Additional Resources:
Dotson R, Wiener-Kronish JP, Ajayi T: Preoperative evaluation and medication. In Stoelting RK, Miller RD, editors: Basics of anesthesia, 5th edition, Churchill Livingstone, New York 2007; 157 – 177.
Hata TM, Moyers JR: Preoperative Patient Assessment and Management. In Barash PG, et al. editors. Clinical Anesthesia 6th edition, Lippincott Williams & Wilkins, Philadelphia PA 2009; 567 – 597.
Chapter 5
Getting Started
Patti Murphy MD, Jordan Zacny MD
Learning Objectives
1 To provide a practical overview of the student’s role as part of the anesthesia care team.
2 To provide a practical overview for establishing intravenous access and monitoring procedures for patients requiring anesthesia care.
Key Points
1 The degree to which students actively participate in the anesthetic care of a patient correlates directly with their knowledge and their acquired technical skill set.
2 The mnemonic ‘STATICS’ can be used as a memory prompt for preparing equipment.
3 A blood pressure (BP) cuff can be used as a tourniquet in patients with difficult intravenous access. Inflation of the cuff to approximately 60 mmHg results in distension of both the deep and superficial veins.
4 To decrease the chance of a medication error, avoid distractions when preparing medications, and label syringes before drawing up medications.
5 For patient safety, students should not attempt to perform unfamiliar tasks unless under supervision.
6 Reasons for prescribing medications prior to an operative procedure can be related to the patient, the procedure, or the patient’s coexisting medical condition.
Introduction:
In this chapter, students are presented with a brief introduction to the anesthetic care of patients beginning with step-by-step guidelines for establishing monitoring procedures, intravenous access, and initial airway management. Students rotating through the operating room may find participating in the anesthetic care of patients daunting. As important members of the anesthesia care team, we encourage students to participate actively in operating room (OR) activities to maximize their learning opportunities. Anesthesiologists are uniquely positioned to pass on a wealth of knowledge in pharmacology and applied physiology as well as important skill sets involving airway management and intravenous access. This knowledge base and accompanying basic skills are valuable for all physicians. Few specialties can offer the precious one-on-one teaching that anesthesia provides. Anesthesiology is a unique and fascinating specialty! We hope all students enjoy their anesthesia rotation!
Preparing the OR:
To ensure safe anesthetic care, a number of steps must be completed before the patient is brought into the operating room.
Anesthesia Machine and Equipment:
The anesthesia machine and equipment must be checked and prepared. A link to the anesthetic machine checkout procedure is provided in the reference section, although the detail extends beyond the expectations and objectives of most students. Students find the mnemonic ‘STATICS’ helpful as a quick reminder of the equipment required for safe management of a patient’s airway (see Chapter 6 for further discussion on this topic). The mnemonic is useful in the operating room and can easily be adapted to any site in the hospital (ward, emergency, post anesthetic care unit [PACU] or intensive care unit [ICU]).
Suction
Tube (endotracheal tube)
Airway (oral and / or nasopharyngeal)
Tape (for securing the endotracheal tube)
Introducer (or stylet for the endotracheal tube)
Circuit (anesthesia machine) or AMBU bag
Scope (laryngoscope)
Medications:
Intravenous medications must be prepared and labelled. Students should ask the anesthesiologist if they can assist. Some anesthesiologists may prefer not to delegate this task, following the principle that they will not give medications that they did not prepare. Preparing medications that are not used is both wasteful and expensive and should be minimized.
1 Medication errors can have serious consequences. They arise when:
2 A correct medication is given to the wrong patient.
3 The wrong medication is given to the right patient.
4 Medication allergies are not identified or checked before a medication is administered.
5 The medication concentration is miscalculated.
6 Look-alike and sound-alike medications are involved.
7 Care providers are distracted or hurried (medication errors are more prevalent at this time).
8 Infrequently used medications are given (medication concentration calculations are more prevalent as is the likelihood of an error).
Before administering any medications, confirm the patient’s identity and any known allergies. Common identified high-risk medications1 with potential serious consequences in the critical care setting include opioids, insulin, heparin, protamine, vancomycin, muscle relaxants, and vasoactive medications, such as phenylephrine and epinephrine. Students should ask their staff anesthesiologist why these medications are considered high-risk.
It is absolutely imperative to be cautious and conscientious when preparing medications.
Always:
Give your full attention to this task.
Avoid distractors (conversation, multi-tasking).
Label the syringe first.
Place the label at the volume that is to be drawn into the syringe.
For example, if 5 mL are to be drawn up, place the label at the 5 mL mark. If the drug is to be diluted, ensure the final concentration is written on the label. For example, ephedrine comes in vials of 50 mg∙mL-1, but it is commonly diluted to 10 mL, which equates to a concentration of 5 mg∙mL-1.
(One mL of drug with a concentration of 50 mg∙mL-1 when diluted to a volume of 10 mL = 5 mg∙mL-1).
Fig. 5.1 Labelled syringes
Preparing Medications:
1 Read the label on the vial.
2 Draw up the drug.
3 Read the label again before you put the vial down.
4 Record the concentration on the label.
5 Consider having another more experienced health care provider check your calculations for drugs that are unfamiliar or used infrequently.
Medications must always be prepared and labelled in unused clean syringes. Once the syringe