když nemohu prodýchnoutdadak,pelikan - akutne.cz · gilles dhonneur professor of anesthesiology...
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Když nemohu prodýchnout ...
Lukáš Dadák, Karel Lukáš Dadák, Karel PelikánPelikán
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Spontanous Vent.
Face Mask
Cuffed oral airways
Level of airway instrumentationAneb aby bylo hned od počátku jasno….
Invasiveness
Extr
ag
lott
ic
Supraglottic (SGA)
Tracheal tube
Timmermann A. 2009; Anasthesiol Intensivmed Notfallmed Schmerzther 44: 246-255
Extr
ag
lott
ic
Eso. closing tube
Surgical airway
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rozepětí žaludku ↑
gastrický tlak ↑
posun bránice kraniálně ↑
distribuce objemuplíce → břicho
Selhání ventilace obličejovou maskou
Compliance ↓
kraniálně ↑
nitrohrudní objem ↓
tlak v d.cestách ↑
Nach Wenzel et al., Resuscitation 1998; 38: 113-8
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DesaturaceDesaturace
Copyright © 2014 Anesthesiology. Published by Lippincott Williams & Wilkins.Copyright © 2014 Anesthesiology. Published by Lippincott Williams & Wilkins.
Benumof, J. L. et al. Critical Hemoglobin Desaturation Will Occur before Return Benumof, J. L. et al. Critical Hemoglobin Desaturation Will Occur before Return
to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine. to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.
Anesthesiology. 87(4):979Anesthesiology. 87(4):979--982, 1997.982, 1997.
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Potíže s intubací na sále a mimo něj
Total no. of patients
>= 3 attempts
OR1
18205
1.5%
Out-of-hospital2
1106
5.5 %
Failed
Difficult or awkward intubation
0.3%
4.3%
2.0 %
14.8 %
1 Rose DK, Cohen MM. Can J Anaesth 19942 Timmermann et al., Resuscitation, 2006
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Nárůst komplikací prolongované intubace
Mort TC: Emergency Tracheal Intubation: Complications Associatedwith Repeated Laryngoscopic Attempts. Anesth Analg 2004;99:607–13
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To se mi nemůže stát ...
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The LMA™ in a difficult airway algorithm
Gilles Dhonneur
Professor of Anesthesiology and Intensive Care Medicine
Jean Verdier University Hospital of Paris, Bondy
Paris XIII University, Bobigny School of Medicine
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GillesGilles AlgorithmAlgorithm(unexpected DAM in OR)(unexpected DAM in OR)
InductionInduction
Facemask ventilationFacemask ventilation
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Gilles Algorithm(unexpected DAM in OR)
Induction
Facemask ventilation
Impossible
Ventilation/Oxygenation (V/0)
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Gilles Algorithm(unexpected DAM in OR)
Induction
Facemask ventilation
Impossible
Ventilation/Oxygenation (V/0)
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Gilles Gilles AlgorithmAlgorithm(unexpected DAM in OR)(unexpected DAM in OR)
InductionInduction
Facemask ventilationFacemask ventilation
ImpossibleImpossible
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
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LMA™ SUPREME
Výhody: zavedení a okamžitá oxygenace v jakékoliv poloze, simultánní aktivníodsávání z dýchacích cest během zavádění – špička Supreme vyčistí HCD
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Gilles Gilles AlgorithmAlgorithm(unexpected DAM in OR)(unexpected DAM in OR)
InductionInduction
Facemask ventilationFacemask ventilation
