Anyone making their patients shave their beard?

[chocomorsel]

Especially the fatties? I live in a fat county, as probably many of y'all and I am sick of fighting with getting a good seal on fat patients with beards. Hell it can be somewhat difficult without the obesity and I was thinking about starting to ask the nurses in pre-op to shave the patients after I talk to them. Have had a few patients desaturate quickly into the 70's and sometimes 60's with me struggling and it's getting old. I feel like honestly its a safety issue for safe anesthesia. And yes, I do get the nurse, tech to help me bag the patient.

Any alternative suggestions are welcome too, but I am getting sick of it. The hospital an hour away does it and it's part of their pre-op prep. I think with all their patients with beards.

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[soorg]

Have done it twice this year. It's a no-brainer. Facial hair grows back in a month. Infarcted tissue doesn't.

 

[KungPOWChicken]

Another option is to place an lma as a way to ventilate prior to intubation

 

[gasblaster]

Haven't tried it but a couple of my attending have mentioned that they will tape over/down beards around the mouth with cloth (or plastic) tape to facilitate a better seal with the mask.

 

[deleted171991]

Probably an LMA is the best. Also high flow nasal cannula during induction.

 

[Arch Guillotti]

Quit ventilating, use sux and stick the tube in!

 

[fakin' the funk]

Preoxygenate by holding the pt's nose closed and having them breathe thru the circuit elbow

 

[urge]

As long as it is not a religious beard should be ok.

 

[pgg]

Preoxygenate by holding the pt's nose closed and having them breathe thru the circuit elbow

I like the snorkel technique also. Good for patients who feel claustrophobic and hate the mask, especially kids. Also, for the obese - upright position, and some CPAP during preO2.


And like Arch said, just stick the tube in already. Mask ventilating bearded Jabbas ought to be plan B, or even C (after an LMA).

A big tegaderm with a hole cut in the middle stuck on the face over the mouth helps with the mask seal.

I've never asked a patient to shave a beard. I don't think I ever will. If I'm that worried about the airway, an awake intubation is probably in order.

 

[Dejavu]

Quit ventilating, use sux and stick the tube in!

This...This

I have been flushing in the white stuff with sux for everybody for over 2 yrs now. Haven't run into any problems and have not had the loss of pre-oxygenation desat problem. I just don't waste that time.

On big people a Glidescope being handy is a good precaution, but I am surprised how easy big people are sometimes.

As a beard wearer, I would tell you "no way!" if you asked me to shave.

 

[BobBarker]

Get a toddler mask, hold the mouth close, and bag mask nasally.

 

[chocomorsel]

Quit ventilating, use sux and stick the tube in!

Gonna start this on some patients. But considering that it took me two tries w a glide to tube my last fattie that prompted this post, not gonna be for all cases. Also I am a small female <55kg and don't have the leverage most others do that comes in handy w the big patients.

 

[Mac4]

You do not have to have the perfect seal to blow oxygen into their lungs, assuming their aiway is not obstructed. Oral airway, jaw trusting and proper position are way more helpful that shaving the beard.

 

[itwasalladream]

Can also try gel on the beard

 

[Dwindlin]

In the few times I've had trouble with a beard I like the Tegaderm method.

 

[Jay K]

No, I've never shaved a patient's facial hair.

Preoxygenate adequately with mask strap.

Induce with succ and intubate.

Rather than leverage, consider positioning - i.e. perform laryngoscopy, some positioning may be improved by a slight lift of head with your right hand, if adeq view achieved, have your circulator continue supporting head in that position while you intubate.

 

[nimbus]

Interesting question. I've done over 17000 cases personally performed with lots of bariatrics in the mix and I've never had someone shave their beard. But if I had a 500 pounder with a Santa Claus beard I would make that request.

 

[pgg]

I would've made this guy shave his beard on principle.

Maybe he had surgery this week, because it was gone for today's game.

 

[cchoukal]

We get a lot of mountain men with grizzly adams/ZZtop/Santa Claus beards, and I've shaved a number of them for central line insertion (hard to sterilize a beard and the dressings don't stick too well to hair) and a couple for mask ventilation, but I generally agree with those who suggested an LMA for "masking" during paralytic dosing or doing them awake. I do a fair amount of both of these and never had an issue.

 

[ASA6]

Gonna start this on some patients. But considering that it took me two tries w a glide to tube my last fattie that prompted this post, not gonna be for all cases. Also I am a small female <55kg and don't have the leverage most others do that comes in handy w the big patients.

The fact that they are difficult is the precise reason you should use succ. Quite wasting time trying to ventilate. preoxygenate well via snorkel method, RSI with succ, and stick the tube in. Also, if you have to ventilate, I stick in an LMA. Ive used the large tegaderm technique as well. Lastly, I never ask the nurse to help (unless i have to of course). If i need to use two hands to ventilate, I put the vent on pressure mode with a pressure of 15-20, and turn it on. Now I can do a two handed mask with an oral airway, and no one in the room is the wiser The reason is this is slicker, and every time I have asked the nurse or tech to squeeze the bag they get all flustered, and ventilate as quickly as they possibly can with as large of a breath as they possible can.

 

[Spinach Dip]

I'm gonna keep this short and sweet...

If I had a beard, and you asked me to shave it pre-op, I'd ask why.

If you then said, "so I can perform easier mask ventilation", I'd laugh at you.

 

[chocomorsel]

That's your prerogative Mr. Spinach. You can find someone else who suits you better. Jerk.

