ENT Rooms and Going 180

[Ronin786]

Just wondering what your usual practice is for ENT rooms where the head of the bed is away from the right side. Do you guys come into the room 180 degrees or always turn after going to sleep?

I've seen it done both ways and while it would be indefensible if something went wrong, it makes things much easier when you've got two people.

Personally, I prefer when they're at 90 degrees, but not all ENT surgeons are OK with that.

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[chocomorsel]

Put them to sleep, then turn them. It gets easier the more you do it. Put all your leads and monitors coming in from the left side of patient if your bed turns to the right, and from the right side if your bed turns to the left. That way, everything moves over easily. Also, get extensions on your IVS. Twitch monitor goes on the foot, by the heel.

 

[drmwvr]

Disconnecting the breathing circuit, unplugging the monitor cables, clamping IV's and placing them on the table for the brief 180 turn avoids the potential for a tangled weave or worse. Takes no time to plug everything back in and reorganize quickly.

 

[psychbender]

If I'm working by myself, I turn the bed after controlling the airway. If I have a second set of hands and no compelling reason not to, I leave the bed turned 180 to start, and have one of us at the airway, the other at the machine. When I turn after intubating, I do as chocomorsel does, and arrange the cables in such a way that they should not tangle or become caught while turning.

 

[scudrunner]

Turning after induction is easy AF. Why would you not perform the part of the anesthetic with the highest disaster potential in your cockpit? What are you really saving, 2 minutes? Not worth it for the sub-optimal induction position. Think about the risk benefit analysis: risk = something, benefit = nothing. Just turn after induction.

 

[jwk]

We always wait till after induction. We had one new surgeon that wanted everything turned prior to induction. Easy answer - hell no. We do the anesthesia, then you can do your procedure. End of discussion.

 

[Ignatius J]

We always wait till after induction. We had one new surgeon that wanted everything turned prior to induction. Easy answer - hell no. We do the anesthesia, then you can do your procedure. End of discussion.

Easy airway and I position them the easiest way possible. Pre-oxygenate, push drugs, PCV to 20 cmH20 at a rate of 12, hold down mask, and intubate when ready. Secure tube and let's get the surgeon in here.

 

[drmwvr]

Easy airway and I position them the easiest way possible. Pre-oxygenate, push drugs, PCV to 20 cmH20 at a rate of 12, hold down mask, and intubate when ready. Secure tube and let's get the surgeon in here.

So not having to turn the bed is worth having the bag six feet away.... in a head/neck case. Would that all "easy" airways were that recognizable. To each his own.

 

[Ignatius J]

So not having to turn the bed is worth having the bag six feet away.... in a head/neck case. Would that all "easy" airways were that recognizable. To each his own.

Yes. I don't always need a bag within a two foot radius of me to properly manage an airway. There are many ways to deliver positive pressure breaths, and a board-certified anesthesiologist should know them and when the appropriate times would be to use them. If one truly is rigid enough to demand this proximity to the bag for each airway, I would say they are 'cRNA-ish'. I do what is safe. When something appears both safe and convenient, I do that just as well.

 

[ranvier]

In our resident graduation video, we had a skit about these ent cases....enough extensions to do the case from the next OR.

 

[Urzuz]

Yes. I don't always need a bag within a two foot radius of me to properly manage an airway. There are many ways to deliver positive pressure breaths, and a board-certified anesthesiologist should know them and when the appropriate times would be to use them. If one truly is rigid enough to demand this proximity to the bag for each airway, I would say they are 'cRNA-ish'. I do what is safe. When something appears both safe and convenient, I do that just as well.

Don't mean to get in between your guys' discussion, but the bolded part above strikes me as being idiotic. That's like saying "if you're so rigid that you demand an anesthesia machine to do an anesthetic, that's CRNA-ish", or "if you demand a laryngoscope to intubate a patient, that's CRNA-ish."

I don't think anyone is DEMANDING proximity to a bag for each airway...they are saying that you HAVE a bag literally five feet away from you and you're choosing not to use it. If you think it saves you a significant amount of time, so be it...as the other poster said, to each his own. I do all my cases solo and have never found turning the bed to be that big of a hassle (takes literally 30 seconds?), so I would never even think about inducing a patient at 180. 90 I suppose I could wrap my head around since I could position myself close enough to my machine and drug cart...but 180? **** no. It's all fun and games until you run into an issue you didn't anticipate...

