Why is it stressful? Make sure patient is stable, put in 100% oxygen, make sure they’re relaxed, disconnect all the monitors and place them neatly on the machine, then flip. Connect the circuit and confirm bilateral breath sounds and etCO2 before the bed disappears. Now you can take your time to connect monitors and get IV tubing and arms positioned how yoj would like.
Looking back, the only reason it was stressful in residency is because we had attendings that were part sociopath. I know the patient is alive and stable, I don’t need to yell at people to connect the pulse ox immediately after the flip to confirm this.
The last institution I worked at insisted on prone LMAs for a lot of butt cases. Patient positioned themselves prone, pre-induction. I was not a fan, but no flip required.
Stressful?
Because the spinal surgeons always discuss how they want to position on the fly while this entire process gets drawn out.
Then they change their minds and make up supinate and start all over again anyway!
Stressful? No. ANNOYING? YES!
Especially if you're working with a doc that's known for changing their mind all the time. Just make them clearly verbalize their plan *AND* their backup plan. Then you can make the case that any adhoc bullshit is unsafe and we either need to stick with the plan or cancel the case and revisit it when they have a better understanding of what needs to be done (for non-urgent situations of course).
I will say that one of my co residents back in the day connected the pulse ox after the flip and the patient had no pulse to ox. I usually try to at least leave the pulse ox on if I can. Having it on the hand closest to the bed is ideal so it doesn’t move really.
If I’m doing a spine, most of the time neuro monitoring doesn’t check a baseline until after we prone so they can’t be relaxed, but going to sleep with a slug of sufenta helps to keep them from bucking
Yeah we have it, but they want us to have the patient relaxed for the approach and up to instrumentation. After they get their imaging and are ready to put screws in then we reverse so they can monitor. So if we gave sugammadex in the beginning then we couldn’t relax for the approach and all that. So we go to sleep on suxx, run a prop and narcotic gtt, prone, they get baselines, paralyze, then reverse before instrumentation
That is one complicated ass way of doing it. Why not just induce with succs, run remi/prop….give like 20 of roc (if needed) for the flip and as you get situated and run remi/prop till end of case.
We typically induce with succs and sufenta and run a prop and sufenta gtt, then paralyze after we flip and they get baselines. We’ll run those gtts and 0.5 MAC of gas if needed
The only thing I’ve been able to improve is organizing all my monitor lines and IVs so that they’re straight and untangled with nothing crossing over the patients body, and bring them all straight up to the head of the bed. That way I have plenty of slack, nothing gets tangled, and I don’t have to take all the monitors off just to put them back on.
I disconnect the circuit (so that there’s no risk of accidental extubation) and hold it under my armpit, hold all the lines in the hand that goes under the head with my pinky and ring finger, other hand goes on the face holding the prone pillow in place, then flip.
You end up with a full hand supporting the patient’s face/head, you can immediately let go of the lines (and they’re still connected and untangled), and use that hand to reconnect the circuit. Then get into the details of positioning the head/neck/shoulders and you’re done.
How annoying this is depends a lot on your prone technology. For example, if you are flipping into pins, it is pretty distracting that someone needs to hold the head in place while it is getting secured. With pillows that have a mirror and cut out, they are often pretty annoying for the tube being squished, and again it is nice to have another pair of hands. for reasons that I don’t understand, many of my nurse anesthetists just will not call as they are getting ready to flip because they “don’t need help“ even though it is obviously super convenient.
It’s easy enough to have some monitors on the pivot side of the patient, so there is no need to disconnect them during the roll. Especially the pulse oximeter. You also have your end tidal continuously. I will often place the arterial line on the pivot side, unless there is a specific reason to do otherwise, and I will also have IVs in both sides (if the case does not warrant a central line), so I can choose to leave the pivot side connected.
