08 - Difficult Airway and Algorithms

VTDAT Approach This should complement teachings you've likely already received on an ABCDE approach. Three boxes: Anesthetic, Surgical, Patient Categories: Hypovolemic, Distributive, Cardiogenic, Obstructive, Mixed Use history, physical, non-invasive and invasive monitors, investigations (ECG, blood work, ultrasound, etc) to rule in or rule out your differential. Trial treatments. Assess response to treatments. Don't anchor, reconsider differential diagnosis if not improving. Have questions, comments, corrections, or concerns? Please reach out via email: [email protected] References: 1. Emergency Manual. “Stanford Medicine Emergency Manual.” Accessed August 27, 2023. https://emergencymanual.stanford.edu/. All research, scriptwriting and recording done by Misa Gillis MSI4 and Blake Birnie, UBC Anesthesiology R3

PDPH is a recognised complication of neuraxial anesthesia. Around 4 minutes I misspoke and stated an 18G spinal needle - I meant epidural needle, I corrected myself the second time I stated it, sorry for the confusion! Have questions, comments, corrections, or concerns? Please reach out via email: ⁠[email protected] References: 1. Gobel, Hartmut. “7.2.1 Post-Dural Puncture Headache.” ICHD-3. Accessed September 16, 2023. https://ichd-3.org/7-headache-attributed-to-non-vascular-intracranial-disorder/7-2-headache-attributed-to-low-cerebrospinal-fluid-pressure/7-2-1-post-dural-puncture-headache/. 2. Plewa, Michael C., and Russell K. McAllister. “Postdural Puncture Headache.” In StatPearls. Treasure Island (FL): StatPearls Publishing, 2023. http://www.ncbi.nlm.nih.gov/books/NBK430925/.  3. Uppal, Vishal, Robin Russell, Rakesh Sondekoppam, Jessica Ansari, Zafeer Baber, Yian Chen, Kathryn DelPizzo, et al. “Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report.” JAMA Network Open 6, no. 8 (August 15, 2023): e2325387–e2325387. https://doi.org/10.1001/jamanetworkopen.2023.25387. 4. Zhang Q, Pang SY, Liu CW. Chronic headaches related to post-dural puncture headaches: a scoping review. Br J Anaesth. 2022 Nov;129(5):747-757. https://pubmed.ncbi.nlm.nih.gov/36085093/ All research, scriptwriting and recording were done by Misa Gillis UBC MSI4 and Blake Birnie UBC Anesthesiology R3

In this episode, we define multimodal analgesia and give a brief introduction to the many agents that can be utilised. Opioids are a mainstay of treating post-surgical pain and the goal of multimodal analgesia is not to avoid opioids (termed opioid-sparing analgesia) but to reduce the negative side effects while providing adequate post-surgical pain. The medications listed are those that are typically used in British Columbia, Canada and may differ from your regional practice. For example, we mention IV acetaminophen briefly, this is difficult to obtain in Canada (at least in British Columbia where we practice) although I am aware that it is quite cheap and widely used in other areas of the world. Apologies for the hissing - we had technical difficulties with the recording equipment. Have questions, comments, corrections, or concerns? Please reach out via email: [email protected] References: 1. Stone AB, Iban YC, Zhong H, et al. B318 Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: a population-based study. Reg Anesth Pain Med. 2022;47(Suppl 1):A234-A235. doi:10.1136/rapm-2022-ESRA.392 2. Rosenberger DC, Pogatzki-Zahn EM. Chronic post-surgical pain – update on incidence, risk factors and preventive treatment options. BJA Education. 2022;22(5):190-196. doi:10.1016/j.bjae.2021.11.008 3. Djaiani G, Silverton N, Fedorko L, et al. Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology. 2016;124(2):362-368. doi:10.1097/ALN.0000000000000951 4. Gropper MA, Cohen NH, Eriksson LI, Fleisher LA, Leslie K, Wiener-Kronish JP. Miller’s Anesthesia. 9th ed. Elsevier Inc.; 2020. 5. Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s Clinical Anesthesiology. 7th ed. McGraw Hill LCC.; 2022. 6. O’Neill A, Lirk P. Multimodal Analgesia. Anesthesiology Clinics. 2022;40(3):455-468. doi:10.1016/j.anclin.2022.04.002 7. Dunn LK, Durieux ME. Perioperative Use of Intravenous Lidocaine. Anesthesiology. 2017;126(4):729-737. doi:10.1097/ALN.0000000000001527 8. Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273. doi:10.1097/ALN.0b013e31823c1030 All research, scriptwriting and recording were done by Misa Gillis UBC MSI4 and Blake Birnie UBC Anesthesiology R3

