Put on surgical attire with PPE (see RCDP article for attire and unattire13). |
Put on 02 pairs of gloves when approaching the bed. |
Checking of PPE by two different professionals (Intubator and Assistant). |
Phase 2 - Initial procedures and patient preparation
|
Guarantee a maximum of 2 anesthetists by the Patient‘s Bed, another anesthetist is wearing the attire outside to provide any assistance. |
Check medication kit with induction drugs and aspirated drugs: Propofol 160mg + Lidocaine: 80 mg (aspirated together in a 20mL syringe) Fentanyl 150 mcg Succinylcholine 100 mg Ephedrine (10mg / mL solution) Atropine (250mcg / mL solution) Phenylephrine (40mcg / mL solution) Epinephrine (5mcg / mL solution) Norepinephrine (16mcg / mL solution) |
Check airway material: Videolaryngoscope + Blade, Bougie, OTT (5.5-8.5) 2 of each, HEPA filters (3), Guedel cannulas Nasopharyngeal cannulas, Laryngeal Masks, Strong clamps, Swivel |
Leave OTT ready with Swivel and Bougie. (Fig 1) Use the red filter cover, occluding the main Swivel outlet. |
Install HEPA filter between the Mask and the CPAP Valve (connected to the Mapleson C system) (Fig. 2), or between the mask, bag and valve (if there is no CPAP Valve). |
Check with the local team if the mechanical ventilator has been tested by personnel in the sector (Intubator). |
Check if HEPA filter is installed between the expiratory branch of the mechanical ventilation circuit (Assistant), confirm it out loud. |
Check all extensions of the ventilator circuit (Assistant) and reinforce them in order to avoid disconnections during the procedure, confirm it out loud. |
Check Mapleson C System equipment connections and reinforce them in order to avoid disconnections during the procedure (Intubator), confirm it out loud. |
Check if the aspiration system is working (Intubator), confirm it out loud. |
Check if the O2 flow system is working in a flow meter at the Wall gas outlet or in an O2 cylinder (Intubator), confirm it out loud. |
Check for the presence of a crash cart close to the bed (Intubator), confirm it out loud. |
Check for presence and ask the local team if the defibrillator has been tested (Intubator). |
Check the presence of 2 waste bins, one on each side of the bed (Assistant), confirm it out loud. |
Check for presence and permeability of venous access (Assistant) with 5 mL of 0.9% SS, confirm it out loud. |
Connect TriWays with coupled induction medications (Assistant) (Fig. 3), confirm it out loud. |
Check if the patient is correctly monitored (Assistant), confirm it out loud. |
Phase 3- Pre-oxygenation
|
Position the patient to maximize safe apnea time (Intubator). |
Seal the face mask tightly in the V / E position (Intubator). |
Perform pre-oxygenation for 3-5 minutes with: 100% O2, always with HEPA filter, 2L / min O2 flow, maintaining CPAP valve at 5 cm H2O (Intubator). |
Phase 4 - Rapid sequence induction
|
Perform anesthesia and deep muscle relaxation (Intubator requests and Assistant administrates it): Fentanyl 150 mcg in the third minute of pre-oxygenation Lidocaine: 80 mg + Propofol 150 mg 01 minute after the fentanyl (Lidocaine aspirated together with Propofol) Succinylcholine: 100 mg (or Rocuronium: 100 mg as soon as the patient is unconscious |
Ensuring complete neuromuscular block before attempting tracheal intubation. |
Do not perform periglottic anesthesia. |
If necessary, request technical maneuvers such as Backward Upward Right Pressure (BURP) to the assistant (Intubator). |
If manual ventilation is required: Use low tidal volumes (200-250 mL) under low pressure (15-20 cmH2O), Preferable four-hand ventilation technique to prevent leakage (through the mask, around the nose and chin) Use an oropharyngeal cannula |
Phase 5 - Orotracheal intubation
|
Perform videolaryngoscopy (Intubator). |
Intubate with a 7.0-8.0 mm tracheal tube (in women) or 8.0-9.0 mm (in men) (Intubator). |
Inflate the cuff while visualizing with the video laryngoscope (Assistant), verbally confirming the visualization (Intubator and Assistant). |
Discard syringe in the waste bin (Assistant). |
Hold the OTT close to the mouth (Assistant) while the Intubator pulls back the Bougie, holding it close to the connection with the Swivel. |
Clamp OTT with strong clamps (Assistant). |
Clamp OTT with strong forceps when the Bougie is above the Cuff outlet (Assistant). |
Throw Bougie in the waste bin (Intubator). |
Remove the swivel red cover and dispose of it in the waste bin (Assistant). |
Connect the ventilation circuit (Intubator). |
Unclamp the OTT (Assistant). |
Ask the Assistant to hold / stabilize the OTT to avoid displacement (Intubator). |
Remove external gloves and put on new gloves (Intubator). |
Ask the attending physician or physical therapist to start mechanical ventilation (Intubator). |
Confirm OTI through observation of chest expansion and EtCO2. Do not auscultate (Intubator). |
Fix OTT (Intubator). |
Place the videolaryngoscope blade in a plastic bag with double zip lock. Seal plastic bag (Assistant). |
Remove external gloves and put on new gloves (Assistant). |
If tracheal aspiration is necessary, use a closed system. |
Administer Midazolam 5mg, Fentanyl 100 mcg, and Rocuronium 50 mg, (Intubator requests and Assistant administers it). |
Ask the local medical team to maintain sedation and analgesia with appropriate drugs, verbally communicating what is administered (Intubator). |
Phase 6- Unattire
|
Carry out unattire (see RCDP article for attire and unattire procedures1313. Oliveira HC, Souza LC, Leite TC, Campos JF. Personal protective equipment in the coronavirus pandemic: training with Rapid Cycle Deliberate Practice. Rev Bras Enferm. 2020;73(Suppl 2):e20200303. doi: 10.1590/0034-7167-2020-0303. https://doi.org/10.1590/0034-7167-2020-0...
). |