitly included Less distinction between RSI and elective induction with facemask ventilation included in both (maintenance facemask ventilation is supported during RSI) Cricoid pressure should be removed if laryngoscopy & intubation difficult (and remain off for insertion of SAD in plan B) Plan B focuses on oxygenation using SAD (with less emphasis on intubation through SAD though this remains an option)

6 Highlights 2 nd generation SADs are preferred ILMA no longer explicitly recommended Human Factors is considered overtly The degree of Neuromuscular blockade should be actively reviewed when intubation fails Emphasis on standardisation and training for plan D Surgical cric as default (Scalpel bougie tube) Cannula techniques an alternative if anaesthetist is trained and skilled in the particular technique Cannula cric with high pressure ventilation reserved for experts only


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