ImpossibleImpossible
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
Step 1Step 1
--
TransTrans --Tracheal V/OTracheal V/O
++
Rescue LMA Fastrach V/O Rescue LMA Fastrach V/O LMA SupremeLMA Supreme
Step 2Step 2
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Gilles Gilles AlgorithmAlgorithm(unexpected DAM in OR)(unexpected DAM in OR)
InductionInduction
Facemask ventilationFacemask ventilation
++ DifficultDifficult
Scenario 2Scenario 2
Tracheal Intubation (OTI)Tracheal Intubation (OTI)
ImpossibleImpossible
Scenario 1Scenario 1
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
Step 1Step 1
--
TransTrans --Tracheal V/OTracheal V/O
++
Rescue LMA Fastrach V/O Rescue LMA Fastrach V/O LMA SupremeLMA Supreme
Step 2Step 2
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Gilles Gilles AlgorithmAlgorithm(unexpected DAM in OR)(unexpected DAM in OR)
InductionInduction
Facemask ventilationFacemask ventilation
++ DifficultDifficult
Scenario 2Scenario 2
Tracheal Intubation (OTI)Tracheal Intubation (OTI)
Direct laryngoscopy OTIDirect laryngoscopy OTI
ImpossibleImpossible
Scenario 1Scenario 1
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
++ --
Step 1Step 1
--
TransTrans --Tracheal V/OTracheal V/O
++
Rescue LMA Fastrach V/O Rescue LMA Fastrach V/O LMA SupremeLMA Supreme
Step 2Step 2
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GEBGEB--gum elastic bougiegum elastic bougie
nepostradatelná pom ůcka nepostradatelná pom ůcka v v neočekávanémneočekávaném
obtížném zabezpe čení obtížném zabezpe čení dýchacích cestdýchacích cest
ESCHMANNESCHMANN
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Gilles Gilles AlgorithmAlgorithm(unexpected DAM in OR)(unexpected DAM in OR)
InductionInduction
Facemask ventilationFacemask ventilation
++ DifficultDifficult
Scenario 2Scenario 2
Tracheal Intubation (OTI)Tracheal Intubation (OTI)
Direct laryngoscopy OTIDirect laryngoscopy OTI
ImpossibleImpossible
Scenario 1Scenario 1
Ventilation/Oxygenation (V/0)Ventilation/Oxygenation (V/0)
++ --
Gum Elastic BougieGum Elastic Bougie
++ --
Step 1Step 1
Step 1Step 1
--
TransTrans --Tracheal V/OTracheal V/O
++
Rescue LMA Fastrach V/O Rescue LMA Fastrach V/O LMA SupremeLMA Supreme
Step 2Step 2
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Gilles Algorithm(unexpected DAM in OR)
Induction
Facemask ventilation
+ Difficult
Scenario 2
Tracheal Intubation (OTI)
Direct laryngoscopy OTI
Impossible
Scenario 1
Ventilation/Oxygenation (V/0)
+ -
Gum Elastic Bougie
+-
Step 1
Step 1
-
Trans -Tracheal V/O
+
Rescue LMA Fastrach V/O LMA Supreme
Step 2
Intubating LMA
+
-
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Metody zavedení LMAMetody zavedení LMA
LaryngoscopeLaryngoscope guidedguided -- gum gum elasticelasticbougiebougie techniquetechnique ::
poprvé popsána v r. 2002: poprvé popsána v r. 2002: poprvé popsána v r. 2002: poprvé popsána v r. 2002:
HowarthHowarth A, A, BrimacombeBrimacombe J, Keller C. Gum J, Keller C. Gum elasticelasticbougiebougie guidedguided placementplacement ofof thethe ProSealProSeal
LMA.CanLMA.Can J J AnesthAnesth 2002, 49, 5282002, 49, 528--529529
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Závěr 1: LMA
�Rychlá, elegantní, bezpe čná pomůcka v DAM
�Menší traumatizace pacient ů
�Cílem není vždy intubovat, ale vždy oxygenovat
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Závěr 2: G.E.B.
�GEB - elegantní pom ůcka v DAM�Menší traumatizace pacient ů
�Dostupnost p ři každém �Dostupnost p ři každém zajišt ění dýchacích cest
�4 možnosti použití (2xBATI,1xBALMI,1xBACT)