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 intubationLaryngoscopysucceedTracheal intubationfailed intubationSTOP AND THINKAssess risks and benefits of:awakening the patient and postponing surgerytracheal intubation through the supraglottic airway deviceproceeding without intubating the tracheaPlan B:Airway management using SAD, maintenance of oxygenation and reviewsucceedSupraglottic Airway Devicefailed oxygenationPlan C:Attemptoxygenation, & ventilationsucceedRevert to face mask ventilationPostpone surgeryAwaken patientCICOPlan D:Rescue techniquesfor "can't intubate,can't ventilate” situationCricothyroidotomy*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 helpDRAFTPlan A: Facemask ventilation & tracheal intubationOptimise head and neck positionPreoxygenateAdequate neuromuscular blockadeDirect / Video Laryngoscopy (no more than 4 attempts in total)External laryngeal manipulation (BURP)BougieRemove cricoid pressureMaintain oxygenation and anaesthesia2015SucceedVerify tracheal intubation with capnographyFailed intubationPlan B: SAD InsertionSTOP AND THINKAssess risks and benefits of:awakening the patient and postponing surgerytracheal intubation through the supraglottic airway deviceproceeding without intubating the tracheaInsert Supraglottic Airway DeviceNo more than 4 attempts in total2nd generation device preferredOxygenate and ventilateSucceedFailPlan C: Maintain oyxgenationBasic structureShould plan c be revert to face mask ventilationWould like to see the phrase ENSURE PARALYSis in the dotted line crossing over to DManagement of unanticipated…Yes I think if in doubt take it out just looks wrongFailed intubationAnd again in this one even tho the title says paralysed…How many goes at SAD insertion were we going to allow4 seems like a lot of faffing about timeDo 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 thinkingAlso 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 difficultAnd 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-oxygenatingRevert to facemask ventilationUse 2 person technique +/- adjunctsReview neuromuscular blockadeSucceedPostpone surgeryAwaken patientFailed OxygenationPlan D: Emergency Front of Neck AccessSurgical Cricothyroidotomy(alternative techniques only if skilled)SucceedPlan for post-operative care
4 Failed intubation, failed oxygenation in the paralysed, anaesthetised patient. DRAFT2015Ensure help is comingPlan D: Emergency Front of Neck AccessSurgical cricothyroidotomyLaryngeal handshakeVertical skin incisionLocate Cricothyroid membraneHorizontal incision through Cricothyroid membraneTurn blade through 900Slide Bougie along blade into tracheaRemove bladeRailroad tubeInflate cuffVentilateVerify with capnographyExclude endobronchial intubationSecureEquipment:1. Scalpel (no 10 or 20 blade)2. Bougie3. 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 recognisedExpanded section around new techniques for preoxygenation and maintenance of oxygenation (including nasal O2)Videolaryngoscopy is explicitly includedLess 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 recommendedHuman Factors is considered overtlyThe degree of Neuromuscular blockade should be actively reviewed when intubation failsEmphasis on standardisation and training for plan DSurgical cric as default (Scalpel bougie tube)Cannula techniques an alternative if anaesthetist is trained and skilled in the particular techniqueCannula cric with high pressure ventilation reserved for experts only
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