Special Cases

Now you know the basics, it’s time to dig into the special cases. These are common sub-specialties within anaesthesia that you might see.

Rapid Sequence Intubation ⏱

Rapid sequence intubation (RSI) is a technique designed to minimise the time between loss of consciousness and tracheal intubation. RSI is most useful in patients at high risk of aspiration (e.g. pregnant and unfasted patients).

 RSI when you have the need for speed

An RSI is different to a conventional induction because…

Awake Fibreoptic 🎥

The awake fibreoptic intubation is ideally suited to the high-risk patient who is still awake and protecting their own airway.2 It is very unpleasant, so you need a cooperative patient to succeed.

Process

A lubricated endotracheal tube is loaded onto a fibreoptic bronchoscope that is guided through the nose (or mouth), the pharynx, and the vocal cords.

Before inserting the scope, we topicalise the entire airway with a mixture of lignocaine and phenylephrine (co-phenylcaine). The lignocaine suppresses coughing and the phenylephrine reduces mucosal bleeding.

Once the tube is passed through the vocal cords, the patient is put to sleep.

Obesity ⚖️

Obesity is associated with virtually every complication of anaesthesia and surgery, including death. The major implications for anaesthesia are…

Pregnancy 🫄

Surgery and anaesthesia are generally safe for the mother and baby at any stage of the pregnancy, but should be avoided unless it’s an emergency.

At first blush, the physiological changes are similar to the those in obesity. The important difference is that these changes are quickly reversed after delivery and are generally occurring in young, healthy individuals.

In the parturient at full term, you can expect to see…

Paediatrics 👶

Children that aren’t neonates are physiologically like miniature adults.

Gas Induction

The hardest part of routine paediatric anaesthesia is induction because children don’t like needles. Gas inductions are one (imperfect) solution to this problem.

They’re not as safe as an IV induction, but they’re virtually unavoidable in small children. The process goes…

  1. Spend time explaining the process to the parent
  2. Get the child as relaxed and entertained as possible
  3. Apply a pulse oximeter
  4. Use a tight-fitting face mask
    • Some kids will hold it on by themselves
    • For the rest, you’ll need to hold it yourself
  5. Have them breathe high-concentration (8%) sevoflurane
    • They will generally fall asleep within ten breaths
  6. Quickly secure IV access and an airway once the child is sleep

Other Differences

  1. Cricoid pressure is controversial. Most contemporary RSI’s omit this step. 

  2. You can’t move anything out of the way with a bronchoscope, so there is no point in using it on an obstructed airway. You’ll just be looking at tongue.