Anesthesia Student Survival Guide.pdf - Index of

240 ● AnesthesiA student survivAl Guide
Exhaustive search for other veins yields no obvious prospects for additional
access. The patient states that she has always been “a tough stick.” How will
you proceed?
You can certainly induce anesthesia with this IV and then attempt to locate
a second site after induction. General anesthesia often leads to vasodilation
and easier location of veins due to direct effects of anesthetics as well as
relief of anxiety, which may cause sympathetic activation and vasoconstriction.
This presumes that you believe that the present IV is indeed intravascular!
You should not proceed with induction if you are not sure. Some
anesthesiologists will inject a dose of a rapid-acting sedative or opioid to
assess whether the drug has entered the blood stream and reached the
brain, but this may not be definitive due to variation in individual patient
responses to the drugs.
You plan a rapid sequence induction with propofol and succinylcholine. 60 s
after injecting propofol, the patient has not lost consciousness. You have not
yet injected succinylcholine. How will you proceed?
At this point, you should suspect that the IV might not be intravascular. You
can determine if this is a pharmacodynamic or kinetic problem (i.e., the
patient has just not yet fallen asleep but the drug is IV) by assessing whether
your injection has had any effect at all on the patient’s level of consciousness.
Although the rapid sequence technique generally implies quick sequential
injection of a hypnotic and a paralytic, you should not inject succinylcholine
at this point. This is because even if not IV, succinylcholine will eventually
be absorbed and will produce weakness or paralysis in an unsedated
patient. Extravascular propofol and lactated Ringer’s are probably benign
(unlike thiopental, which can be irritating). However, you should monitor
the limb for signs of edema, or compartment syndrome by observation and
palpation of the distal pulse. If possible, elevate the arm somewhat over the
level of the chest.
Can you induce anesthesia by inhalation instead?
This technique is commonly performed in children but is rarely employed
in adults in modern practice. In this case, however, it is contraindicated
because the emergency nature of the surgery, the fact that the patient has
consumed food in the last few hours, and the abdominal nature of the
emergency, all of which relatively contraindicate mask ventilation.