Call Night Duties
Upon arrival to Presbyterian:
1. Call resident on call for the night (P1 or P2). Get attendance form from
computer room so resident can sign it. (It’s better to do this at the
beginning of the night when you first find the residents or else they may go
to bed or be in the middle of a tough case.) THE CODE IS 55114*
2. Write your name and pager number on the board beside the main surgical
board.
3. Check rooms 11,12, 16 and 18 (trauma rooms—top priority) first to
determine if need restocking/preparation for the night. On the weekends
14/15 are important as well.
4. Restock/ prep all other rooms as needed, assist cases with residents
(once again, this is the main reason you are here)
5. Observe, help, hang out, etc. as situation arises.
6. Turn in attendance form on June Fish’s door.
Upon arrival to Everett Tower:
1. You’ll need to pick up a time slip in the residents room in the OB
anesthesia area on the 4th floor “high risk” side.
2. Find the OB anesthesia resident on call for the night and see if they have
any special requests or need any assistance.
3. Stock the three epidural carts. There is one cart outside the anesthesia
resident’s room and two in the new “low risk” area marked “EPIDURAL
CARTS”. One of the carts is “hidden” behind the other (keypad combo is
1173 *) Make sure there is wide silk or foam tape, plenty of tegaderms,
sterile gloves (various sizes), 10 cc syringes, and vented nitro tubing or
the new yellow tubing.
4. Check the carts in the OB surgical suites and resupply as needed.
Remember they use 6, 6.5, and 7 ET tubes in OB. Most supplies you can
get from the core between the rooms. The core room between all the OR’s
has new med trays and an area to return used trays. If you need any extra
supplies get them from the 3rd floor OR ANESTHESIA WORKROOM.
5. Call over to the Children’s OR and check to see if they need any help.
6. Go over to Presby to help out in case things are busy over there. This is
also a good time to turn in your time slip under June Fish’s door.
To change over an operating room (after room has been cleaned by staff):
1. Wipe off all leads (EKG, pulse ox, blood pressure cuff, art line) with wash
cloth dipped in cleaning solution found in the sink in the core area
2. Needs: Purple hose package (contains gray vent bag, long CO2 tube,
hose), CO2 monitor hose (yellow), facemask, suction tube + suction, red
suction bucket with top, EKG pad package, unopened drug tray, head
pad/donut. Obtain all from anesthesia workroom.
3. Replace suction bucket and top. Connect suction tubing to outlet of bucket
and to suction (which remains in package with only one end of package
opened) and place in 2nd drawer of machine.
4. For the new machines. You will need to remove the yellow CO2 hose and
attach the plastic part between the purple hose and the clear bracket that
the mouthpiece attaches to. Now attach the hose from the yellow part to
the area over the anesthesia machine. You can’t miss them because you
have 3 little hoses and they only fit in their respective spot.
5. On bed, place EKG leads with white on right and black+red on the left. On
top of clean sheets at head of bed, place donut. On top of donut place one
green towel spread out. On top of towel place 3 EKG pads. Note: to
remember which EKG lead goes where on body and bed: White on right,
Smoke over Fire on left (White on right side, black and red on left).
6. In anesthesia cart, replace drug tray in cart drawer number 1 with new
drug tray. Return old tray to workroom. Note: make sure that blue label in
used tray has patient sticker on it. If not, ask resident (this will usually be
done but be aware).
To set up room (Remember: Rooms all rooms but 12 and 18 need to have “dry”
set-up—no IV or art lines needed, just equipment set up on machine and on cart.
Rooms 12 and 18 must have an art line, IV, and hot line set up):
On anesthesia machine table:
1. Tongue depressor + oral airway (1st drawer of machine) + a couple of
various sized nasal airways
2. Miller 2, 3 and Mac (curved blade) 3, 4 and a working handle. Remember
to test all blades and handle to ensure light illuminates. Cover the blades
with a fresh green towel to avoid contamination.
3. Face mask
4. Pulse Ox wire (2nd drawer of machine)
5. Esophageal temp probe (2nd drawer of cart)
6. 7.0, 7.5, 8.0 endotrach tube with 10 cc syringe open and attached to end.
