Describe how you will prepare for this patient
Mrs Angela Stoop is about to arrive in the operating theatre from the emergency department to undergo an emergency laparotomy. She last ate 2 hours ago.
What will be an ideal response?
Answer:
Having eaten only 2 hours ago, Mrs Stoop has not fasted for the required timeframe for surgery. Generally, fasting times are 6 hours for food and 4 hours for water. Mrs Stoop is likely to be suffering from an acute abdomen, a condition that causes nausea and vomiting and where gastric emptying is delayed. In addition she will be in pain, which can delay gastric emptying, making Mrs Stoop at risk of aspiration during intubation.
Mrs Stoop will require a rapid sequence induction, which is a technique used to secure the airway rapidly to reduce the risk of pulmonary aspiration of the acid stomach contents. Aspiration could result in severe pneumonitis, which is known as Mendelson's syndrome and is often fatal.
The technique involves the anaesthetic nurse using their fingers to apply pressure on the cricoid cartilage, pressing it firmly backwards onto the cervical vertebral bodies behind it and occluding the upper end of the oesophagus, thus preventing the aspiration of gastric contents. This is known as a Sellick's manoeuvre and was first described in 1961 (Tasch &Langeron 2013). The sequence of the technique is as follows:
locate appropriate equipment (e.g. ETT, laryngoscope and suction)
secure IV access
apply haemodynamic monitoring
pre-oxygenate the patient using a face mask
locate the cricoid cartilage and apply pressure using two fingers when instructed to do so by the anaesthetist, usually as the induction agent is being administered
administer IV induction agent and short-acting muscle relaxant (e.g. suxamethonium)
observe for muscle twitching or fasciculations, which indicates the muscle relaxant is taking effect
intubate , inflate cuff and ventilate patient
confirm correct position of ETT (i.e. equal chest inflation and end-tidal carbon dioxide displayed waveform)
release cricoid pressure only on the advice of the anaesthetist once the position of the ETT has been confirmed (Nagelhout, 2014)
It is important that patients are warned that they will feel pressure on their neck as their anaesthetic is being induced.
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