Going through your anesthesia checklist before starting a case isn’t exciting. However the anesthesia checklist can potentially save your patient’s life by allowing you to find risks and correct them before they cause harm. I found early in my career that if I skip this step, unwelcome surprises can occur.
Case #1:
As a first-year resident, at change of shift, I took over an appendectomy that was just getting ready to start. My fellow resident had already set up the room and drawn up the drugs. I entered the OR the same time as my patient. I chose rapid sequence induction and when ready I pushed the pentothal and the succinylcholine. The patient lost consciousness and promptly vomited. With the help of my supervising staff, I immediately turned the patient on his side and reached for my suction. To my horror — it wasn’t set up. I had just assumed it was there. I started wiping emesis from the mouth with the sheet while the room crew dashed to set up suction. After suctioning the patient’s mouth, we turned him supine and I intubated. Fortunately, our fast actions prevented aspiration.
Opportunities to Improve: In our rush to start the case, neither I, nor my staff supervisor, had noticed the suction was not set up because we didn’t stop to check it. We needed to slow down to check the equipment.
From that point on, I became a compulsive pre-case checklist believer. Running through your anesthesia checklist is especially important if you, like me, work in a different surgery center or hospital every day. Variability in ORs and supplies from place to place increases the risks because it’s easier to miss the fact that something is missing.
S.O.A.P Anesthesia Checklist
I personally don’t carry a paper anesthesia checklist. However, I always use a useful mnemonic called S.O.A.P for checking my equipment before every case. S.O.A.P stands for:
S: suction
O: oxygen and other gases
A: airway equipment and ancillary equipment
P: pharmacy
And I run through my checklist in that order.
S = SUCTION
Of all the things students, and even rushed experienced providers can forget, suction is high on the list. Suction is essential to improving visualization when secretions block the airway and is life-saving if there is emesis during intubation or extubation. Suction comes first.
Always check the suction yourself. Even if you’re lucky enough to have an assistant turning your room over between cases, don’t assume it works just because the suction tubing is there. Make sure that it really will suck when turned on. A poor seal anywhere in the apparatus prevents a vacuum. Turn it on and place the tubing against your finger to verify it’s working. I often have to troubleshoot suction. In the past year I have encountered these common problems left by my helpful turnover crew. All were solved before bringing the patient in the room.
- No suction equipment set up in the OR (still in the back hall)
- Suction tubing and yankauer curled on top the suction cannister — but not attached to each other. Looked good but not ready.
- Cannister was loose in the holder with top not tight — no vacuum
- Accessory ports remain open on top of the cannister —no vacuum
- Suction tubing and catheter ready in its holder, but end not attached to the cannister —false sense of security with non-functional suction
- Everything attached but the on/off switch to the suction source on the side of the machine is turned off. Note this is separate from the suction control dial on the face of the anesthesia machine.
Refamiliarize Yourself With The Suction In Your OR
An additional purpose of checking your suction is that it forces you to review how that suction works. This sounds ridiculous, but you will find that as you move from place to place, the suction set-up can vary a lot. I work at 6 different clinical locations. Suction canisters are alternatively mounted either on the left or the right of the machine. They can be mounted high or low on the sides, towards front or back. They can also be separate from the machine. The control dial can be on the left or right in either the upper or lower part of the control panel. Some machines have a handy attachment to hold the suction catheter ready at hand. Some do not and the suction tubing is tucked, kinked off, sticking out the corner of one of the drawers.
You want to be able to reach for, turn on, and use your suction at a moment’s notice. You can’t do that if you don’t know where it is. Follow the anesthesia checklist and always check it.
O = Oxygen and Other Gases
“O” in the SOAP anesthesia checklist stands for oxygen and other gases. The anesthesia machine is the ultimate source of oxygen. Even if my machine has an electronic check sequence, I will do a manual check for my own reassurance. I feel more secure if I can see with my own eyes that the circuit holds pressure and that the pop-off valve works.
Always check your circuit even if you are lucky enough to have a turnover crew. Just the other day my highly competent charge nurse replaced my CO2 absorber, but didn’t notice that a piece of suction tubing got caught in the gasket, preventing vacuum. Don’t discover a circuit leak after your patient is induced.