Open one end of endotrach wrapper, test balloon with syringe and leave
syringe attached to tube and tucked in wrapper. Rooms 12 and 18 are the
only room to set these out in. In all other rooms, make sure they are
present but leave them in the cart with syringe.
7. On anesthesia cart table:
1. Stack of green towels
2. 1x 20 cc, 1x 10 cc, 2 x 5 cc, 2 x 3 cc syringes. Each with 18 G
1.5”needle (pink wrapper) inserted and ready. Label 5 cc with
Lidocaine, 5 cc with Fentanyl, 3 cc with Midazolam. NOTE: Leave
blue tops to syringes next to syringes.
In Rooms 12 and 18 make sure a new box with Level 1 tubing is available.
Do not open it. If asked to set up a level 1, always use NS not LR to avoid
problems with blood infusion. Also, make sure there is a Boushee in the second
drawer of the med cart.
Components of IV/Art Lines (Ask the resident/tech to assist in setting up and
clearing out air bubbles until you are comfortable doing this on your own):
Unless immediately prior to an incoming case, leave as much white tape on the
tubing in order to signify that it has not been used. Also, always use military time
and date all fluids that are spiked.
IV: (see video)
 1 bag NaCl, 4 way stopcock (4th drawer of cart), “Y-type” blood solution
tube (6th drawer of cart)
 After set-up, write date and time on silk tape and apply to bag.
Art line: (see video)
 Infusion bag (bag with pump)—6th drawer of cart, 500 mL heparin (6th
drawer of cart or hidden on bottom shelf of drug tray return cabinet in
anesthesia workroom), single/double line kit (ask resident whether
single or double is preferred).
 Place the heparin in the infusion bag and pump the bag until the gauge
shows green. Once you see green, move the valve to the closed
position (hint: the positions are on the infusion bag)
 IMPORTANT: Before you attach the art line to the infusion bag, first
check the attachments on the tubing to make sure they are all tight.
Generally, they are very loose and are prone to come apart in a case
unless YOU tighten them.
 Once you have inserted the art line into the heparin bag, it is helpful to
turn the line upside down as you clear it so air can easily escape.
(Make sure the stopcocks are in the correct position to direct flow.)
 Attach the art line to the IV pole in the correct position. Remember, the
connector always points down.
 Attach P1 lead from machine to the connector that looks like a phone
cord on the art line tubing from the red side.
 If using double line, also connect P2 to the connector from the venous
side which is blue
“Hot” line: (see video)
 Hot line tubing (6th drawer of cart) attaches to the end of the Y-type IV
tubing onto the stopcock and “snaps” into the hot line machine on the
IV pole. Attach a Discofix IV extension (third drawer of cart) to the end
of the hotline
Important Hospital Codes
Everett Tower
ET OB
1173*
Presbyterian Tower
OR locker rooms and the doctor’s lounge
Computer Room
use your slide card
55114*
Quick Reference Guide
Fluid Management
Maintenance:
4 ml/kg/hr for first 10 kg
2 ml/kg/hr for next 10 kg
1 ml/kg/hr for the remainder
ET Tubes and Airway Management
Age
Premie
Term-6 mo
6-12 mo
12-20 mo
2 years
4 years
6 years
8 years
10 years
12 years
Adult (50-70 kg)
Adult (70-100 kg)
Pregnant
Adult nasal intub.