We discussed the VTDAT approach to unstable patients in the OR (although this could also apply to out-of-OR situations). Vitals (Alert the Room) Temporize Differential Diagnosis Assessment Treatment We also discuss an approach to high airway pressure - patient to machine or machine to patient. Have questions, comments, corrections, or concerns? Please reach out via email: ⁠[email protected]⁠ References: 1. Emergency Manual. “Stanford Medicine Emergency Manual.” Accessed August 27, 2023. https://emergencymanual.stanford.edu/. 2. Hess, Dean R. “Respiratory Mechanics in Mechanically Ventilated Patients.” Respiratory Care 59, no. 11 (November 2014): 1773–94. https://doi.org/10.4187/respcare.03410. 3. Nickson, Chris. “High Airway and Alveolar Pressures.” Life in the Fast Lane • LITFL (blog), January 4, 2019. https://litfl.com/high-airway-and-alveolar-pressures/.   All research, scriptwriting and recording were done by Misa Gillis UBC MSI4 and Blake Birnie UBC Anesthesiology R3

We give an example of an "unanticipated" difficult airway situation along with a basic overview of some of the algorithm suggestions. I would strongly encourage you to check out the Vortex approach, the link is at the bottom of the references. Have questions, comments, corrections, or concerns? Please reach out via email: ⁠[email protected]⁠ References: 1. Apfelbaum, Jeffrey L., Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, et al. “2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway*.” Anesthesiology 136, no. 1 (January 1, 2022): 31–81. https://doi.org/10.1097/ALN.0000000000004002. 2. Butterworth, John F., David C. Mackey, and John D. Wasnick. Morgan & Mikhail’s Clinical Anesthesiology. 7th ed. McGraw Hill. LCC., 2022. 3. “DAS Guidelines Home | Difficult Airway Society.” Accessed August 20, 2023. https://das.uk.com/guidelines. 4. “The Vortex Approach to Airway Management.” Accessed November 18, 2023. https://vortexapproach.org/ All research, scriptwriting and recording was by Misa Gillis UBC MSI4 and Blake Birnie UBC Anesthesiology R3

This episode focuses on an overview of physiological changes in pregnancy and how this can impact anesthesia. We discuss the preference for neuraxial anesthesia and use the ABCDE approach to cover some anesthetic considerations. Have questions, comments, corrections, or concerns? Please reach out via email: [email protected] References: 1. Gropper MA, Cohen NH, Eriksson LI, Fleisher LA, Leslie K, Wiener-Kronish JP. Miller’s Anesthesia. 9th ed. Elsevier Inc.; 2020. 2. Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s Clinical Anesthesiology. 7th ed. McGraw Hill LCC.; 2022. 3. McClelland SH, Bogod DG, Hardman JG. Apnoea in pregnancy: an investigation using physiological modelling. Anaesthesia. 2008;63(3):264-269. doi:10.1111/j.1365-2044.2007.05347.x 4. LoMauro A, Aliverti A. Respiratory physiology of pregnancy. Breathe (Sheff). 2015;11(4):297-301. doi:10.1183/20734735.008615 5. Sullivan P, Birdi T, Bould D, et al. Ottawa Anesthesia Primer. Echo Book Publishing; 2012. 6. UpToDate. https://www.uptodate.com/contents/airway-management-for-the-pregnant-patient 7. https://www.anesthesiaconsiderations.com All research, scriptwriting and recording was done by Misa Gillis UBC MSI4 and Blake Birnie UBC Anes R3

