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.