 

[nimbus]

Don't mean to get in between your guys' discussion, but the bolded part above strikes me as being idiotic. That's like saying "if you're so rigid that you demand an anesthesia machine to do an anesthetic, that's CRNA-ish", or "if you demand a laryngoscope to intubate a patient, that's CRNA-ish."

I don't think anyone is DEMANDING proximity to a bag for each airway...they are saying that you HAVE a bag literally five feet away from you and you're choosing not to use it. If you think it saves you a significant amount of time, so be it...as the other poster said, to each his own. I do all my cases solo and have never found turning the bed to be that big of a hassle (takes literally 30 seconds?), so I would never even think about inducing a patient at 180. 90 I suppose I could wrap my head around since I could position myself close enough to my machine and drug cart...but 180? **** no. It's all fun and games until you run into an issue you didn't anticipate...

I don't feel strongly either way. I've actually done it both ways and haven't run into any problems. As an aside, I don't routinely mask ventilate before intubation or lma insertion. And as you say, if I do encounter a problem, it literally takes 30 sec to turn them 180. The issue is not really worth arguing about.

 

[Ignatius J]

I don't feel strongly either way. I've actually done it both ways and haven't run into any problems. As an aside, I don't routinely mask ventilate before intubation or lma insertion. And as you say, if I do encounter a problem, it literally takes 30 sec to turn them 180. The issue is not really worth arguing about.

My thoughts exactly. Only wrong answer would be saying something has to be done a certain way over another. All roads lead to Rome so long as the patient is safe.

 

[Ignatius J]

Don't mean to get in between your guys' discussion, but the bolded part above strikes me as being idiotic. That's like saying "if you're so rigid that you demand an anesthesia machine to do an anesthetic, that's CRNA-ish", or "if you demand a laryngoscope to intubate a patient, that's CRNA-ish."

I don't think anyone is DEMANDING proximity to a bag for each airway...they are saying that you HAVE a bag literally five feet away from you and you're choosing not to use it. If you think it saves you a significant amount of time, so be it...as the other poster said, to each his own. I do all my cases solo and have never found turning the bed to be that big of a hassle (takes literally 30 seconds?), so I would never even think about inducing a patient at 180. 90 I suppose I could wrap my head around since I could position myself close enough to my machine and drug cart...but 180? **** no. It's all fun and games until you run into an issue you didn't anticipate...

Good. You can turn the table back in 30 seconds. Gives you about 3-4 minutes still to figure the airway out if you preoxygenate properly.

 

[pgg]

Good. You can turn the table back in 30 seconds. Gives you about 3-4 minutes still to figure the airway out if you preoxygenate properly.

If it takes only 30 seconds to turn the table back during an emergency, why is it so inconvenient to turn it 180 after the airway is secure?

 

[Urzuz]

Good. You can turn the table back in 30 seconds. Gives you about 3-4 minutes still to figure the airway out if you preoxygenate properly.

That's fine, as I said, to each his own. The part that I don't get and what strikes me as idiotic is you calling someone else CRNA-ish for wanting to be next to a bag that is sitting there in the room...?

 

[fakin' the funk]

Personally, I prefer when they're at 90 degrees, but not all ENT surgeons are OK with that.

I'm in solo MD only practice.

None of our ENTs or facial plastics surgeons ask to start any position other than normal, and then we turn after intubation. It's usually as soon as the ETT is in and taped. It doesn't matter if it's 90 or 180 really.

They always ask at the end if I'm going to turn back to zero degrees for wakeup. My answer consists of a puzzled look and "yes, please."

 

[Ignatius J]

That's fine, as I said, to each his own. The part that I don't get and what strikes me as idiotic is you calling someone else CRNA-ish for wanting to be next to a bag that is sitting there in the room...?

Rigid thinking, if you think that's how you are SUPPOSED to do it. As if a protocol was written down and needed to be followed. No thinking. Just read the protocol. Do it however just understanding you can peel an onion however you would like.

 

[Ignatius J]

If it takes only 30 seconds to turn the table back during an emergency, why is it so inconvenient to turn it 180 after the airway is secure?

