The Same Simple Mistakes at Induction (and Emergence) Happen Over and Over Again—So Develop a Checklist, and Make it Ironclad
Brandon C. Dial MD
Randal O. Dull MD, PhD
For the airplane pilot, the most critical moments of a successful flight are takeoff and landing. So it is with anesthesia—the most critical moments occur at induction and emergence of general anesthesia. Like the pilot with a preflight checklist, the successful anesthesiologist has a checklist of important items that are reviewed prior to every induction to avoid many of the common pitfalls that may occur at these crucial times. Preventable anesthetic mishaps are often caused by a lack of familiarity with anesthetic equipment and a failure to check the anesthesia machine for proper function.
INDUCTION
Although there are many such checklists, the following mnemonic has been used at our institution to help ensure that the anesthesia machine and other equipment are ready for use by the prepared practitioner.
S—Suction
O—Oxygen
A—Airway
P—Positive-pressure ventilation
M—Medications
M—Monitors
S is for suction, probably the most easily and hence most commonly overlooked piece of equipment necessary for a successful induction. Although it is not always used, its presence is crucial for patients at risk for emesis and aspiration of gastric contents. It should be turned on and readily available with an appropriate tip and suction strength (−125 to −200 cm H2O). If you have checked your suction but then left the operating room (OR) for something, you must recheck it again right before induction.
O is for oxygen. The anesthesia machine should be checked to ensure that oxygen is being delivered from the wall outlets and that the flow meters for oxygen and air are working appropriately. A secondary source of oxygen should be available. This is accomplished most commonly by an auxiliary oxygen E-cylinder located at the back of the anesthesia machine. The valve
should be opened and the pressure checked to ensure that it is full and ready for emergency use.
should be opened and the pressure checked to ensure that it is full and ready for emergency use.
A is for airway equipment. Laryngoscope handles should be connected to blades to ensure that the light source is working. If it is not, the batteries or light bulb may need to be replaced. Several sizes of laryngoscope blades should be available, including both straight and curved blades. Despite the thorough preoperative airway exam, many difficult airways are realized after induction. Other airway devices such as oral and nasal airways for mask ventilation should be a close reach away. The Eschmann stylet (or Bougie) is a helpful airway tool for the unexpected difficult laryngoscopy. Assorted laryngeal mask airways should be ready for use. Other devices for the difficult airway are noted in the American Society of Anesthesiologists (ASA) emergency airway algorithm. These should be available and the practitioner familiar with their use, including supplies necessary to create a surgical airway. Preparation is paramount in the “can’t intubate, can’t ventilate” clinical emergency.
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