Steps to intubate

[Pox in a box]

Doing first anesthesia rotation and just want to learn the generals for now and get the specifics down the road...the books I've seen are a bit overwhelming so far.

Could someone please help me to learn the basic steps to intubation (normal healthy adult patient intubated in normal fashion)? Please list drugs/doses (by kg) if you know them...thanks!

For example:

1. Pre-oxygenate
2. Anxiolysis with Midazolam
3. Fentanyl
4. Propofol
5. Succinylcholine
6. etc.

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[Precedex]

you might want to give the midaz a little earlier!

like most things in anesthesia, this kind of stuff can be done many different ways.

for example, a 'typical' induction might involve preoxygenating, fentanyl (100-200 mcg), propofol 2mg/kg, mask ventilate then give paralytic (vec, roc, miv, cisatra - very institution dependent, doses easy to look up) then wait 2-3 minutes to kick in then laryngoscopy time.

but as you'll see some folks will not use fentanyl and instead load up with opioid in the period before induction (demerol, morphine, dilaudid). There may be a reason to use alfentanil but i have not seen it used frequently. Then you sedative hypnotic, read about propofol (most common in most institutions), pentothal, etomidate. Lots of muscle relaxants to choose etc. There are specific reasons to use sux which you should try to learn about. And there is the rapid sequence induction. You dont necessarily need a muscle relaxant, there are papers just with propofol and remifentanil. So mostly at your stage you should just see what people are doing and read about it as you go.

 

[BaylorGuy]

Propofol by it self works most of the time, but it does nothing for the pain side which is why either the fentanyl or other class of opoids are used as analgesics. Make sure gas flows aren't too high.

 

[nimbus]

As a student I would focus on comprehensive airway management and not just intubation. We intubate far fewer patients than when I first entered practice, mostly because of the LMA. I would get familiar with mask ventilation, oral and nasal airways, when to intubate, when not to intubate, and most importantly when and when not to extubate. These skills and knowledge are at least as important as intubation.

that said, the following sequence is my usual routine (with many exceptions):

1. Patient/airway exam
2. Equipment/drug check
3. patient positioning
4. moniters/check vitals
5. self positioning. Am I comfortable? do I have enough space? Bed too high or too low?
6. pre-O2
7. IV induction
8. tube
9. confirm tube placement
10. recheck vital signs.

Again, the focus on intubation is misplaced by most medical students. I delivered a few babies in medical school and I see now that it was a completely worthless endeavor for me.

 

[Mapleson D]

Yeah, folks at my institution (and I'm sure elsewhere) say that the most important skill for a student to learn on an anesthesia rotation is effective mask ventilation.

 

[VolatileAgent]

Yeah, folks at my institution (and I'm sure elsewhere) say that the most important skill for a student to learn on an anesthesia rotation is effective mask ventilation.

couldn't agree more. it's breathtaking (pun intended) how bad people are at doing this outside of the OR. i've been to far too many "code blues" where what-seems-to-be a simple procedure is done so poorly and can make a huge, immediate difference in initial patient care.

learn how to do this effectively. if you become adept at doing this one thing during your rotation, then you've succeeded.