GASNet

Practical Tips, Tricks and Techniques for the Anesthesiologist

Presented in cooperation with Anesthesiology News

Many of the initial ideas have been collected by the author from 35 years of practice at over 30 different hospitals in eight countries. The nature of these practical tips is that some have been learned consciously or unconsciously from another individual, some were developed through collaboration, some have occurred simultaneously in different places, and only a few can be attributed safely to one inspired original individual. Unless specifically claimed or attributed to an individual, therefore, originality or ownership is neither implied or claimed. Each idea presented here, however, has satisfied the following criterion: several people, to whom it was not initially familiar, expressed interest and resolved to try it and, perhaps, incorporate it into their practice.

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October, 1996

Dr. Alan W. Grogono offers the readers of Anesthesiology News another set of helpful tips in this month's installment of "Tricks of the Trade." In this column, Dr. Grogono examines methods for facilitating extubation, preventing air emboli that may originate in infusion bags, and clearing air from I.V. lines. In addition to theoretical knowledge and technical skill, the successful anesthesiologist employs an impressive array of practical techniques that contribute to safety, efficiency and speed. Many of these useful ideas are individual or personal and, therefore, not widely known. The emphasis that today's medicine is placing on cost-effectiveness, time saving and risk management requires that practical ideas be collected, reviewed and disseminated. This column will present such ideas monthly; in addition, they may be found as a collection on the World Wide Web at GASNet.


Extubate Patients while they are Prone

The prone patient is, conventionally, turned supine prior to extubation. In practice, this may result in either a lightly anesthetized patient coughing and straining, or a delay, because a patient is kept deeply anesthetized and is slow to emerge from anesthesia. With appropriate precautions, the advantages of prone extubation outweigh the disadvantages. The prone position facilitates maintenance of a clear airway because the tongue falls away from the posterior pharyngeal wall; any vomit or secretions leave via the mouth instead of contaminating the larynx or trachea. The principal risks involve possible mandatory ventilation or intubation; these are met by requiring that a stretcher is available and properly located to receive the patient, and that sufficient staff are present and ready to turn the patient. The technique that facilitates this maneuver ensures that the patient is lightly anesthetized and partially paralyzed. After the final sutures are inserted and the stretcher and personnel are available, anesthesia is discontinued, high oxygen flows are administered and muscle relaxation is reversed. The patient is extubated when the following criteria are met: little nitrous oxide (or nitrogen) remains; successful reversal is anticipated and achieved; and the patient is awake, responds to commands, and is capable of sustaining a head lift. When these criteria are satisfied, successful extubation is routinely achieved and the patient can be turned supine without haste or anxiety.


Embolism From Infused Air

When connecting the infusion set to a fresh bag of fluid, the set is used to spike the bag and then withdrawn. The bag is carefully squeezed until very little air remains. The set is then reinserted; even if the bag is then infused under pressure, there will be insufficient air to reach the patient.


Force Air Back out of the I.V. Line

After an infusion bag is empty, it is common for several milliliters of air to enter the I.V. line below the drip chamber. This may be safely evacuated without needles or opening the stopcock as follows: The I.V. control is clamped closed and a new infusion bag attached, and the line above the control is then wound tightly around a finger or pen. The air is forced back up into the drip chamber.

Precautions: In neonates or patients with known atrial septal defect (ASD), be meticulous to ensure all air is located and evacuated; this technique only works in lines that have no check valve to prevent reflux.