Emergency as in what?

No one said it was inconvenient, but if it is just as safe and takes less steps, what's so wrong about that?

 

[pgg]

Emergency as in what?

How about we define "emergency" as "any unusual or unexpected peri-induction event that wasn't anticipated but requires prompt action to avoid having to fill out extra paperwork"? I'll grant that it's a loose and vague definition.

No one said it was inconvenient, but if it is just as safe and takes less steps, what's so wrong about that?

There's a reason why the rest of us put the head of the bed conveniently close to the machine, the monitor, the suction, the anesthesia cart. Even if 99 times out of 100 we don't need to touch the monitor, the suction, or anything in the cart between induction and tube-taping.

You assert that inducing a patient in a position where you can't reach the airway with one hand and the machine with the other is "just as safe" ... measuring "safety" is hard; if it wasn't there wouldn't be any MD vs CRNA debate. But that's just an assertion without evidence. I'm not interested in proposing a study to an IRB, but I don't see the point of needlessly handicapping yourself because you expect everything to go as you expect, purely for the sake of saving a 30-second bed turn after induction.

I admit I'm being argumentative here a little bit for the sake of being argumentative, but I don't see the up side, but I can see potential down sides. That's all.

 

[Ignatius J]

How about we define "emergency" as "any unusual or unexpected peri-induction event that wasn't anticipated but requires prompt action to avoid having to fill out extra paperwork"? I'll grant that it's a loose and vague definition.




There's a reason why the rest of us put the head of the bed conveniently close to the machine, the monitor, the suction, the anesthesia cart. Even if 99 times out of 100 we don't need to touch the monitor, the suction, or anything in the cart between induction and tube-taping.

You assert that inducing a patient in a position where you can't reach the airway with one hand and the machine with the other is "just as safe" ... measuring "safety" is hard; if it wasn't there wouldn't be any MD vs CRNA debate. But that's just an assertion without evidence. I'm not interested in proposing a study to an IRB, but I don't see the point of needlessly handicapping yourself because you expect everything to go as you expect, purely for the sake of saving a 30-second bed turn after induction.

I admit I'm being argumentative here a little bit for the sake of being argumentative, but I don't see the up side, but I can see potential down sides. That's all.

I want a specific instance where you feel that going 180 prior to induction places the patient at risk. We can't just use vague definitions to describe vague circumstances and use that as a crutch.

Keep in mind that it's already been mentioned that certain airways may be better just to have the patient in the standard position.

I have actually seen an extubation on the 180 turn. I can also see lost IV access and other monitors coming off. Shouldn't happen, but it does.

Not saying this is why one should induce at 180. Just that nothing is fool proof and 100%.

 

[pgg]

The fact that

nothing is fool proof and 100%

is all the more reason to conduct one of the most hazard-prone portions an anesthetic within easy reach of your stuff.

That's all. I'm not sure how much clearer I can put it.

 

[fakin' the funk]

Easy airway and I position them the easiest way possible. Pre-oxygenate, push drugs, PCV to 20 cmH20 at a rate of 12, hold down mask, and intubate when ready. Secure tube and let's get the surgeon in here.

You're doing a solo 180 induction...and your surgeon's not even in the room???!!! Why the hurry then???

 

[Ignatius J]

You're doing a solo 180 induction...and your surgeon's not even in the room???!!! Why the hurry then???

They may be in the room. They may be talking in the hall. They may be in the lounge. Who cares. I don't really care so long as they scrub when we're ready.

I don't need an anesthesia machine in my hip pocket to safely manage an induction. To each his own.

 

[nimbus]

You're doing a solo 180 induction...and your surgeon's not even in the room???!!! Why the hurry then???

I do it to streamline the process. It is done safely every day.

 

[Ronin786]

Ignatius/Nimbus, do you guys feel the same about extubating?

 

[Ignatius J]

Ignatius/Nimbus, do you guys feel the same about extubating?

Sure.

 

[nimbus]

Ignatius/Nimbus, do you guys feel the same about extubating?

I'm more likely to mask ventilate at extubation than intubation so no. If it's an lma case then I'll pull it with the bed turned or go to recovery with it in.