Is the oxygen turned on? Surgicenters typically turn the master oxygen source off at the end of the day. One of the staff usually arrives early to turn it and the wall suction back on before cases start.
Ensure that your vaporizers are full at the start of the day. Recheck before each case and refill as needed throughout the day. And if you switch ORs make sure to check that the vaporizers in your new room are ready. One of my prior partners was notorious for running his vaporizer close to empty and then not refilling when he left for the day. You don’t want to be the one whose patient wakes up because the vaporizer ran dry.
If your patient’s surgery is a high fire risk, make sure your anesthesia machine is hooked up to deliver air in addition to oxygen. I work at a few surgery centers where air isn’t available in all ORs. That means airway surgery, for example, can only be done in the ORs that have air.
A = Airway Equipment and Ancillary Equipment
Airway Equipment
In the S.O.A.P. anesthesia checklist, A does double duty as airway equipment and ancillary equipment. In addition to the supplies you know you will need, always check the emergency supplies you might need.
Case #2:
I did my routine S.O.A.P. checklist and verified that I had a laryngoscope and blade in my drawer prior to starting a case with an LMA. Handle and blade were in sterile wrappers which I did not open. I induced the patient. Despite several attempts and changing sizes the LMA still failed to seat properly. I switched to intubation. After pushing additional propofol and the succinylcholine I grabbed the laryngoscope handle and blade — only to discover that they were of two different manufacturers and that they would not mate. There was no way to assemble my laryngoscope. Fortunately, I could easily ventilate the patient while my nurse ran next door and grabbed a matching set. Intubation then proceeded without difficulty.
Opportunities to improve: I hadn’t known ahead of time that there were 2 incompatible laryngoscopy sets available. The center started labeling the different sets and began purchasing additional blades with the goal of standarizing around one manufacturer.
Always Have Back Up Airway Equipment
Even if you plan monitored anesthesia care with sedation or the use of a Laryngeal Mask Airway (LMA), always make sure you have the correct sized ventilation mask, a functioning laryngoscope handle and set of blades of appropriate size for your patient, and an endotracheal tube and a stylet. I always have an LMA available for my patient for use as a potential emergency airway even if I plan intubation. Have the correct size oral, and optimally a nasal airway, for your patient. You don’t have to contaminate the equipment if you don’t plan to use it, but it must be present. You never know when a change in anesthetic plan, or an airway emergency, will occur.
Don’t forget tongue blades and lubricant. These can be essential to ease insertion of LMAs, and nasal airways.
There should be a manual ventilation bag, such as an Ambu style ventilation bag available. It’s rare, but someday you may need one. I have actually had to use an Ambu bag in the middle of a case during a machine failure (a circuit board in a top-of-the-line electronic machine failed). I also had to use one during a rule-out malignant hyperthermia episode. Optimally there should be one attached to each of your anesthesia machines. If not, there should be at least one immediately available and attached to the crash cart.
Ancillary Equipment
This category includes everything you need to monitor and improve safety for your patient. You should always have the routine monitors of course — EKG leads, a BP cuff that fits, end-tidal-CO2, and a pulse oximeter sensor.
Other things you may need depending on the length, complexity of the case and the status of the patient include, among other things:
- Tape (taping eyes, taping ETT or LMA, reinforcing IVs, well in reality — for just about everything)
- Gloves (sterile or exam) in your size
- Needles or kits for nerve blocks
- Ultrasound machine, lubricant
- Pillows and straps for positioning
- Forced air warming devices/extra blankets
- Fluid warmers
- Invasive monitors like arterial lines or CVPs
- Bispectral (BIS) or Patient State Index (PSI) monitors and their sensors for EEG
- Eye protection
Run through the case in your mind before you bring your patient into the room. Make sure you have all the equipment you need. You don’t want to have to send your team member out of the room in the middle of a procedure or halfway through positioning a patient. Anything that breaks the flow is a distraction.
