procedures
topics
basic procedures
- airway procedures
- oral endotracheal intubation
- nasotracheal intubation
- supraglottic airway insertion
- catheterization procedures
- peripheral intravenous line
- arterial line
- central venous line
regional procedures
- upper extremity blocks
- supraclavicular brachial plexus block
- thoracic and abdominal blocks
- quadratus lumborum nerve block
- lower extremity blocks
- adductor canal block
- femoral nerve block
- obturator block
- intravenous regional anesthesia
- bier block
- neuraxial procedures
- spinal
- epidural
basic procedures
airway
Nasotracheal intubation
- Answer. Why? Answer. How? Answer.
- Nasal RAE
- McGill forceps
- Mac blade (DL is easier than VL)
- Afrin nasal spray
- Lubrication jelly
- Warm saline (alternatively, warm blankets with Bair hugger)
- +/- Nasal trumpets
Room setup? (6 required and 1 optional components)
catheterization
Peripheral intravenous lines.
- Answer. Why? Answer. How? Answer.
- Sub-Answer
- Resources
Sub-Question
Arterial line. Indications? (2)
- "Arterial lines are often used to "monitor blood pressure directly and in real-time and to obtain samples for arterial blood gas analysis." (Wikipedia)
- Arterial line kit (radial or femoral)
- Pressure transducer
- (Spare) 20G catheter with introducer needle
- (Spare) PVC extension with stopcock
- Position forearm in supination and wrist in dorsiflexion (secure with tape)
- Palpate radial artery (+/- ultrasound visualization)
- Setup arterial line kit with sterile technique
- Open arterial line kit
- Turn on ultrasound
- With sterility, drop ultrasound sterile cover
- With sterility, drop PVC extension with stopcock
- With sterility, put on procedure gloves
- Setup ultrasound (maybe do this on myself in the morning)
- Probe: Linear array probe (e.g. hockey stick)
- Gain: Reduce until you can just barely see vessel to maximize needle visibility
- Depth: Reduce depth to shallow
- Laterality: Lift or tap under probe for left-to-right orientation
- M-Mode: On
- Catheterization technique
- Ultrasound-guided catheterization approach
- 1. Confirmation of artery (pulsatile, incompressible flow)
- 2. Before inserting needle, use acoustic shadowing to center needle
- 3. Insert needle at a 30-45 degree angle ~1cm in front of linear array transducer
- 4. Once bevel appears on US screen, slide away with linear array transducer until bevel disappears
- 5. Advance needle until bevel appears again on US screen (repeat until artery cannulation)
- 6. Once bevel is in the center of the artery, flatten needle angle to below 30 degrees
- 7. Slide away with linear array transducer until bevel disappears followed by advancing needle until it reappears (2-4x)
- Techniques: Catheter over needle technique, catheter over wire technique (Seldinger technique), transfixation "through-and-through" technique
- Arterial line calibration (Deranged Physiology)
- Resources
Room setup? (2 required and 2 spare components)
Radial artery catheterization steps? (? steps)
- resources: rk.md
- resources: apsf, wikem, annemergmed
regional procedures
upper extremity peripheral nerve blocks
Supraclavicular.
- Answer. Why? Answer. How? Answer.
- Block cart code: 1234-enter
- Medication: Midazolam (*NO sedation before timeout)
- Medication: 20mL 0.2% ropivicaine or 0.25% ropivicaine (10cc 0.5% ropivicaine + 10cc IVF)
- Medication: 5mcg epinephrine per 1mL ropivicaine (~ 100mcg epi in 20mL)
- Method: 0.1mL of 1mg/mL epinephrine into 20mL 0.25% ropivicaine syringe
- Ultrasound
- Ultrasound Programming: Patient last name, first name, MRN (for ID)
- Ultrasound probe cover
- Arrow continuous peripheral nerve block kit
- Sterile gloves (x2)
- Chloraprep (large)
- Tegaderms (large x4)
- Mastisol
- Dermabond
- *Remember to consent for regional anesthesia
- *Remember to attach pulse oximeter, NIBP, IVF
- "Peripheral nerve catheters stay in for 3 days. Our team will seem them in the hospital or call them each day while at home. The patient will be able to remove the catheter themselves at home the evening of POD3."
- "A pump or onQ ball will be attached that they carry around in a fanny pack that will infuse local anesthetic on its own. The patient doesn't have to do anything."
- "Risks: Infection, bleeding, nerve damage (very rare, on the off chance it happens, unlikely permanent)."
- Benefits: "Reduce opioid use; nerve catheters in our opinion are the best option for pain control."
- Resources
Block setup?
Consent details?
lower extremity peripheral nerve blocks
Adductor canal.
- Answer. Why? Answer. How? Answer.
- Block cart code: 1234-enter
- Medication: Midazolam (*NO sedation before timeout)
- Medication: 20mL 0.2% ropivicaine or 0.25% ropivicaine (10cc 0.5% ropivicaine + 10cc IVF)
- Medication: 5mcg epinephrine per 1mL ropivicaine (~ 100mcg epi in 20mL)
- Method: 0.1mL of 1mg/mL epinephrine into 20mL 0.25% ropivicaine syringe
- Ultrasound
- Ultrasound Programming: Patient last name, first name, MRN (for ID)
- Ultrasound probe cover
- PAJUNK peripheral nerve block kit
- Sterile gloves (x2)
- Chloraprep (large)
- Tegaderms (large x4)
- Mastisol
- Dermabond
- *Remember to consent for regional anesthesia
- *Remember to attach pulse oximeter, NIBP, IVF
- "Peripheral nerve catheters stay in for 3 days. Our team will seem them in the hospital or call them each day while at home. The patient will be able to remove the catheter themselves at home the evening of POD3."
- "A pump or onQ ball will be attached that they carry around in a fanny pack that will infuse local anesthetic on its own. The patient doesn't have to do anything."
- "Risks: Infection, bleeding, nerve damage (very rare, on the off chance it happens, unlikely permanent)."
- Benefits: "Reduce opioid use; nerve catheters in our opinion are the best option for pain control."
- Resources
Block setup?
Consent details?
intravenous regional anesthesia
neuraxial anesthesia
Spinal anesthesia.
- Answer. Why? Answer. How? Answer.
- 1. Skin
- 2. Subcutaneous fat
- 3. Supraspinous ligament
- 4. Interspinous ligament
- 5. Ligamentum flavum
- 6. Epidural space -> dura mater -> subdural space
- 7. Arachnoid mater -> subarachnoid space
- "The length of the spinal cord varies according to age. In the first trimester, the spinal cord extends to the end of the spinal column, but as the fetus ages, the vertebral column lengthens more than the spinal cord. At birth, the spinal cord ends at approximately L3. In the adult, the terminal end of the cord, known as the conus medullaris, lies at approximately L1. However, MRI and cadaveric studies have reported a conus medullaris below L1 in 19%–58% and below L2 in 0%–5%. The conus medullaris may lie anywhere between T12 and L3." (NYSORA)
- Ultrasound probe cover
- PAJUNK spinal kit (comes with bupivicaine)
- +/- attending preference spinal anesthetic (e.g. mepivicaine)
- Sterile gloves (x2)
- Chloraprep (large)
- *Remember to position patient appropriately
- *Remember to attach pulse oximeter, NIBP, IVF
- Benefits: Analgesia with reduced opioid usage, avoidance of risks associated with GA
- Mild-Moderate Risks: N/V, postdural puncture HA, failed spinal
- Major Risks: Infection, bleeding, nerve injury
- Total spinal anesthesia ~ cardiovascular collapse, respiratory depression, loss of consciousness
- Resources