Preparation Patient For Conscious Sedation

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Preparation Patient For Conscious Sedation

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بسم الله الرحمن الرحيم ((اللهم اشرح لي صدري ويسر لي امري واحلل عقدة من لساني يفقهوا قولي)) Dr Rami Adel Alqudsi CONSULTANT OF ANESTHESIOLOGY (KKGH) MD JORDAN BOARD IN ANESTHESIOLOGY P reparation Patient F or Conscious Sedation

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Definition   conscious sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation.

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THE GOAL The goals of conscious sedation are to provide : 1-analgesia 2-amnesia 3-sedation 4-protect the airway and adequate spontaneous ventilation 5-keep cardiovascular system within normal range

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Summary  Safe conscious sedation can provide by following situation : 1.Fit patient selection 2.Adequate preoperative assessment 3.Adequate preparation 4.(Familiarity with Ready & Functioning Equipment & Medications) 5.Functional monitoring 6.Adequate IV access 7.Experienced personnel ( D octor and Nurse) 8.Recovery room( staff -monitoring-discharge criteria )

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Contraindication 1. Non fasting patient 2. Physical class III –IV or greater 3. Lack of support staff, drugs, monitoring or equipment 4. Lack of experience/ approved on part of clinician 5. Patient not ready ,no consent

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Conscious Sedation in the hospital has policies and guidelines approved by : 1- The Head of Anesthesia 2- The nurse manager 3- The appropriate department heads

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Physicians   who perform conscious  sedation are certified as appropriate in BCLS, ACLS,PALS, NALS .  And have privileges granted to perform conscious sedation

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Nurses who assist with sedation/analgesia are certified in BCLS, ACLS or PALS , NALS according to the age of the patient .

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Conscious sedation is performed only in areas identified in policy and the following equipment is available to provide safe care An oxygen source Airways and Bag mask ventilation Laryngoscopes (direct and video) Several endotracheal tubes of different sizes Suction ,tape Oximetry AND Capnography Stethoscopes All equipment for DIFFICULT AIRWAY or INTUBAIONT…!? Blood pressure and electrocardiography (ECG) monitors Intravenous access with all anesthetic medication Crash cart with defibrillator

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The contents of a crash cart vary from hospital to hospital, but typically contain the tools and drugs needed to treat a person in or near cardiac arrest. These include : Monitor / defibrillators, suction , bag valve masks (BVMs) of different sizes Advanced cardiac life support (ACLS) drugs such as epinephrine, atropine, amiodarone, lidocaine, sodium bicarbonate, dopamine, and vasopressin First line drugs for treatment of common problems such as: adenosine, dextrose, diazepam or midazolam, epinephrine for IM use, naloxone, nitroglycerin, and others Drugs for rapid sequence intubation:  succinylcholine , rocuronium or another paralytic, and a sedative such as etomidate or midazolam; endotracheal tubes and other intubating equipment Drugs for peripheral and central venous access· Pediatric equipment (common pediatric drugs, intubation equipment, etc.) Other drugs and equipment as chosen by the facility

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crash cart

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Medications using in conscious sedation : Diazepam = Valium Flumazinil = Romazicon Lorazepam = Ativan Midazolam = Versed Naloxone = Narcan Propofol = Diprivan Sodium Thiopental ketamin Fentanyl P ethidine

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Pulse Oximetry and capnography Pulse Oximetry : Measures of spo2 95 % - 100% Normal 90 % - 95% - Mild – Normal for COPD < 90 % - low – Need Oxygen Capnography : USED IN VERIFICATION OF ETT PLACEMENT

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Different sizes of nasal airway

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Different sizes of the oral airway

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Different sizes of the ambu bag

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The anatomy of the mouth and throat can vary significantly from person to person. Different sizes of the face mask (transparent)

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The anatomy of the mouth and throat can vary significantly from person to person. Different sizes of the face mask (black rubber)

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Grade I- Mask ventilated easily Grade II- Mask ventilated with ( oral airway or nasal airway) Grade III- Difficult to mask ventilate even with airways Grade IV- Unable to mask ventilate Note : 8 min of hypoxia may be causes irreversible brain damage

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Different sizes of the LMA

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Macintosh blade Miller blade Wisconsin blade The anatomy of the mouth and throat can vary significantly from person to person.