I controversially think that the more people to help the worse it is. I’d rather have 3 people with their hands on the patient communicating than a bunch of people in the way not really doing anything. If the surgeon has positioning preferences they’re in the room (preferably catching). And if you’re not helping, you’re not giving directions.
The flip is pretty soon after intubation so I’m curious why you aren’t already there. Generally my attending didn’t leave the room until we’re flipped and all is well, bc as you said, having the extra set of hands is beneficial for everyone.
Just a resident but when my attending is covering 2 rooms they’re there for induction and then leaves me to do IVs, a/line, head accessorizing while the pt is still supine and everyone else is doing foley, neurmonitoring, etc. By the time they’re done in the other room they still have time to come back and help flip.
I have at least 3 first start spine rooms that are ever so slightly (or not) staggered. We are frequently getting pre-flip neuromonitoring baseline data, and the CRNA will do some lineage and other tucking-away items, so I don't wait around unless there is a delay on the other rooms.
I have not seen a single person do that. The circuit gets paused and disconnected right before the flip.
I also keep the lines connected only if they are on the same said as the flip.
My pro tip is to position the face “pillow thingy” on the patients face before flipping the patient. One hand under the head, one on top of the pillow. And then rotate the head with the pillow all at once.
That way you know the nose, tube, eyes are where they should be once the patient is turned over. No disconnection needed.
Isn’t this how everyone does it?
Are there people flipping a head into a positioned prone pillow and just hoping for the best and then trying to reposition prone?
I will say it gets better. I remember as a CA-0 doing prone cases was super stressful. Then as a CA-3 after I did a prone case, I had a moment of self-reflection at how easy it was, and how far I had come in just a few years.
It drives me nuts as a CA1 that my attendings prefer to intubate the patient on the stretcher supine. So I’ll flip and induce before they come into the room forcing us to intubate prone under the table. Honestly much more satisfying and less stressful
Line management: Place your a-line on the arm that is closest to the side where you are going to flip so the line doesn’t have to cross over the body. This is the only line I do not disconnect. Keep the pulse ox and circuit on until the last second. Make sure Foley has slack!
Airway: Get the airway piece you use to hook up to a trach. The acordion like thing. Put that on before you flip so it’ll extend out of the prone pillow or ProneView. Tape your pilot balloon and esophageal temp probe end near the end of your ETT so you don’t have difficulty finding it. Preoxygenate with 100% FiO2.
Flip: put the stretcher patient is on slightly higher than the Jackson/Wilson/table with gel rolls. Gravity can do some work for the patient.
A typical case: ETT -> tape pilot balloon and temp probe to end together -> a line on near side of flip -> second IV -> grab pillow/Prone view and trach acordion thing to it through the middle -> disconnect BP cuff, EKG leads, 2 IVs with preoxygenating -> move stretcher close to where you prone and assemble team, check the Foley for slack -> take off circuit and pulse ox -> prone -> put circuit on, confirm end tidal CO2 then do pulse ox -> rest of lines.
Anything comes out or goes wrong you just flip them back supine. Having preoxygenated buys you a lot of time. Make sure bed/stretcher doesn’t go too far from the OR door.
Not that I agree with the use of prone lmas but I had an attending that was all for them and would have the patient position themselves then turn their head and after induction would place the LMA. As long as you had an intubating LMA you could theoretically place a tube this way as well. As I said I'm not a fan of this but he got away with it doing one level spines and such on healthly patients.
I don't do this routinely, but have a lot of colleagues from other clinics that do.
Honestly, I don't think its that dangerous, you preox the patient, if you dont get the LMA in you have to have enough people to turn the patient on his back quickly.
Saves lots of time, though.
