| Pre-procedure |
- Before surgery, establish patient suitability for this technique
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- At the multidisciplinary team brief, confirm each patient's suitability, agree on an individualized immediately deliverable rescue oxygenation strategy and the SpO2 value that triggers intervention
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- Undertake the entire procedure in the operating room. Prior to induction, complete the WHO Surgical Safety Checklist (adapted as necessary).
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- Apply standard monitoring and note baseline SpO2 prior to commencement of HFNO
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- Check gas is flowing through nasal cannulae and ensure the humidifier is at the chosen temperature
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- Position the patient in a head-up position. Optimize operating room ergonomics.
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- Commence HFNO (FiO2 1.0), increasing gas flow to ≥50 liters minute–1, as tolerated (≥5 minutes of preoxygenation, ideally with mouth closed)
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- Check SpO2 has risen above baseline (ideally to 100%). If the desired SpO2 is not achieved, consider suitability of this technique.
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- Apply remaining monitoring, including carbon dioxide monitoring (if available)
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- At the surgical pause, ensure entire team readiness (including clear role allocation) and that the patient is draped prior to induction of anesthesia
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- Ensure the equipment for the patient's individualized rescue oxygenation strategy is immediately available and functional (eg, facemask, supraglottic airway, laryngoscope, microlaryngoscopy tube, or jet ventilation kit)
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| Peri-procedure |
- Administer total intravenous anesthesia. Rocuronium is recommended if a neuromuscular blocking drug is used. Ensure the oxygen gas flow is set at 70 liters minute–1.
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- Maintain airway patency with jaw thrust +/– oropharyngeal airway until surgical instrumentation
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- Check effectiveness of facemask ventilation prior to commencing surgery (with waveform capnography)
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| For compressible nasal cannulae with flow-diversion capability (eg, Optiflow Switch), this is achieved without removal of cannulae |
- Commence surgery, ensuring a patent airway is maintained throughout
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| Post-procedure |
- Be ready to retake control of the airway on procedure completion (this can be achieved by jaw thrust +/– airway adjunct with continued HFNO, face mask, supraglottic airway or tracheal intubation)
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- Prior to emergence, reverse neuromuscular blocking drug if used (if rocuronium is used, then sugammadex is recommended)
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- Confirm adequate spontaneous respiration before transfer to the post anesthesia care unit
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- Consider taking HFNO nasal cannulae to post anesthesia care unit with patient to facilitate ongoing HFNO, as required.
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