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Different sizes of the ENDOTRACHEAL TUBE (ETT)

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IN MRI All equipments should be MRI Compatible EG.MRI Compatible Laryngoscope Handle and blade

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POSITIONING When cervical spine pathology is suspected, the head must be kept in a neutral position during all airway manipulations . BAG AND MASK VENTILATION Bag and mask ventilation (BMV) is the first step in airway management BUT In rapid sequence inductions avoid BMV or positive pressure ventilation to avoid stomach inflation and to reduce incidence of aspiration .

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Orotracheal Intubation NOTE: After tube insertion Do bilateral chest auscultation

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AIRWAY MANAGEMENT Airway management associated with conscious sedation consists of : • Airway assessment • Preparation and equipment check • Patient position • Preoxygenation • Bag and mask ventilation (BMV) (if indicated ) • Intubation (if indicated) • Confirmation of endotracheal tube placement • Intra procedure management • Extubation

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Clinical Significance of Conscious Sedation Airway assessment is a critical tool before sedation ,anesthesia and intubation. conscious sedation may be associated with depression of airway reflexes and ventilation , so pre‐sedation history and airway assessment are critical to the delivery of safe sedation . .

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ASSESSMENT OF THE AIRWAY : Pre Procedure: Consent Explanation of the risks, benefits, and alternatives to sedation must be provided to patient. Airway assessment is the first step in successful airway management . Several anatomical and functional investigation can be performed to estimate the difficulty of ( conscious sedation or endotracheal intubation ((IF INDICATED)) ) However, it is important to note that successful ventilation (with or without intubation) must be achieved by ANESTHESIA DOCTOR …..

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ASSESSMENT OF THE AIRWAY : I . History : Medical, surgical or anaesthetic factors may be indicative of a difficult airway (DA). II . General, physical and regional examination : include the following: look for masses inside nasal cavity Mouth opening iii. Teeth : Prominent upper incisors. Palate : A high arched palate, narrow mouth may present difficulty. vi . Temporo -mandibular joint movement : It can be restricted ankylosis , fibrosis , tumors…

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vii. Measurement of submental space ( hyomental / thyromental length should be > 6 cm). viii. Observation of patient’s neck : A short, thick neck is often associated with difficult intubation.. ix. Presence of hoarse voice/stridor or previous tracheostomy may suggest stenosis . x. Any systemic or congenital disease requiring special attention during airway management (e.g. respiratory failure, significant coronary artery disease, acromegaly,allergy …). xi. General assessment of body habitus can give important information. xii. Infections of airway (e.g. epiglottitis, abscess, croup, bronchitis, pneumonia ). NOTE : ASA classification 1‐3 are eligible for moderate/deep sedation American Society of Anesthesiologists (ASA) :

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Pre Procedure Fasting 1- infants are feed breast milk up to 4 h 2- formula or liquids and a “light” meal up to 6 h 3- Clear fluids 2–3 h before sedation 4- adult up to 6 h before sedation NOTE These recommendations are for healthy neonates, infants, children and adult without risk factors for decreased gastric emptying or aspiration

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Thyromental distance : the distance between The mentum and the superior thyroid notch. A distance greater than 3 fingerbreadths is normal Sterno-mental distance : the distance from the suprasternal notch to the mentum If less than 12 cm suspected difficult airway and intubation . Neck circumference : a neck circumference of greater than 27 in is suggestive of difficult airway and intubation .