Behind the Drapes: Highlights of teaching sessions in the operating room. Ep 1: Airway Assessment - A Deeper Dive with Dr. John Veall. TLDR: Airway management is a complex interplay of anatomy, physiology, circumstance and human factors. Our assessment, preparation and training should reflect that. References: Huitink JM, Bouwman RA. The myth of the difficult airway: airway management revisited. Anaesthesia. 2015 Mar;70(3):244-9. doi: 10.1111/anae.12989. Epub 2014 Dec 16. PMID: 25511477. Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology. 1992 Jul;77(1):67-73. doi: 10.1097/00000542-199207000-00010. PMID: 1610011. The Vortex Approach to airway management: The Vortex Approach The Elaine Bromiley story: Just A Routine Operation - YouTube The Airway Triage app: Airway Triage on the App Store (apple.com)

This episode focuses on general anesthesia in pediatric patients.  When organising your "considerations" - (I wouldn't worry about this much as an MSI3, but for any MSI4s preparing for electives this is a good thing to start practising) try to develop a system to maintain an organised approach. We introduce an ABCDE method in this episode.  Link to the website / app for Anesthesia Considerations:  https://www.anesthesiaconsiderations.com/ References:  1. Butterworth J, Mackey D, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. McGraw-Hill Education; 2013. 2. https://www.anesthesiaconsiderations.com/ 3. Lerman J., Coté C.J., Steward D.J. (2016) Foundations of Pediatric Anesthesia. In: Manual of Pediatric Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-319-30684-1_1 Have questions, comments, corrections, or concerns? Please reach out via email: [email protected] All research, scriptwriting and recording was by Sandy Wu UBC MSI3 and Blake Birnie, UBC Anesthesiology R1

References:  1. Uptodate 2. Sullivan P. Ottawa Anesthesia Primer. ECHO BOOK PUBLISHING; 2012. 3. Butterworth J, Mackey D, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. McGraw-Hill Education; 2013. 4. Snider, K. T., Kribs, J. W., Snider, E. J., et al. (2008). Reliability of Tuffierʼs Line as an Anatomic Landmark. Spine, 33(6), E161–E165. doi:10.1097/brs.0b013e318166f58c 5. Capdevila X, Aveline C, Delaunay L, et. al. Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study. Adv Ther. 2020 Jan;37(1):527-540. doi: 10.1007/s12325-019-01171-6. Epub 2019 Dec 11. PMID: 31828612; PMCID: PMC6979445. 6. Broadbent CR, Maxwell WB, Ferrie R, et al. Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia 2000;55:1122–6. 7. Schlotterbeck H, Toure Y, Schaeffer R, et al. Is assessment of lumbar interspace as inaccurate in the clinical setting of obstetrical regional anesthesia as it is in experimental studies? Anesthesiology 2003;99:A1189. 8. Jespersen MS, Jæger PT, Ægidius KL, et al. Sphenopalatine ganglion block for treatment of post-dural puncture headache. Ugeskr Laeger. 2019 May 6;181(19):V12180846. Danish. PMID: 31120017. 9. https://www.openanesthesia.org/differential_spinal_block/ Have questions, comments, corrections, or concerns? Please reach out via email: [email protected] All research, scriptwriting and recording was by Blake Birnie, UBC Anesthesiology R1 + Sandy Wu UBC MSI3

Neuromuscular Blockade: - Facilitates intubation - Facilitates better surgical conditions - Facilitates mechanical ventilation (i.e. ARDS, hyperventilating in increased ICP) Two Categories:  - Depolarizing: ex. Succinylcholine (1-1.5mg/kg IV) depolarizes the muscle and prevents repolarization. - Non-depolarizing: ex. Rocuronium (0.6-1.2mg/kg IV) Outcompetes ACh for the receptor on the endplate. Big thanks to Suzanne George MD 2022 Candidate from the University of Calgary for editing the episode script! References: 1.  Butterworth J, Mackey D, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. McGraw-Hill Education; 2013. 2.  https://www.openanesthesia.org/aba_phase_ii_depolarizing_blockade/ 3.  Zhang Z, Guo Q, Wang E. Hyperventilation in neurological patients: from physiology to outcome evidence. Curr Opin Anaesthesiol. 2019;32(5):568-573. doi:10.1097/ACO.0000000000000764