Monitoring

Monitoring is established, the minimum being:

• Electrocardiogram (ECG)
• Non-invasive blood pressure (NIBP)
• Pulse oximeter with the beep turned on
• Capnography

Checking drugs

The check should include both emergency and anaesthetic drugs.

Checking equipment

This should include the following:

• Laryngoscopes (check the light sources are working on the available blades)
• Suction
• Bougie
• Tracheal tubes
  • The pilot balloon
  • The tube size planned to be used
  • Tubes a size larger and smaller than planned for use to be available
• Magill’s forceps
• Supraglottic airway devices (Laryngeal Mask Airway)

A minimum list of equipment is described in the ASA Guidelines 1 and on the DAS website.

Backup plans

The anaesthetist should always be prepared for unanticipated difficulty, so that adequate expertise, equipment and assistance are available.

All anaesthetists should be familiar with the DAS guidelines.

Skilled assistance

This should include:

• The most experienced Operating Department Practitioner (ODP) available
• A runner

Intravenous access

Intravenous access in a few patients may be difficult or not possible.

Access is achieved by a colleague during inhalational induction of anaesthesia.

Positioning

Positioning of the patient, 'sniffing the morning air', is achieved by placing a pillow (or similar bolster) under the head to flex the lower neck, and by extension of the head on the neck.

Wherever possible, the patient should be positioned at a height which is comfortable for the anaesthetist.

Poor patient positioning is the single most common cause for difficulty and failure of intubation. Always optimize the patient position before and between attempts.

Preoxygenation

Administer 100% oxygen by tight-fitting mask for approximately 3-4 min, aiming to ensure that the functional residual capacity is full of oxygen.

Induction

When the patient is undergoing elective surgery and no difficulty with tracheal intubation is anticipated, intravenous induction of anaesthesia and neuromuscular blockade are established.

The vocal cords should be abducted and non-reactive before passage of the tracheal tube is attempted.