 

[ketap]

never shaved my patient's beard either...i work at emergency settings..so ,no time for it..i usually do 2 person ventilation for preoxygenation..works well until today...by the way, i never used a relaxant(as suggested by anyone in this forum..i think i posted a case n we had great discussion about this somewhre ) on such pts, since no succs anymore in my country, evryone use Roc in my country..i will usually did awake intubation (because obese and beard pts were so frightening ) and promote optimal positioning (sometime it is impossible tough)..and get my glidescope or any size and kind of laryngoscpe near me...suprisingly..i didn't need to use the glidescope quiet often..
by the way...
PGG: what is snorkel method? never heard of that..please share it with us..or where can i get info about that..many thanks in advance..

 

[ketap]

oh, sorry forgot to ask..

Rocurworld:if u don't have succs, will u likely intubate a difficult airway with Roc's? i am interested with your comment

and yes, that is very true..i often ask them to be 'calm' as the nurses usually just bag in too much..haha...thanks..

 

[Spinach Dip]

That's your prerogative Mr. Spinach. You can find someone else who suits you better. Jerk.

I <3 you too.

 

[pgg]

PGG: what is snorkel method? never heard of that..please share it with us..or where can i get info about that..many thanks in advance..

Just preoxygenating/denitrogenating without the mask. You give the patient the circuit minus the mask, they wrap their lips around the plastic tube, and they breathe. Requires a cooperative patient. Patients who hate the mask because they're claustrophobic or just being difficult will usually cooperate. You get a perfect seal and good preO2. Doesn't help with mask ventilation of course.

 

[Spinach Dip]

That's your prerogative Mr. Spinach. You can find someone else who suits you better. Jerk.

Wait wait wait... hold up just a minute... You're an attending? And you just called me a jerk on a public forum over some hypothetical situation?

There are several things you might call me. Ignorant? Occasionally. Opinionated? Frequently. But a Jerk?

Is this real life?



...

Now, perhaps my own experiences have shaped my views on medicine, but I have always been under the impression that the most important person in the OR is neither the anesthesiologist, nor the surgeon, nor the scrub nurse.... but the patient.



Also, I am genuinely curious why you call me a jerk so plainly. Is it because I refuse to shave my (hypothetical) beard solely for your convenience? Or because I (hypothetically) laugh at you when I find your reasons insufficient?

 

[ketap]

PGG: oh..i see..never heard of that..but great to try haha..thank u so much..by the way, should the patient close their nose while they do that?thx

 

[Arcan57]

How well does gel/petroleum jelly work with getting a seal on beards? It was widely referenced as an adjunct to BVM in residency, but I never had a patient that required it. For those with experience, does it work better then the tegaderm method (which I heard referenced for the first time on this thread)?

 

[chocomorsel]

Firstly Spinach, I called you a jerk because you responded in a jerky manner to a valid question as I was truly looking for people's ideas and or opinions. Saying you would laugh at me was jerky and unnecessary.

Secondly, the PATIENT is THE most important person in the room and that is precisely why I would ask them to possibly shave, in order for me to be able to mask ventilate them effectively. A beard can grow back, it's cosmetic, where as I feel like if a PATIENT is desaturating and I can't ventilate them well because of a beard, then the PATIENT's life could be in danger as previously mentioned. I had a difficult time passing the tube and ventilating a fat patient with a beard.

Thirdly, what does being an attending have to do with anything? Yes, this is an anonymous internet forum with lots of hypotheticals. I guess that's why people feel they can type jerky things with disregard to who's reading it. But this was a true scenario that has happened to me multiply, so if you don't have any words of wisdom then just move on.

 

[chocomorsel]

How well does gel/petroleum jelly work with getting a seal on beards? It was widely referenced as an adjunct to BVM in residency, but I never had a patient that required it. For those with experience, does it work better then the tegaderm method (which I heard referenced for the first time on this thread)?

Yes, I have been told of this as well. Haven't tried it though. I have been however doing the prop/suxx tube without ventilating over the past few days and its been working well. Haven't tried it on a fat patient yet though. Baby steps. Just that we are always taught to test ventilation in residency before relaxation and that's just how I have been doing it.

 

[pgg]

PGG: oh..i see..never heard of that..but great to try haha..thank u so much..by the way, should the patient close their nose while they do that?thx

They're cooperating so you can just instruct them to mouth breathe. The kind of patients who I snorkel are the kind of patients who don't like the mask so I just assume that they wouldn't like me pinching their nose either. But yeah breathing through the nose would defeat the purpose.

 

[ketap]

They're cooperating so you can just instruct them to mouth breathe. The kind of patients who I snorkel are the kind of patients who don't like the mask so I just assume that they wouldn't like me pinching their nose either. But yeah breathing through the nose would defeat the purpose.

hmmm...nice thought..thx,PGG..great explanation..helpful like always..

 

[Jay K]

I have been however doing the prop/suxx tube without ventilating over the past few days and its been working well.

brilliant

 

[BobBarker]

Had a guy for a crani recently. Looked like ZZ Top. Had bed already turned 90. Induced with 250mcg fentanyl and 1mg/kg roc. My CA1 tried to bag mask. Actually did ventilate a little bit. He asked for an oral airway. I said how about we just intubate. Sometimes you just got to have faith. Little guy, reassuring airway exam. Most difficult portion of the case was securing the tube with all of his hair in the way. 360 with silk tape twice worked fine.