| Anesthetic risk | Strategies and precautions |
| Airway obstruction and respiratory depression with sedatives and opioids | - Avoid or minimize sedative premedication
- Use titrated infusion rather than bolus dosing of sedatives to decrease episodic respiratory depression
- Consider sedatives without respiratory depressant effects (eg, dexmedetomidine)
- Use continuous oximetry and ventilation monitoring (eg, capnography) when sedatives are given
- Use PAP device, hypoglossal nerve stimulator, or oral appliance for patients accustomed to these devices, if sedatives are administered
- Administer supplemental oxygen to avoid hypoxemia during monitored anesthesia care
|
| Gastroesophageal reflux disease and pulmonary aspiration | - Premedicate with prophylactic agents (proton pump inhibitors, H2-receptor antagonists, or non-particulate antacids)
- Consider cricoid pressure and rapid sequence induction and intubation
|
| Difficult airway (mask ventilation, supraglottic airway ventilation, laryngoscopy, and intubation) | - Assure availability of airway adjuncts and personnel for assistance
- Position with head elevated (reverse Trendelenburg) for preoxygenation and laryngoscopy
- Use maximally effective preoxygenation (tight-fitting mask, >3 minutes, consider PAP, end-tidal oxygen fraction of 0.87 to 0.9)
- Use two-person mask ventilation if mask ventilation is difficult
- Use apneic oxygenation with nasal oxygen insufflation or if available, transnasal humidified high-flow oxygen (up to 70 liters/minute–1) via purpose-made nasal cannulae, to prolong apnea time
- Follow difficult airway guidelines and algorithms
- Consider sugammadex for reversal of rocuronium or vecuronium in the cannot-intubate-cannot-oxygenate difficult airway scenario
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| Atelectasis and lung injury | - Positive end expiratory pressure and lung recruitment maneuvers
- Protective ventilation (low tidal volumes, low driving pressures, and low plateau pressures)
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| Rostral fluid shift leading to airway narrowing | - Administer fluid judiciously
- Avoid fluid with high salt content
- Position head up when feasible
|
| Prolonged postoperative effects of anesthetic agents (airway obstruction and respiratory depression) | - Consider short-acting general anesthetic agents, including intravenous and insoluble volatile agents (eg, desflurane, remifentanil, propofol)
- Minimize opioids by using regional anesthesia or multimodal analgesia techniques as appropriate (eg, nonsteroidal antiinflammatory drugs, COX-2 inhibitors, acetaminophen, tramadol, ketamine, dexmedetomidine, dexamethasone)
|
| Post-extubation airway obstruction | - Verify full reversal of neuromuscular blockade
- Consider use of sugammadex for reversal of rocuronium (or vecuronium)
- Extubate with patient awake (fully conscious and cooperative; airway reflexes intact)
- Extubate and recover in a non-supine position (head-up or lateral)
- Apply PAP early for patients using it preoperatively, or to treat hypoxemia or obstruction
- Resume use of oral appliance or hypoglossal nerve stimulation therapy in patients using them preoperatively
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