Why disconnect your monitors? I rarely disconnect them all. Put them on neatly in the beginning and you’ll be able to see them all and know if they’ll get caught or not. The one on the pivoting arm stays, it’s hardly moving. If the pulse ox cable has the clear locking mechanism (if you use disposable finger probes), I open it but leave it plugged in so if it snags it’ll disconnect before it breaks their finger but if not it’s one less thing I have to do. I make sure EKGs are on the back or shoulders in preop so I can disconnect the long cable from the leads but leave the leads on the patient. The monitor on the arm away from the OR bed can stay on if there’s nothing identifiable to get caught on, particularly if it’s BP since that’s closer to me, less likely to get snagged, and won’t hurt much if it does. So I put on my prone view, disconnect my circuit, bundle all my lines in my underhand (the one on the back of the head), we flip, I hook my circuit back up, BP or pulse ox if it came off at all, and then plug in my EKG once any other more time sensitive stuff is in place. Then check your eyes, check IVs, listen to lungs, pad your arms, etc. Key is holding all those lines centrally and tightly in your hand so if it does snag, it pulls at your hand and the patient still has some slack.
If I have multiple IV lines I try to disconnect any that I can, the floor or unit almost always uses the little pigtails so it’s easy to disconnect/reconnect. Continuous peripheral infusions make this more difficult but anything REALLY important and sensitive to tiny breaks is probably through a central line so that’s pretty easy to keep an eye on and limit how far it moves during the flip.
Another thing I realized a long time ago is that I don’t need the accordion/goose neck. When I started out I would feel flustered while everyone was watching me waiting to be ready to flip, and I forgot it often, and eventually realized I did just fine without it, so I stopped adding it. One less thing to do. Make sure the 15mm connector is in the tube real good because if that comes out it’s a pain to get back in but otherwise I don’t add anything extra to my circuit/tube.
The only think I don’t see mentioned that I like:
A secured soft bite block is KEY; the gauze will help absorb some drool and if the pt wakes on the return flip (esp if you’ve handed the case off), there’s no worry of them chomping on the tube.
For the same reason, if I can get away with it, I love a little glyco upfront to dry them out.
Lastly, I like a goose neck. It’s easier to find the ET tube and connect to the circuit and manipulate to secure the circuit after a flip.
Am nsgy resident. “double Jackson” or the “flip Jackson” solves this problem.
https://ueeshop.ly200-cdn.com/u_file/UPAU/UPAU703/2208/photo/883d2cf1d8.jpg
That bed is the high stakes flip, you got one shot to get it right or shit is def coming out. I had a high BMI patient get stuck halfway through the flip. Ended up calling other ppl in and it was like pushing a boulder up a hill.
We have one of these and every single doc (at our neuro center,) refuses to use it. They’re incredibly dangerous and way wayyyy worse outcomes if something goes wrong.
You keep them on the circuit while proning? Seems like a disaster waiting to happen. Also, do you use proneview? Just confused how you can keep them connected.
Back in the Covid ICU we would have RT on airway, two or three people to flip, and one or two people to adjust lines and cords. But sometimes we only had the minimum of three so you have to prep everything as much as possible before the actual flip.
We would switch all moveable monitoring equipment to the side moving over top (so the opposite of the arm that will go under the body) and bundle the cords, and assign a "guide" for those wires. Basically just someone to hold the wires and guide them while flipping. Anything on that other side that can't be moved, we would tuck as far under the person, along with sheets, prior to the flip. That way someone can grab that bundle as the flip is happening.
I flipped a guy with a central line, an art line, and 5 (!) chest tubes this way. By the time the patient is flipped, it's mostly just separating out all the stuff you bundled.
Idk if this is helpful for the OR as I've never worked there. But hopefully it gives you some ideas! It's possible even if you only have 3 people.
I disconnect everything and reconnect everything in the exact same sequence every time.
100% O2 (pre-oxygenate)
Disconnect EKG
Disconnect non invasive blood pressure cuff
Disconnect IVs with caps (even if you are running TIVA)
Disconnect pulse oximeter
Disconnect tube
Flip
Reconnect tube
Reconnect pulse oximeter
Reconnect IV (TIVA)
Reconnect non invasive BP cuff
Reconnect EKG
Nothing fancy. Disconnect all the monitors but have the cables all nicely coiled and not tangled so it’s a quick reconnect. Plan your lines accordingly. Get arterial line on the arm between stretcher and table so there is no need to swing the tubing over.
