Anesthesiology Resident Manual of Procedures A Step by
Step Guide
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Acknowledgments
The contents of this book are based on the outstanding education that I
received as an anesthesiology resident while training at the University
of California, San Diego. I must give special thanks to the many UCSD
educators who have taught me over the years, including, but not limited
to: Dr. Daniel E. Lee, Dr. Gerard R. Manecke, Dr. Ruth Waterman, Dr.
Jonathan Benumof, Dr. Alyssa Brzenski, Dr. Piyush Patel, Dr. Rodney
Gabriel, Dr. Arthur Lam, Dr. John Drummond, Dr. Lawrence Weinstein,
Dr. Leon Chang, Dr. Karim Rafaat, Dr. Mark Greenberg, and Dr. Rick
Bellars.
About the Book
This book was developed with the goal of helping medical trainees in all
stages of training who work in critical care settings in the operating
room, emergency department, and the intensive care unit. In such
environments, we must provide quality medical care even under high
stress situations with little time to prepare. The purpose of this book is
to enable learners to quickly prepare for critical procedures and
perform them well.
Contents
1 Airway Anatomy and TracheobronchialTree
Preoperative Airway Evaluation
TracheobronchialTree Anatomy
Distances to Know
Estimating the Depth of the Endotracheal Tube (ETT) for
Intubation
Reference
2 Optimizing Intubation Positioning
How to Make a Ramp
Common Pitfalls and How to Approach Them
3 How to Assemble and Use the Fiberoptic Scope and Tower
Range of Motion
How to Maneuver the Scope
Features on Standard Anesthesia Scopes
How to Hold the Scope
Where to Stand Relative to the Patient
How to Set up the Fiberoptic Scope (FOB) and Tower
4 Asleep Fiberoptic Intubations
Method #1:Intubating Without Maintaining Ventilation, Using
an Intubating Oral Airway
Method #2:Intubating Without Maintaining Ventilation,
Without an Oral Airway
Method #3:Intubating While Mask Ventilating, Using an Oral
Airway and an Aintree Catheter
Method #4:Intubating While Ventilating Through an LMA,
Using an ETT Exchanger
Method #5:Intubating While Ventilating Through an LMA,
Using an Aintree Catheter
5 Awake Fiberoptic Intubation
Indications for Awake Intubation
Relative Contraindications to Awake Intubation
But ENT Said It Was Not Necessary…
(I) Psychological Buy-In
(II) Antisialogogue
(III) Topicalization
Technique #1:Nebulizer
Technique #2:Popsicle Stick
Technique #3:Viscous Spray
(IV) Nerve Blocks
(V) Sedation
Intubation Technique
6 Nasotracheal Intubation
Nasal Intubation by Direct Laryngoscopy
Nasal Fiberoptic Intubation
7 Codes/Out of or Emergency Airway Management
Assess the Patient
MOMSAID for Out of OR Situations
8 Airway Exchanges
Indications
Airway Exchange Devices
9 Deep Extubations
Indications
Contraindications
Technique
10 Aspiration on Induction
Risk Factors
Preventive Measures
What if Patient Vomits Right Before Induction?
What if Patients Vomits/Aspirates upon/After Induction?
11 Intubating Without Muscle Relaxant
Indications
Technique
Confirming Patient Is Anesthetized and Deep Enough for
Intubation
12 Jet Ventilation for ENT Surgery
Indications
Induction
Maintenance
13 Intubating with a Bougie
Why Would I Need a Bougie?
When to Use a Bougie
Equipment
Instructions
14 Intubating with C-Spine Precautions
Scenarios
Airway Management Decisions
How to Prevent Damage?
Intubating with C-Collar Still in Place
Intubating Without C-Collar
15 Intubating with Video Laryngoscope
Challenges
Equipment
Instructions
16 Intubating on the Ground
Scenarios
Intubating Positions
#1 Sniper
#2 Toddler
#3 Kneeling
#4 Reverse Direct Laryngoscopy
17 Double-Lumen Endotracheal Tubes
Indications for One-Lung Ventilation
Choosing a Double-Lumen Endotracheal Tube
Why Use a Double-Lumen Endotracheal Tube
Equipment
How to Place a DLT – Assuming Left-Sided DLT
How to Use DLT for One-Lung Ventilation (Assuming Left-Sided
DLT)
How Does the Operative Lung Deflate?