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A-O Extension ( Atlanto -Occipital)

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A-O Extension ( Atlanto -Occipital)

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Evaluate the 3-3-2 rule : Mouth opening 3 fingerS H yiod - chin distance 3 fingerS Thyroid cartilage – mouth floor distance 2 fingerS

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Mallampati classification : Difficult airway and intubation may be in class (III),( IV) ■ Class I :all are visible : tonsills,uvula,soft and hard palates ■ Class II : the upper part of the Tonsills and upper part of uvula and soft and hard palates are visible . ■ Class III : only the soft and hard palates are visible. ■ Class IV : only the hard palate is visible . Test is performed with the patient in the sitting position, head in a neutral position, the mouth wide open and the tongue protruding to its maximum

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GRADE IV GRADE III GRADE II GRADE I Mallampati classification

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Breathing Sounds Normal Wheezes Cripetation Stridor Listen on every patient End of Expiration End of Inspiration During both phases ( inspiration , expiration )

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Normal Respiratory Rates Adult Children Infants Newborns 12 – 20 / min 18 – 24 / min 22 – 36 / min 40 – 60 / min

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Factors Affecting Respiratory Rate Sleep High co2 tension Insufficient Oxygen !!! Depressant medication Fever Anxiety Stimulant medication Stress … Respiratory Rate

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Respiratory Diseases COPD Asthma Pneumonia Pulmonary Edema Pulmonary Embolus Trauma Morbid obesity : my be causes of respiratory impairment

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Condition associated with difficult airway C-spine immobilized trauma patient Protruding tongue Short, thick neck Prominent upper incisors (“buckteeth”) Receding mandible High, arched palate Beard or facial hair Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or obstruction Morbid obese pt.

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Joint disease Acromegaly Thyroid or major neck surgeries Airway Tumors Epiglottitis Previous problems in surgery Diabetes Pregnancy Obesity Condition associated with difficult airway

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Morbid OBESITY Morbid obesity and body mass index (BMI) of 26 or greater my be suspected difficult airway or intubation . NOTE: Not only may these patients prove to be difficult intubation, but routine ventilation with bag and mask also may be problematic . Note : 8 min of hypoxia may be causes irreversible brain damage

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. Difficult mask ventilation describes the situation in which it may be difficult or impossible to oxygenate and ventilate a patient It is not possible for the unassisted anesthesiologist to maintain SPO2>90% using 100% O2 and positive pressure mask ventilation in a patient whose SPO2 was > 90% before anesthetic intervention using a bag mask technique by experienced and skilled doctor . Difficult tracheal intubation describes a situation in which it may be difficult or impossible to correctly place an endotracheal tube by experienced and skilled doctor .

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Signs and Symptoms of Airway Obstruction : Increased Respiratory Effort Sternal Retractions Inspiratory Stridor Hypoxemia Hypercarbia Absence or Diminished Breath Sounds

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Here we have some pictures for patients with difficult airways ,in these situations should not be do conscious sedation without attendance of high qualified A nesthesia D octor

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submandibular mass

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submandibular mass

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Burn patient

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Down’s syndrome Poorly developed or absent bridge of the nose , macroglossia

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Goldenhar’s syndrome Auricular and ocular defects, malar and mandibular hypoplasia

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Kippel-Feil syndrome Congenital fusion of a variable number of cervical vertebrae, restriction of neck movement

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Treacher -Collins syndrome Auricular and ocular defects, malar and mandibular hypoplasia

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Pierre-Robin syndrome Micrognathia , macroglossia , cleft soft palate

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PREPARATION FOR DIFFICULT AIRWAYS SOME EQUIPMENTS USED IN DIFFICULT AIRWAY OR INTUBATION

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Different sizes of BOUGIE

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Different sizes of STYLET

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COMBITUBE The Combitube is usually inserted blindly through the mouth The Combitube has two inflatable cuffs , a 100-mL proximal cuff and a 15-mL distal cuff , both of which should be fully inflated after placement

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McCoy blade

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C-MAC® Flexible Intubation Video Scopes

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BONFILS Optical Stylet

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C-MAC®  Pocket Monitor

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FIBEROPTIC BRONCHOSCOPE

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Proseal LMA

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King Laryngeal Tube

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Glidescope

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Glidescope

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INTUBATING LARYNGEAL MASK AIRWAY

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Intubating laryngeal mask airway (LMA C trach)

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Res-Q-Scope

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THANK YOU Dr Rami Adel Alqudsi CONSULTANT OF ANESTHESIOLOGY (KKGH) MD JORDAN BOARD IN ANESTHESIOLOGY

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