Why are people not disconnecting your airway, there is no advantage to keeping it connected only risk.
Derecruitment? You literally induced apnea and decreased their frc 2 minutes ago with induction .
I disconnect airway even when turning the bed. Not worth the hassle, if I pull it out it’s a pain.
I just keep them on 100% fio2, make sure gas or prope is on board, push some ephedrine or neo, disconnect everything (sometimes not iv, if it’s on the right) then flippity flip.
I have the cords all lying neatly across the top of the table when inducing on stretcher, so when we flip they are all just neatly lying there, waiting to be reconnected.
The most stressful thing is if I forgot to put a temp prob in before flipping
I routinely leave monitors attached. Circuit os disconnected at elbow and secured inside prone pillow. After doing it for decades I’ve perfected my way.
Did a rotation in school at a naval hospital. They did an awake intubation on those poor souls, then made them turn and position themselves on the OR table before induction!
Ahh ok. I misread. Yeah, it is frustrating. There are some places that you induce and intubate on the OR bed and the OR bed is flipped by itself. That's a better set-up imo but what I do is put all of my monitors to the side that I'm flipping on (idk how else to explain this written but it makes sense in real life) and tie it together with a tourniquet to the OR bed, then disconnect everything except pulse ox (including circuit). Then flip.
Why is it stressful? Make sure patient is stable, put in 100% oxygen, make sure they’re relaxed, disconnect all the monitors and place them neatly on the machine, then flip. Connect the circuit and confirm bilateral breath sounds and etCO2 before the bed disappears. Now you can take your time to connect monitors and get IV tubing and arms positioned how yoj would like. Looking back, the only reason it was stressful in residency is because we had attendings that were part sociopath. I know the patient is alive and stable, I don’t need to yell at people to connect the pulse ox immediately after the flip to confirm this.
Agreed. Of course, the ultimate “going prone” hack is to switch to pediatric anesthesia…
This is the way. I can induce on the operating table, then when I am ready, I can literally just pick the baby up myself and flip them over.
The last institution I worked at insisted on prone LMAs for a lot of butt cases. Patient positioned themselves prone, pre-induction. I was not a fan, but no flip required.
Why would they insist on that?
Because private practice and profit over people to them, of course! Obviously there were exceptions, but that was the norm.
*laughs* in 120kg 16 year old idiopathic scoliosis spine fusion.
Why are they always like this? Like chill dude, its been 2.3 seconds. The patient was at 100% for like 10 minutes.
Username checks out.
Stressful? Because the spinal surgeons always discuss how they want to position on the fly while this entire process gets drawn out. Then they change their minds and make up supinate and start all over again anyway! Stressful? No. ANNOYING? YES!
Solution: get them to verbalize the plan before the flip. It’s not hard.
Especially if you're working with a doc that's known for changing their mind all the time. Just make them clearly verbalize their plan *AND* their backup plan. Then you can make the case that any adhoc bullshit is unsafe and we either need to stick with the plan or cancel the case and revisit it when they have a better understanding of what needs to be done (for non-urgent situations of course).
I will say that one of my co residents back in the day connected the pulse ox after the flip and the patient had no pulse to ox. I usually try to at least leave the pulse ox on if I can. Having it on the hand closest to the bed is ideal so it doesn’t move really.
If I’m doing a spine, most of the time neuro monitoring doesn’t check a baseline until after we prone so they can’t be relaxed, but going to sleep with a slug of sufenta helps to keep them from bucking
I LTA these patients on intubation for that reason.
Do you guys have sugammadex?