P = Pharmacy
“P” in the S.O.A.P anesthesia checklist stands for pharmacy. This category breaks down into the drugs you know you will need and the drugs you might need. This will vary depending on the case. However, think ahead to potential emergencies. Emergency drugs that you might need should either in the room with you, or easily retrievable by your nurse at a moment’s notice.
Safe Use Of Meds Starts With You!
I move from place to place. Each surgicenter has the medications set up in different drawers and in a different arrangement within those drawers. Sometimes seconds count in treating an allergic reaction, hypotension, hypertension, or bronchospasm. Review your cart’s drug drawer in the morning to refresh your memory on where those emergency drugs are — and what they look like.
Drug shortages have forced our supply folks to buy what they can when they can. And this may mean that you have look alike drugs sitting in adjacent bins, or maybe accidentally mixed together within the same bin. Look-alikes can hurt your patient if you are not careful.
- Read the label on the vial— don’t go by color alone — before drawing up your drug.
- Draw up your med and then read the label again before you throw the vial away.
- Clearly label your syringe immediately.
- When giving a drug, read the syringe label, don’t just go by the color of the label.
- Read the label again before you push the plunger.
As long as we are discussing safe pharmacy practices, part of your cart preparation should include safe labeling of syringes. Here is an example of how NOT to label a syringe. Note how easy it would be for someone helping you to miss the fact that this syringe is full of 0.25% marcaine – which could be fatal if injected intravenously.
For further information on avoiding medication errors see:
Use The Anesthesia Checklists
Use your S.O.A.P. anesthesia checklist and follow a regular safety routine protects your patient. Failure to consider risks tempts us to skip steps, rush, take short cuts, or fail to prepare for the unexpected. Other articles discussing complications and how to avoid them can be found here:
As an alternative, after having similar experiences during residency, I offer the one I came up with: Suction, DAMMIT! (and spelled that way, it’s not impolite, either)
SUCTION
Drugs
Airway
Machine
Monitors
IV stuff
The rest … based on the specific case.
In addition to reading the lable of the drug before drawing it and before giving it, we use a four-eye-system. Another person in the room confirms, that you took the right vial and labeled you syringe correctly.
Before pushing the drug we do a so-called “STOP-INJECT CHECK”, where we check, that it acutally is the right drug in the right dose for the right patient.
Very nice post, I love working with checklists to improve performance and safety!
Thank you so much for your comment. It is too easy to make a mistake. Using checklists and helpers to prevent mistakes is a sign of intelligence, not weakness.
Dr. Whitten, you are amazing. Thank you so much for this excellent post and all the others you have done as well. I’m in my second year, and your website has been incredibly helpful. Still trying to get good with DL and Miller blades.
The more you intubate the better you’ll get and soon you’ll be doing the teaching. Good luck with your career and stay safe.
Dr. Christine your teaching materials are amazing. My anaesthesia post graduates needs to learn a lot from you. How can I contact you. This is my email edwardjohnson2310@gmail.com
Do you advise pre-opening a sterile Yankhauer suction and leaving it unattended in an OR suite, Endo room, or ED bay for a “just in case” scenario. I have seen this a lot lately and from an Infection Prevention perspective, I don’t understand how it can be okay to allow this now breached sterile item to sit there unused for hours, overnight, over days, with patient after patient coming in and out of those rooms and bays. Introducing a breached sterile product, even into a ‘dirty mouth’, could potentially set up the patient, who does end up needing the suction, for an infection. Please explain how this is okay. Thanks in advance.
Thanks for your question and the point you are making is absolutely valid. For example, I do not open endotracheal tubes or LMAs but leave them inside their sealed packaging but readily available. Deciding risk benefit in situations like this is not easy. However, having to unwrap a yankauer, attach it to the suction tubing (assuming that the tubing itself is already connected) takes time. A patient can aspirate in seconds. I have been in a situation where a patient aspirated because the suction was not ready to use.
What I do is barely open the back end of the yankauer packaging just enough to attach to the suction tubing, leaving the rest of the yankauer covered. The yankauer is then placed inside a partially closed drawer on the anesthesia machine. In my opinion I would personally rather waste suction catheters than risk not being able to suction the airway quickly enough to prevent injury to the patient.