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DAS Guidelines update April 2015

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

3 DRAFT Any problems call for help 2015 Basic structure
Management of unanticipated difficult tracheal intubation-during induction of anaesthesia in an adult patient (includes RSI) Any problems call for help DRAFT 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 2015 Succeed Verify tracheal intubation with capnography Failed intubation Plan B: SAD Insertion STOP AND THINK Assess risks and benefits of: awakening the patient and postponing surgery tracheal intubation through the supraglottic airway device proceeding without intubating the trachea Insert Supraglottic Airway Device No more than 4 attempts in total 2nd generation device preferred Oxygenate and ventilate Succeed Fail Plan C: Maintain oyxgenation Basic structure Should plan c be revert to face mask ventilation Would like to see the phrase ENSURE PARALYSis in the dotted line crossing over to D Management of unanticipated… Yes I think if in doubt take it out just looks wrong Failed intubation And again in this one even tho the title says paralysed… How many goes at SAD insertion were we going to allow 4 seems like a lot of faffing about time Do we need a (including RSI) bracket at the end pof the basic algo- I know its stating the obvious but I can be remarkably stupid and it is one of the biggest changes in thinking Also given that the guidelines are going to be the things on display in the anaesthetic room that people look at in a crisis should it say release cricoid pressure if difficult And should Laryngoscopy be Primary Laryngoscopy or in bold or something to show that it’s a title otherwise it looks like a list where laryngoscopy comes before optimising head position and pre-oxygenating Revert to facemask ventilation Use 2 person technique +/- adjuncts Review neuromuscular blockade Succeed Postpone surgery Awaken patient Failed Oxygenation Plan D: Emergency Front of Neck Access Surgical Cricothyroidotomy (alternative techniques only if skilled) Succeed Plan for post-operative care

4 Failed intubation, failed oxygenation in the paralysed, anaesthetised patient.
DRAFT 2015 Ensure help is coming Plan D: Emergency Front of Neck Access Surgical cricothyroidotomy Laryngeal handshake Vertical skin incision Locate Cricothyroid membrane Horizontal incision through Cricothyroid membrane Turn blade through 900 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) Cannula cricothyroidotomy (only if skilled) Fail

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 2nd 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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