General Anesthesia Maintenance, Emergence, and Extubation Lauren Hojdila, MSA, AA-C Nova Southeastern University

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Steps for Maintenance with: Sux at Induction Check for reversal of sux-induced muscle paralysis with nerve stimulator Dose NDMR for level of surgical blockade as required Give medications as indicated by the patient’s vital signs Narcotics Muscle relaxants Inhalational agent (adjust concentrations)

Steps for Maintenance with: Roc at Induction Check for level of muscle paralysis with nerve stimulator Dose additional NDMR for level of surgical blockade as required Give medications as indicated by the patient’s vital signs Narcotics Muscle relaxants Inhalational agent (adjust concentrations)

Steps for Emergence Monitor the neuromuscular blockade with nerve stimulator When you have at least one twitch you can reverse the muscle relaxant with a combo of: Neostigmine Glycopyrrolate •Gradually decrease inhalational agent Goal is no agent at the end when extubating the patient Increase patient’s EtCO2 to stimulate the patient to spontaneously ventilate when reversed Titrate narcotics to respirations Suction patient – Suction Saves Lives!!

Steps for Emergence When patient is able to follow commands and meets the requirement of extubation Deflate cuff of ETT Squeeze anesthesia bag to give a breath as you pull the ETT from the patient Place mask back on the patient to ensure that they are able to spontaneously ventilate adequately Look for chest rise, +vapor and +ETCO2 & adequate tidal volume Transfer patient to PACU with O2: via nasal cannula, face tent, face mask as indicated

Nerve Stimulator

Nerve Stimulator Handheld machine to “test” recovery of paralysis Best location for placement to monitor block of vocal cords is orbicularis occuli •Best location for monitor of skeletal muscle block is adductor pollicus

Nerve Stimulator Choices •Tetanus vs TOF (train of four)