Common DLT Malpositioning Errors
18 Emergency Cricothyroidotomy
Knife-Finger-Bougie
Percutaneous Cricothyroidotomy
19 Laryngeal Mask Airways (LMAs)
Absolute Contraindications
Relative Contraindications
Indications
Choosing an LMA
Instructions
Troubleshooting LMAs
20 Troubleshooting Tracheostomies
Things to Know About a Patient’s Existing Tracheostomy Tube
Multiple Purposes of a Tracheostomy Tube
Common Complications of a Tracheostomy Tube
Airway and Breathing Assessment in a Patient with a
Tracheostomy Tube Who Has Arrested
Ventilation and Reintubation After Removal of Tracheostomy
Tube
Components of a Tracheostomy Tube
How to Change Out an Existing Tracheostomy Tube in an Awake
Patient
21 Ultrasound-Guided Peripheral IVs
Equipment
Instructions
Cross-Sectional View:Slide Catheter off Needle
Cross-Sectional View:Advance-Needle Tip-Repeat
Longitudinal View
Through and Through
22 Where to Look for Peripheral IV
Scenario
Sites to Look “Blindly”
Instructions
23 Subclavian Central Lines without Ultrasound
Equipment
Choosing a Side
Positioning
Indications
Risks
Instructions:Without Ultrasound
Caution
How to Straighten out the Guidewire
24 Internal Jugular Central Line Without Ultrasound
Choosing a Side
Position
Landmarks
Instructions
25 Femoral Lines Without Ultrasound
Indications for Femoral Central Line Placement
Indications for Femoral Arterial Line Placement
Patient Positioning
Femoral Arterial Line
Femoral Central Line
26 How to Assemble an Arterial Line Transducer
Equipment
Instructions
27 Radial Arterial Lines
Indications
Contraindications
Equipment for Self-Assembled Radial Arterial Line Kit
Instructions
Troubleshooting Radial Arterial Lines
When to Check an Arterial Blood Gas
Utility of Venous Blood Gas
28 Dorsal Pedal Arterial Lines
Pedal Versus Radial Arterial Lines
Equipment for Self-Assembled Pedal Arterial Line Kit
Instructions
29 Belmont Infuser
What Is the Belmont?
How Does the Belmont Stop Air and Blood Clots?
How to Set Up the Belmont
30 Single Shot Spinal
Placing a Spinal
Dosing a Spinal
Complications of Spinal Block
Assessing Block Level
31 Lumbar Epidurals
Spinal Cord Anatomy
Dermatome Coverage
Key Dermatome Landmarks to Know
Patient Positioning
Insertion and Depth
Loss of Resistance (LOR) Techniques
Lumbar Epidural for Labor
Lumbar Epidural for Cesarean Section
Lower Extremity Motor Exam
32 Continuous Spinal
Indications for Continuous Spinal rather than General
Anesthesia
Indications for Continuous Spinal rather than Single Shot
Spinal
Technique
How to Dose
Why Aren’t Continuous Spinal Catheters More Common?
Intrathecal Narcotics
Special Populations
33 Combined Spinal-Epidurals
Indications for CSEs
Why Not to Do CSEs for Labor
How to Place a CSE
How to Dose CSEs for Labor
34 Thoracic Epidurals
Benefits
Risks
Insertion Technique
35 Wet Taps and Epidural Blood Patches
Common Scenarios
Risk Factors
Indications for Blood Patch
Contraindications to Blood Patch
Diagnosing Post-dural Puncture Headache
What to Do if You Wet Tap a Patient
Does Wet Tap =Post-dural Puncture Headache?
When to Do a Blood Patch
How to Counsel Patient About Epidural Blood Patch
Blood Patch Technique
36 Total Intravenous Anesthetics
Indications for TIVA
Goals of Anesthesia
What Drugs Can Be Used for TIVA?
Awareness Under Anesthesia
Example TIVA Technique
37 Monitored Anesthesia Care
Rules of Thumb
Indications for MAC/Sedation
Ideal Patient
Anesthetic Techniques
Airway Management
Conversion to General Anesthesia
38 Emergence Without Nitrous Oxide
Instructions
39 Craniotomies
What Is Wrong with Nitrous Oxide?
General Set-Up for Craniotomy
Drugs to Prepare
Anesthetic Plan Without Nitrous Oxide
Anesthetic Plan with Nitrous Oxide
Neuro Exam While Intubated, Immediately Postop
Multiorifice Catheter
Hyperventilationand ICP
Mannitol
Hypertonic Saline (3% NaCl)
40 Liver Transplants
Drugs
Blood Products
Monitors and Lines
Preoperative Evaluation
Manifestations of Liver Disease and Their Anesthetic
Implications
Phases of Liver Transplant
Guidelines for Acute Massive Blood Loss
Contents of Blood Products
Reference
Index
About the Author
Claire Sampankanpanich Soria
is a board-certified pediatric anesthesiologist. She completed her
undergraduate training at the University of California, Los Angeles;
medical school at Johns Hopkins University School of Medicine;
residency in anesthesiology at the University of California, San Diego;
and fellowship in pediatric anesthesiology at Children’s Hospital of Los
Angeles. She currently works on faculty at the University of California,
San Diego.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
C. Sampankanpanich Soria MD et al., Anesthesiology Resident Manual of Procedures
https://doi.org/10.1007/978-3-030-65732-1_1
1. Airway Anatomy and
Tracheobronchial Tree
Claire Sampankanpanich Soria1 , Daniel E. Lee1 and
Gerard R. Manecke1
(1) Department of Anesthesiology, UCSD Medical Center, San Diego,
CA, USA
Claire Sampankanpanich Soria (Corresponding author)
Email:
[email protected] Daniel E. Lee
Email: [email protected]
Gerard R. Manecke
Email: [email protected]
Keywords Airway exam – Tracheobronchial tree – Airway anatomy –
Airway distances
Preoperative Airway Evaluation
Ideally patient is sitting upright at 90° angle to optimize view of the
mouth [1].
1. Long upper incisors
2. Overriding upper incisors (‘buck teeth’)
