- Patient features: facial hair, small mouth, arched/high palate, short neck, thick neck, protruding teeth
- Mallampati Classification
- Class I: Soft palate, entire uvula, faucial pillars
- Class II: Soft palate, major part of uvula, faucial pillars
- Class III: Soft palate, base of uvula
- Class IV: Only hard palate
- Mouth opening/interincisor gap (ideally >3 cm)
- Thyromental distance (ideally >6.5 cm)
- Mandibular protrusion
*The addition of “E” denotes Emergency surgery (An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part).
Preoperative Cardiac Assessment Algorithm for CAD
ASA Guidelines for Preoperative Fasting/Pharmacologic Recommendations
- M – Machine check, including ventilatory settings
- S – Suction on with catheter in place
- M – Monitors on patient (blood pressure cuff, pulse oximetry, ECG, ETCO2 detector, temperature probe)
- A – Airway equipment (oral/nasal airway, face mask, stylets, ET tube, laryngoscope with working bulb)
- I – IV access for administering drugs and giving fluids
- D – Drugs, including induction agents, muscle relaxants, resuscitation drugs
- S – Special equipment, including video laryngoscopes, arterial lines, prone view, BIS, NG tube
Premedication – Adult
- Anxiolysis/Amnesia – Versed 1-2 mg IV (when rolling to the OR); DO NOT give to elderly without checking with attending
- Analgesia – Fentanyl 25-50 mcg doses
- PONV – Scopolamine transdermal patch (when you see patient in preop) – Ensure you warn patients of side effects
- Antacids – Sodium citrate (PO) 10-20 mL
- Anticholinergics – Glycopyrrolate 0.2 mg (useful for drying oral secretions)
- Pre-op interview – The best premedication is a good pre-op interview that builds rapport and confidence with the patient and the family
FDA Anesthesia Apparatus Checkout Recommendations, 1993
This checkout, or a reasonable equivalent, should be conducted before administration of anesthesia. These recommendations are only valid for an anesthesia system that conforms to current and relevant standards and includes an ascending bellows ventilator and at least the following monitors: capnograph, pulse oximeter, oxygen analyzer, respiratory volume monitor (spirometer) and breathing system pressure monitor with high and low pressure alarms. This is a guideline that users are encouraged to modify to accommodate differences in equipment design and variations in local clinical practice. Such local modifications should have appropriate peer review. Users should refer to the operator manual for specific procedures and precautions.
Emergency Ventilation Equipment
*1. Verify Backup Ventilation Equipment is Available & Functioning.
High Pressure System
*2. Check O2 Cylinder Supply
- a. Open O2 cylinder and verify at least half full (about 1000 psi).
- b. Close cylinder.
*3. Check Central Pipeline Supplies
- a. Check that hoses are connected and pipeline gauges read about 50psi.
Low Pressure System
*4. Check Initial Status of Low Pressure System
- a. Close flow control valves and turn vaporizers off.
- b. Check fill level and tighten vaporizers’ filler caps.
*5. Perform Leak Check of Machine Low Pressure System
- a. Verify that the machine master switch and flow control valves are OFF.
- b. Attach “Suction Bulb” to common (fresh) gas outlet.
- c. Squeeze bulb repeatedly until fully collapsed.
- d. Verify bulb stays fully collapsed for at least 10 seconds
- e. Open one vaporizer at a time and repeat “c” and “d” as above.
- f. Remove suction bulb, and reconnect fresh gas hose.
*6. Turn On Machine Master Switch and all other necessary electrical equipment.
*7. Test Flowmeters
- a. Adjust flow of all gases through their full range, checking for smooth operation of floats and undamaged flowtubes.
- b. Attempt to create a hypoxic O2/N2O mixture and verify correct changes in flow and/or alarm.
*8. Adjust and Check Scavenging System
- a. Ensure proper connections between the scavenging system and both APL (pop-off) valve and ventilator relief valve.
- b. Adjust waste gas vacuum (if possible).
- c. Fully open APL valve and occlude Y-piece.
- d. With minimum O2 flow, allow scavenger reservoir bag to collapse completely and verify that absorber pressure gauge reads about zero.
- e. With the O2 flush activated, allow the scavenger reservoir bag to distend fully, and then verify that absorber pressure gauge reads < 10 cm H2O.
*9. Calibrate O2 Monitor
- a. Ensure monitor reads 21% in room air.
- b. Verify low O2 alarm is enabled and functioning.
- c. Reinstall sensor in circuit and flush breathing system with O2.
- d. Verify that monitor now reads greater than 90%.
10. Check Initial Status of Breathing System
- a. Set selector switch to “Bag” mode.
- b. Check that breathing circuit is complete, undamaged and unobstructed.
- c. Verify that CO2 absorbent is adequate.
- d. Install breathing circuit accessory equipment (eg, humidifier, PEEP valve) to be used during the case.
11. Perform Leak Check of the Breathing System
- a. Set all gas flows to zero (or minimum).
- b. Close APL (pop-off) valve and occlude Y-piece.
- c. Pressurize breathing system to about 30cmH2O with O2 flush.
- d. Ensure that pressure remains fixed for at least 10 seconds.
- e. Open APL (pop-off) valve and ensure that pressure decreases.
Manual and Automatic Ventilation Systems
12. Test Ventilation Systems and Unidirectional Valves
- a. Place a second breathing bag on Y-piece.
- b. Set appropriate ventilator parameters for next patient.
- c. Switch to automatic ventilation (Ventilator) mode.
- d. Turn ventilator ON and fill bellows and breathing bag with O2 flush.
- e. Set O2 flow to minimum, other gas flows to zero.
- f. Verify that during inspiration bellows delivers appropriate tidal volume and that during
- expiration bellows fills completely.
- g. Set fresh gas flow to about 5 L/min.
- h. Verify that the ventilator bellows and simulated lungs fill and empty appropriately without sustained pressure at end expiration.
- i. Check for proper action of unidirectional valves.
- j. Exercise breathing circuit accessories to ensure proper function.
- k. Turn ventilator OFF and switch to manual ventilation (Bag/APL) mode.
- l. Ventilate manually and assure inflation and deflation of artificial lungs and appropriate feel of system resistance and compliance.
- m. Remove second breathing bag from Y-piece.
- Check, Calibrate and/or Set Alarm Limits of all Monitors
Capnograph – Pulse Oximeter -O2 Analyzer Respiratory Volume Monitor (Spirometer)-Pressure Monitor with High and Low Airway Pressure Alarms
14. Check Final Status of Machine
- a. Vaporizers off
- b. APL valve open
- c. Selector switch to “Bag”
- d. All flowmeters to zero (or minimum)
- e. Patient suction level adequate
- f. Breathing system ready to use
This FDA checklist can be downloaded at http://vam.anest.ufl.edu/fda-checklist4fold.doc