Size ET
2.5-3
3
3-3.5
3.5-4
3.5-4.5
4-5
4.5-5.5
5-6
6.5
7
7-8
8-9
6.5-7
6.5-7.5
Blade
0 Mil
1 Mil
1 Mil
1.5 Mil
1.5 Mil
2 Mil
2 Mil/Mac
2 Mil/Mac
2-3 Mil/Mac
3 Mil/Mac
3 Mil/Mac
3-4 Mil/Mac
3-4 Mac
3-4 Mil/Mac
Dist @ Lip
8-10
10-11
11
12
13
14
15-16
16-17
17-18
18-20
20-22
22-24
20-22
add 2-3
LMA/ inflate
N/A
#1/ 2-4cc
#1/ 2-4cc
#2/ 10 cc
#2/ 10 cc
#2/ 10 cc
#2.5/ 14 cc
#2.5/ 14 cc
#2.5/ 14 cc
#3/ 20cc
#4/ 30cc
#5/ 40cc
N/R
N/A
Hemodynamic Formulas
Variable
Cardiac Index
Stroke Volume
Stroke Index
Mean Art Pressure
Sys Vas Resistance
Equation
CO/ Body Surface Area
CO/ HR x 1000
SV/ Body Surface Area
Dias Press + 1/3 PP
[(MAP-CVP) / CO] x 80
Normal Values
2.8-4.2 l/min/m2
60-90 ml/beat
40-60 ml beat/m2
80-120 mm Hg
90-1400 dynes/sec/cm
Pul Vas Resistance
CO
=
HR
=
SV
=
PP
=
MAP =
CVP =
PAP =
PCWP =
[(PAP-PCWP) / CO] x 80 100-250 dynes/sec/cm
cardiac output
heart rate
stroke volume
pulse pressure
mean arterial pressure
central venous pressure
mean pulmonary artery pressure
pulmonary capillary wedge pressure
Pulmonary Equations
Alveolar to arterial gradient
= (Fi02%/100) * (Patm - 47 mmHg) - (PaCO2/0.8) - PaO2
(all units mmHg)
Arterial oxygen content (Ca02)
= (Hb x 1.36 x Sa02 / 100) + Pa02 / .0031
Tidal volume
= minute volume / breaths per minute
Oxygen consumption / minute
= minute volume(O2 fraction inhaled - O2 fraction exhaled)
Pounds to Kilograms
Divide the number in pounds by 2 and subtract 10% from that number.
For example…
268 lb. divided by 2 is 134. 10% of 134 is 13. 134-13 is 121 kg.
HOW TO INTUBATE
Prior to intubation, always check equipment and make sure everything you might need is not only
within your reach, but also properly working. If in the operating room, a complete check of the
anesthesia equipment at the start of each day as well as a modified check before each new case
is imperative. If in the emergency room or the hospital wards, make sure you know where all of
your equipment is and, also, that you have the necessary resources to support the patient once
intubated. Prior to positioning the patient:






Make sure that your laryngoscope is locked into
position and that the incandescent light on the blade
tip functions. Also make sure that you have several
alternate blades available in case the one you have
chosen does not allow for visualization of the cords.
Examine the endotracheal tube. Make sure that the
cuff inflates by using a 10-mL syringe to inflate the
cuff and then detach the syringe to ensure that the
cuff pressure is maintained. Be sure to deflate
deflate the cuff after testing it.
Attach the connector to the proximal end of the
tube. Push it in as far as possible to lessen the
likelihood of disconnection.
If you are going to use a stylet, it should be inserted
into the ET tube and bent to resemble a hockey
stick to facilitate intubation of an anteriorly
positioned larynx. Even if you do not plan on using
a stylet, one should be within easy access in case
the intubation proves to be more difficult than
anticipated.
Ensure a functioning suction unit to clear the airway in case of unexpected blood, emesis
or secretions.
Ensure that you have tape within your reach to secure the tube once it is in place.
Proper patient positioning can be the difference between a successful and failed intubation.



The patient’s head should be level with the physician’s xiphoid process.
To achieve the sniff position (which allows for optimal visualization of the glottic opening),
elevate the patient’s head and extend the atlanto-occipital joint. This can be achieved by
sliding your free hand (right hand if you are right handed, left hand if you are left handed)
beneath the patient’s head and gently lifting it up and towards you. Or, you can gently
position the chin up and mouth open before attemting laryngoscopy.
The "scissor technique" can also be used to further open the patients mouth. Cross your
right forefinger and thumb and insert into the right side of the patient's mouth. Apply
pressure to the upper teeth with your forefinger and the lower teeth with your thumb to
open the mouth. Be sure to position your hands so as NOT to obstruct your view.
Mask Ventilation is often used in the operating room after induction, prior to intubation. If
you are able to achieve signs of ventilation using this technique, you are afforded the knowledge
that, if intubation fails, you are able to achieve ventilation using the bag-mask-valve device.
