Let’s review what a complete operating room anesthesia set up entails using the well known “MSMAIDS” mnemonic.
MSMAIDS stands for machine, suction, monitors, airway, IV, drugs, and special.
- Start the anesthesia machine, monitors, and computer
- Run the self-test
- Adjust the machine parameters depending on your case (general anesthesia, MAC) and patient’s information (age, ideal body weight)
- Check the volatile agent levels
- Between cases, the most important self-test is the low-circuit pressure test. To do this, we occlude the Y-piece, close the pop-off valve, flush O2, and ensure that there’s no pressure leak up to 40 cm H2O. I also like to switch on the ventilator just to see if it works.
- Make sure there’s an AmbuBag (bag-valve mask) in the room!
- Make sure the suction circuit is connected and that a Yankauer suction tip is available. Most of the time you’ll also need to get a OG tube prepped with lubrication to evacuate the gastric contents prior to a general anesthetic.
- I usually switch the suction off at this point but make sure it’s readily available.
- Outside of the machine’s internal monitors (O2 analyzer, etc), you’ll need a plethora of external monitoring devices.
- EKG leads, pulse oximeter, temperature probe (esophageal stethoscope, Foley, skin probe), blood pressure cuff
- Depending on the nature and duration of the case, you may need a transesophageal echo (TEE), arterial/central line set up, BIS monitor, cardiac output monitor, or something entirely new. Anesthesia techs are extremely helpful in setting these up!
- Standard or reinforced endotracheal tube (ETT) with stylette placed and cuff checked for a leak
- Laryngoscope of your choice – I’ve been using the Mac 4 recently. Make sure the light is functional.
- Oral airways
- Make sure laryngeal mask airways (LMAs), bougies, and Glidescope/C-Mac are readily available in the event of a difficult airway
- I usually do this after the room is set up. Most of my patients start with a 20 gauge peripheral IV (PIV) for anesthesia induction. If I need more lines, I put them in after they’re asleep. 🙂
- This is also when I decide whether the patient needs a pre-induction arterial line. Otherwise, it goes in after intubation.
MEDICATIONS (a few examples)
- Pre-medication: fentanyl, midazolam, Pepcid, Reglan, Bicitra
- Induction: propofol, etomidate, rocuronium, succinylcholine, lidocaine, Nimbex
- Volatiles: sevoflurane, isoflurane, desflurane
- Pressors: phenylephrine, norepinephrine, ephedrine
- “Downers”: nitroglycerine, esmolol
- Analgesics: Toradol, morphine, fentanyl, hydromorphone, Tylenol
- Antibiotics: cefazolin, cefepime, vancomycin, etc
- Reversal: neostigmine, glycopyrrolate
- Other: Zofran, dexamethasone
- The obligatory “catch all” category. This is for everything else: OG/NG tubes, Bair Hugger blanket, fluid warmer, etc.
Now here are two images comparing my set up at two different hospitals. Notice the similarities and differences.