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Department of Anesthesiology - Residents Section

Survival Tools - Post OR

Code Box Setup

  1. Laryngoscope Handle
  2. MAC&Mac226; # 3 and # 4 Blades
  3. Miller&Mac226; #2 or # 3 Blades
  4. ETT Size 6-8 (Sizes #7, #7.5 and #8 with the stylets in)
  5. Nasal ETT Size 5-8
  6. LMA&Mac226; size 3-4
  7. Oral Airways
  8. Nasal Airways
  9. Tongue Depressor
  10. CO2 Detector
  11. Local Anesthetic spray
  12. Tincture benzoin
  13. 4 X 4s
  14. Lubricant
  15. Syringes
  16. Stylets
  17. Adhesive Tape
  18. Drugs:
      A. Muscle Relaxants:
    1. Succinylcholine
    2. Rocoronium
    3. Pancuronium
    4. Mivacurium
    5. Vecuronium

      B. Induction Agents:
    1. Thiopental
    2. Propofol
    3. Etomidate
    4. Ketamine

      C. Emergency Drugs:
    1. Atropine (ready to use vial)
    2. Lidocaine (ready to use vial)
    3. Ephedrine
    4. Epinephrine (ready to use vial)
    5. Phenylephrine

      D. Adjuvant:
    1. Albuterol inhaler (with ETT connector)
    2. Normal Saline (10 ml Vials)
    3. Glycopyrolate
    4. Decongestant spray

Pediatric Code Box Setup

The same setup except for:

  1. Blades:
    • R.Shaw&Mac226; size #0 and #1
    • Miller&Mac226; size #0 and #1
    • Mac.&Mac226; Size #0, #1 and #2
  2. ETT:
    • Size #3.5 through #6 (uncuffed)
    • Size #4.5 through #7 (cuffed)
  3. Appropriate size oral and nasal airways
  4. Drugs: Atropine (0.4 mg/ml)

Indications:

Emergency
Emergency indication for cardioversion is usually as a result of acute changes resulting in hemodynamic instability. Anesthesia may be required. Assess hemodynamic staus. In this situation follow Basic ACLS protocol and choose the right drug as the condition of the patient permits.

Get help from an Attending anesthesiologist when you are in doubt.

Elective
Most cardioversions are performed elective

Best location:
- Preferably near OR/ PACU
- In down state practice either Electrophysiology lab or most of the time regular floors.

Best time: early morning

Indication:
- Atrial Fibrillation
- Atrial Flutter
- Supraventricular tachycardia refractory to medical treatment

Preop assessment:
- Current health status, Medications including use of Heparin / Coumadin., Allergies,
- R/o H/o GERD, Thromboembolism, Stroke, CNS disorders
- Assess CVS, and CNS status
- Make sure patient is NPO
- Check anticoagulation status. (Good anticoagulation status prevents chance of thrombo-embolic phenomenon)

Equipment Needed:

Intubating equipment:
- Medications: including Midazolam, Fentanyl, Propofol, Pentothal, Etomidate Ephedrine, Neosynephrine, Glycopyrrolate and Atropine and other ancillary medications
- Supplemental Oxygen
- Ambu bag
- Suction
- Resuscitation equipment
- Working IV line

Anesthetic technique:
- Standard monitors
- Invasive monitoring is rarely required
- Pre-oxygenation (De-nitrogenation!!)
- Sedation with Midazolam, Propofol, or Etomidate
- Protect airway and monitor vital signs
- Synchronized Counter Shock administered when well sedated
- Maintain the airway and support ventilation until consciousness is regained
- Watch for any recurrence of arrhythmia and complication from drugs.
- Record all the events in the anesthesia record including the details of medications administered during the cardioversion.
- Once pt is awake and alert leave monitoring to responsible primary care team.

Don't give sedation to patient without the presence of Attending Anesthesiologist.

GOOD LUCK!