Further, it allows for pre-oxygenation. Preparation for induction and intubation in the operating
room also involves pre-oxygenation with several (eight) deep breaths of 100% oxygen.
Preoxygenation provides an extra margin of safety in case the patient is not easily ventilated after
induction.
After preoxygenating the patient and positioning the patient in the Sniff position, with the patient’s
mouth widely open, carefully introduce the blade, held in your LEFT HAND, into the right side of
the mouth. Regardless of which blade is used, IT MUST NEVER PRESS AGAINST THE TEETH
or dental trauma will result. The tongue is then swept to the left and up into the floor of the
pharynx by the blade’s flange.
The curved Macintosh blade is inserted past the
tongue into the vallecula (at the base of the tongue).
Providing sufficient lifting force in parallel with the
handle, yet avoiding posterior rotation that causes the
blade to press against the teeth, pressure is applied
deep in the vallecular space by the tip of the blade
immediately anterior to the epiglottis, which flips out
of the visual field to expose the laryngeal opening.
The straight
Miller blade is
inserted deep
into the oropharynx, PAST the epiglottis. Providing
sufficient lifting force in parallel with the handle, yet
avoiding posterior rotation that causes the blade to press
against the teeth, under direct vision, the blade is slowly
withdrawn. It will slip over the anterior larynx and come to
a position at which it holds the epiglottis flat against the
tongue and anterior pharynx, exposing a view of the
larynx.
With either blade, the handle is raised up and away from the patient in a plane perpendicular to
the patient’s mandible. Avoid trapping a lip between the teeth and the blade and AVOID using
the teeth as leverage and avoid posterior rotation of the blade.
Once a view of the larynx is obtained via laryngoscopy, the ETT is introduced with the RIGHT
HAND through the right side often mouth. Directly observe the tip of the tube passing into the
larynx, between the abducted cords. Pass the tube 1 cm through the cords. The ETT should lie
in the upper trachea but beyond the larynx (3 to 4 cm proximal to the carina). If the patient is
going to be repositioned, the cuff should be closer to 2 cm beyond the cords.
Remove the laryngoscope, careful not to displace the ET tube and not to cause trauma to the
teeth, lips or mucosa.
Inflate the cuff with the least amount of air necessary to create a seal during positive pressure
ventilation (usually 4-8 mL of air).
Remove the mask from the bag-valve device and attach the 15 mm connector on the proximal
end of the ET tube to the bag-valve device (into which oxygen is flowing and to which the carbon
dioxide detector is attached). Provide positive pressure and immediately (and quickly):




ausculatate the chest for breath sounds
check the capnoraphic tracing on the monitor to ensure end tidal CO2
check the connector for fog
look at the chest for expansion with each breath
If there is any question as to whether the tube is in the esophagus or trachea, remove the tube,
ventilate with a mask and try again, this time attempting to adjust anything that may have
interfered with your first attempt. You might reposition the patient, use a different blade, decrease
tube size, or add a stylet.
If you are sure that your intubation is successful, turn on the mechanical ventilator. Continuously
provide positive-pressure ventilation at a volume of 350-700 ML per 70 kg (5-10 mL/Kg) and at a
sufficient rate to maintain normal end tidal CO2 (8-12 respirations per minute).
Proceed to tape or tie the tube to secure its position. Do not tape or tie the cuff. To prevent the
patient from biting and occluding the ETT during emergence from anesthesia, a roll of gauze can
be placed between the teeth or an OPA can be inserted.
Document the view of the larynx obtained during laryngoscopy using the following criteria:




Grade I: full view of the cords
Grade II: partial view of the cords
Grade III: view of the epiglottis
Grade IV: No view of the cords or epiglottis
HOW TO START AN IV
Preparing the arm:
Apply a tourniquet high on
the upper arm. It should be
tight enough to visibly indent
the skin without causing
patient discomfort. In order to
maximize venous
engorgement, have the
patient squeeze his hand into
a fist several times.
