I do some things differently.  I give no premedication.  Use same induction with nitous oxide and sevoflurane.  Place cannula after induction with a nurse holding the mask.  I use pethidine for analgesia 1 - 2 mg /Kg and atracurium 0.3 - 0.5mg /Kg, turn off the nitrous oxide and ventilate with oxygen and sevo just before intubation.

I extubate immediately the operation is finished thus avoiding emergence laryngeal spasm.  The surgeon always applies suction and haemostasis so I don't suck out any more unless necessary thus avoiding overstimulation.  I give reversal drugs just before extubation then sit at the top of the table ventilating the lungs with oxygen thus maintaining good oxygenation and getting rid of sevoflurane.

I transfer to the trolley after patient is breathing well.

Usually not too many problems.  One case only of clot in the trachea - quite worrying at the time as it caused complete obstruction.  Reintubated and it came out when I re-extubated.

Quote from: jafo1964 on October 13, 2007, 10:22:43 AMWhat should one do next.

From your description the most likely cause of of failure to ventilate would be obstruction due to laryngeal spasm.

It should be easy to assess the circuit without calling for another one which would waste valuable time.  Self inflating bags in my view have no place except in total failure.  You cannot apply CPAP with a self inflating bag and CPAP is a valuable aid to oxygenation and overcoming laryngeal spasm.

I would assess the situation by quick laryngoscopy.  If laryngeal spasm was confirmed I would continue efforts with a mask, Guedal airway, turning the head to the side and maximum extentions while asking someone esle to give suxamathonium.  You would not need more than 25 mg to reverse the situation and get oxygen to the alveoli.  You would then be able to deepen anaesthesia and decide as to whether you would not be better off giving a non-depolarising relaxant.  You could then place the LMA.

I would not go straight to the LMA in these circumstances because if there is laryngeal spasm the LMA would simply leak and you would be worse off than with mask and airway.

I would not go for an ETT unless specifically indicated.  A LMA will cause less irritation.  And I would try to avoid passing it through cords that are in spasm.

Quote from: jafo1964 on January 07, 2008, 02:12:20 PMi wonder if post-operatively will it apply to a patient on Hudson mask and all the residual effects of anaesthesia

It certainly does work at the end of an operation or in a Recovery Room.  There is a lot of wooley thinking on this subject.  Most anaestheists perhaps unwittingly use apnoeic oxygenation when after reversal of a muscle relaxant and a few breaths of oxygen they stop the ventialtion and await resumption of spontaneous breathing.

I have taken this practice a step further.  For some thirty years I have looked on the end of the operation as usually being the end of the need for the patient to be in theatre.  Once the dressing is complete, and the patient transferred to the trolley, provided he is haemodynamically stable I take him to Recovery Room.  There the LMA (or ETT) is attached to a 300 ml light plastic open bag and oxygen source.

These bags are very nice.  If you fill the bag, occlude the opening and turn the oxygen off you have a very good monitor of both the heart and lungs, far better than looking at or feeling the abdomen which is what nurses instictively do.

If there is no breathing you simply turn the oxygen on, give a few puffs and leave the patient apnoeic in the same way as you would in theatre.  While the oxygen is off it is quite instructive to demonstate that you can quite easily see the heart beat and even make out the heart rhythm.  Furthermore, if you can see the heart beat it tells you immediately that there is no upper airway obstruction as with laryngeal occlusion or spasm.

After a short time breathing will resume.  In the meantime the theatre orderley has been able to clean the theatre and get the next patient on the table.  There is a definite and significant saving in time.

In thirty years I have not had any major problem with this policy.  I work in smaller hospitals and the nursing staff are used to me.  I find it more comfortable than trying to establish spontaneous breathing in theatre.  There is no pressure.  There is no need to lighten the patient, perhaps prematurely.  During transport the patient is quiescent.  It always strikes me as odd to actively go from a stable quiescent state to an unstable awakening state just before transporting a patient to Recovery Room.

I routinely take the filter and mask to the Recovery Room.  If after removal ot the LMA or ETT there is any stridor or breathholding or even just as a routine I attach the 300 ml bag to the mask via the filter and have a ready means of applying positive pressure breathing and CPAP.

Thank you jafo1964 for your information and reference.  It is exactly what I was looking for and it was in relation to apnoeic oxygenation that I was seeking the information.  I find where I work that Recovery Room nurses have next to no knowledge of apnoeic oxygenation and can be quite worried about the patient being left apnoeic for as little as one or two minutes even though I am present and the SO₂ is 99 the whole time.  It appears that there is an unwritten policy not to teach them about this subject. Do you have this problem?

Quote from: yogenbhatt1 on November 25, 2007, 03:50:34 PM
    My observation in past few cases show, that when CO2 Narcosis takes place, the patient takes quite some time to sattle down ...

On the question of CO₂ retention I wonder if anyone can tell me or give me a reference in answer to the following question:

If an average paralysed or sedated adult with a P_aCO2 of 30 - 40 mmHg and who is afebrile is left apnoeic after a period of ventilation with oxygen being supported with apnoeic oxygenation at what rate does the P_aCO2 rise?  I have tried to find the answer to this question in physiology texts but so far without success.  From my training days I seem to recall the figure is 2.5 mmHg per minute.  Is this correct?