This non exhaustive list is not an anaesthesia course, but a reminder of some simple issues junior anaesthetists tend to forget. That might also help you understand some of your consultants’ idiosynchrasies!
Do not attempt to simply imitate the practice of more experienced anaesthetists. Just stick to the basics and do things by the book.
Preassessment
Scared, starved and sometimes lacking sleep, patients often forget important parts of their medical history when you interview them on the day of surgery. They also might be upset because they are asked the same question several times. Therefore it is important to read the patient’s notes (especially if there is a thick set).
Typically, patients forget:
- Events “a long time ago”, even if it is a cervical spine fusion or a Hodjkin lymphoma
- Unusual diseases they do not understand, i.e. neurological conditions
- Conditions who do not give them concern such as chronic Hep B carrier or an ongoing cold
- Conditions they would rather not think about such as schizopherenia
Chest auscultation should be done with a stethoscope designed for the purpose. Most cheap sthetoscopes attached to the nurse’s monitoring stations are designed for manually checking the blood pressure, not medical auscultation. Especially, they will miss most murmurs and discreet wheezes.
IV Access
If the patient looks difficult to cannulate, it is better to look first on both upper limbs before choosing the best vein. Veins are usually bigger on the dominant side. It is also safer to use a mechanical tourniquet rather than a human one who might be distracted and whose hands might be too small for a big arm.
Hold the patient’s hand below his body’s level, gravity helps to fill up the veins.
In order to avoid the skin wrinkling and the veins “rolling”, keep the skin as tense as possible. Ask the patient to slightly bend his/her wrist and manually pull the skin down from the chosen puncture site.
Some novice anaesthetists introduce the catheter slowly, under the assumption that it would be less painful for the patient. Unfortunately, the most painful zone in most needles procedures is the skin. Therefore it is less traumatic to cross the skin as fast as possible and if needed, to change direction once the sharp part of the needle has passed the skin.
Induction
Remember that most anaesthetic drugs decrease both the heart rate and the blood pressure. The combination of induction drugs and halogenated gases can be too much for some fragile patients. Therefore it might be useful to check the blood pressure before starting the gases.
If you are unsure of the outcome of your anaesthetic, give plain oxygen rather than the O2/N2O mixture. Switch to less than 100% O2 only once you are happy that your patient is stable.
All anaesthetic manoeuvres (ventilation, airway manipulation) are much easier to perform if you wait until the patient is fully asleep beyond Guedel stage 2. If you stimulate the patient in stage 2, he is liable to cough, laryngospasm etc… making you induction much longer than planned.
Intubation
Having the patient’s head in the right position would make your intubation tremendously easier and quicker. You can simply check the position of the head by standing at the patient’s side before induction. Also check that the trolley/bed is flat and there are no knots or headgear at the back of the head. Pillow should be of the right size to have the head in the sniff position. A pillow too thick will induce a flexion of the neck and reduce your laryngoscopic view. There is also less strain on your back if you have the trolley/bed in the right position relatively to your own height and size. The patient’s nose should be roughly at the level of your navel and his mouth within 30-40cm from you.
Securing the Airway
When the patient is ventilated in positive pressure each inspiration pushes the LMA out and might make it leak. This is why it is rather difficult to use a PEEP with an LMA. What keeps it in place is a good fitting within the pharynx and the tie/tape.
Tie versus Tape
Tie is usually less precise than tape to hold an ETT in the same position. Depending on its fabric and position around the head it has some laxity. It can also induce pressure sores if it is too tight. However, a tied tube is much less likely to be accidentally pulled out.
Where to tie the knot?
- A knot tied on the airway will usually be soaked in saliva and would difficult to undo manually at the end of the anaesthetic. Therefore keep a pair of scissors at hand.
- A knot tied on the cheek is easier to undo, but can “pull” the airway on the side.
Tape usually ensures a more precise position, however, it is difficult to use in some patients:
- those who had an allergic reaction to it
- those with skin lesions around the mouth
- patients with beard/moustache
- patients with cream/make-up
Places where to put the tape
The thing to remember is that the lower jaw is MOBILE. Anything secured against it is liable to change position. If you choose to secure an ET tube on the lower jaw (like in many ENT procedures) it might be pulled out when the mouth is open or pulled further in if the mouth is fully closed. This can lead to a selective intubation.
Transfers/Lines
The two things to watch during transfers are the airway and the IV line +++
If you have several IV lines hiding under the surgical field, you can label them. If the drugs you are injecting do not seem to have the expected effect, check whether your line has not been pulled out or disconnected.
Temperature monitoring
Oesophageal probes are meant to be in the oesophagus to be accurate. An oesophageal probe is very unlikely to be in the oesophagus if you have inserted it after an LMA.
Central lines
There is a whole catalog of situations when you cannot rely on the CVP reading to guide your fluid filling. This includes:
- catheter in the wrong position (especially if not checked with X-Rays)
- severe cardiac failure
- tachycardia above 120-130
- severe valvulopathies
- severe pulmonary hypertension
Therefore if your CVP reading seems odd, check the patient is not in one of those situations.
Extubation
Modern anaesthetic gases are mostly eliminated by BREATHING. If the patient is not breathing, he is not going to eliminate them. Therefore you need to have a clear extubation strategy:
- If you want to extubate the patient “deep”, you let him resume spontaneous breathing.
- If you want to extubate the patient fully awake, waiting for him to resume spontaneous breathing and eliminate his gases at his own pace is actually going to take longer than to clear the gases with mechanical ventilation.
Spinal
An important element for a quick and successful spinal is communication with the patient BEFORE and during the procedure.
During preassessment, it is wise to examine the patient’s back before making unrealistic plans. It is not uncommon to see spine abnormalities such as scoliosis or absence of a posterior process.
You also need to explain the patient what to expect and what position to take. References to cats and coctail shrimps might sometimes be useful. You can show them the position by bending your back yourself and even ask them to take the position during preassessment to make sure they have understood. That would save some time during the actual spinal.
The most important thing for an easy spinal is the patient’s position. It is nearly impossible to reach the CSF from the median approach if the patient has some degree of lordosis. Therefore the position is the first thing to check before any attempt.
If the patient can sit cross-legged, it would bring the back in the optimal position.
Also put the patient in a comfortable position for yourself with the injection site at the level of your elbows.
If you are expecting the spinal to be difficult and needing several attempts, it is important to have a good and wide local anaesthesia, possibly on several levels. You also need to wait a few minutes before your local anaesthetic starts to work. All this ensures maximal patient comfort and cooperation. Do not forget your maximal toxic doses and aspirate before injecting.
The needles you find in the Department are 9cm, standard length and 12cm.
If you fail to get into the space, your need to reflect on your failure. It might give you some clues about where the actual space is. You need to analyse the feel at the end of the needle:
- Superficial bone contact: superior spinal process
- Deep bone contact: lower spinal process
- No bone contact: paravertebral muscles
- “Scrunchy” hard bone contact: lateral process
- Feeling to have entered the ligamentum flavum but no CSF: needle too lateral or not deep enough, possible need for a longer needle
If the spinal was difficult, it is important to write a good report in the notes, especially if the patient might need another spinal in the future.