Now start the search for
suitable distended subcutaneous veins. If you cannot see any veins popping up from the
distention caused by the tourniquet, you can sometimes feel them by palpating the arm. If you still
cannot find any veins, then it might be useful to cover the arm in a warm compress to help with
peripheral vasodilation. If after a meticulous search no veins are found; release the tourniquet
from above the elbow, place it around the forearm and search in the distal forearm, wrist and
hand. If no suitable veins are found, then you will have to move to the other arm. Be careful to
stay away from arteries which
are pulsatile.
Once a suitable vein is found,
then it is necessary to clean
and disinfect the area by
swiping it several times with
two alcohol wipes. If the arm
is particularly hairy in this
spot it may be necessary to
use a disposable razor to
shave the hair partially too
make a region that will be
clean.
Select Angiocatheter
Usually a 20 or 22 gauge
angiocatheter is suitable.
Take it apart and put it back
together to get a sense of
how it works and how much
force is required to slide the
plastic catheter over the metal
stylet.
Puncture Vein
Use one hand to apply
counter tension against the
skin. This hand, generally the
left hand, will be pulling the
skin distally towards the wrist
in the opposite direction to
the needle will be advancing.
When applying counter
tension be careful not to
compress inflow to the vein
which may cause the vein to
collapse. Advance the angiocatheter through the skin over top of the vein or adjacent to the vein.
Use a quick, jab motion to minimize patient discomfort. Slow pokes through the skin will maximize
the sensation of pain. Then advance the angio catheter well into the vein and look for the dark red
flashback of blood at the angio catheter hub indicating that the angio catheter is within the vein.
If this first pass is unsuccessful in entering the vein and there is no flashback then slowly
withdraw the angio catheter, without pulling all the way out, and carefully watch for the flashback
to occur. If you are still not within the vein, then advance it again in a 2 nd attempt to enter the vein.
While withdrawing always stop before pulling all the way out to avoid repeating the painful initial
skin puncture. If after several manipulations the vein is never entered and the attempt is
considered a failure; release the tourniquet, place a gauze over the skin puncture site, withdraw
the angiocatheter and tape
down the gauze. Now it is
time to move onto the other
arm.
Advance Plastic Catheter
Once the angiocatheter is
well seated within the vein,
slide the plastic angio
catheter forward deeper into
the vein over top of the
needle. The hub of the angio
catheter should be all the way to the skin puncture site. The plastic catheter should slide forward
easily. Do not force!!
Release Tourniquet
Once the angio catheter is
advanced in the vein up to
the hub, release the
tourniquet, apply gentle
pressure over the vein to
collapse it, so that blood will
not pour out of the angio
catheter when the stylet
(needle) is removed. Once
you remove the stylet
(needle) set it aside to be
disposed of in a Sharps container.
Attach SmartSet
Attach the male end of the Smart Set to the
female hub of the angio catheter. This is a
press fit.
Lock Tubing Connection
Lock the iv tubing to the angio catheter by
advancing and rotating the luer locking
mechanism. It requires a clockwise twist to
fully lock. At this point, quickly test the iv with a
small injection of saline to make sure it is
working properly. The saline should flush
easily. If the saline does not flush easily, check
to be sure the tourniquet is released. Also try
straightening the arm because sometimes
bending the elbow can kink a vein and prevent
the iv from functioning. If it still does not flush
easily, try aspirating. Sometimes an iv will
begin to work if it is withdrawn slightly so the
tip of the iv seats in a better position within the vein.
Secure with Tape
Tape the iv in place using
three or four strips of tape to
prevent accidental removal.
Place one or two pieces over
the actual skin puncture site.
Place additional pieces over
loops of tubing so that there
is some strain relief. Consider
taping to be one of the most
important tasks because it
prevents you from having to
repeat the iv insertion in the
event of an inadvertent tug
on the iv tubing.
Test iv
To test the iv inject saline.
There should be no
resistance. If necessary you
may also test the iv by
removing the Smart Prep MR
Adaptor and aspirating until
blood is seen entering the iv
tubing. Alternatively you can
test by engaging the clamp
and injecting the side port or
aspirating by the side port.
Helpful Links:
http://w3.ouhsc.edu/anesthesiology/students/
http://w3.ouhsc.edu/anesthesiology/ ****Click on the residency link in the middle
of the page and when the page comes up, scroll to the bottom of the page and
there are many helpful links (including the residents pics).