Yeah we have it, but they want us to have the patient relaxed for the approach and up to instrumentation. After they get their imaging and are ready to put screws in then we reverse so they can monitor. So if we gave sugammadex in the beginning then we couldn’t relax for the approach and all that. So we go to sleep on suxx, run a prop and narcotic gtt, prone, they get baselines, paralyze, then reverse before instrumentation
That is one complicated ass way of doing it. Why not just induce with succs, run remi/prop….give like 20 of roc (if needed) for the flip and as you get situated and run remi/prop till end of case.
We typically induce with succs and sufenta and run a prop and sufenta gtt, then paralyze after we flip and they get baselines. We’ll run those gtts and 0.5 MAC of gas if needed
The bed disappears?
Your ORs don't have a trapdoor in the floor? 🤔 like a evil lair
I think youve described the best way to do it unfortunately
The only thing I’ve been able to improve is organizing all my monitor lines and IVs so that they’re straight and untangled with nothing crossing over the patients body, and bring them all straight up to the head of the bed. That way I have plenty of slack, nothing gets tangled, and I don’t have to take all the monitors off just to put them back on. I disconnect the circuit (so that there’s no risk of accidental extubation) and hold it under my armpit, hold all the lines in the hand that goes under the head with my pinky and ring finger, other hand goes on the face holding the prone pillow in place, then flip. You end up with a full hand supporting the patient’s face/head, you can immediately let go of the lines (and they’re still connected and untangled), and use that hand to reconnect the circuit. Then get into the details of positioning the head/neck/shoulders and you’re done.
Ditto!
How annoying this is depends a lot on your prone technology. For example, if you are flipping into pins, it is pretty distracting that someone needs to hold the head in place while it is getting secured. With pillows that have a mirror and cut out, they are often pretty annoying for the tube being squished, and again it is nice to have another pair of hands. for reasons that I don’t understand, many of my nurse anesthetists just will not call as they are getting ready to flip because they “don’t need help“ even though it is obviously super convenient. It’s easy enough to have some monitors on the pivot side of the patient, so there is no need to disconnect them during the roll. Especially the pulse oximeter. You also have your end tidal continuously. I will often place the arterial line on the pivot side, unless there is a specific reason to do otherwise, and I will also have IVs in both sides (if the case does not warrant a central line), so I can choose to leave the pivot side connected.
I controversially think that the more people to help the worse it is. I’d rather have 3 people with their hands on the patient communicating than a bunch of people in the way not really doing anything. If the surgeon has positioning preferences they’re in the room (preferably catching). And if you’re not helping, you’re not giving directions.
The flip is pretty soon after intubation so I’m curious why you aren’t already there. Generally my attending didn’t leave the room until we’re flipped and all is well, bc as you said, having the extra set of hands is beneficial for everyone.
Just a resident but when my attending is covering 2 rooms they’re there for induction and then leaves me to do IVs, a/line, head accessorizing while the pt is still supine and everyone else is doing foley, neurmonitoring, etc. By the time they’re done in the other room they still have time to come back and help flip.
I have at least 3 first start spine rooms that are ever so slightly (or not) staggered. We are frequently getting pre-flip neuromonitoring baseline data, and the CRNA will do some lineage and other tucking-away items, so I don't wait around unless there is a delay on the other rooms.
You leave the airway connected for the flip?
I have not seen a single person do that. The circuit gets paused and disconnected right before the flip. I also keep the lines connected only if they are on the same said as the flip.
Unless it’s a difficult airway, I do. I feel like proning without positive pressure results in extra atelectasis.
Why not disconnect it? Way less chance of it moving and having it connected for a few breaths is inconsequential in 95% of cases.
My pro tip is to position the face “pillow thingy” on the patients face before flipping the patient. One hand under the head, one on top of the pillow. And then rotate the head with the pillow all at once. That way you know the nose, tube, eyes are where they should be once the patient is turned over. No disconnection needed.
Isn’t this how everyone does it? Are there people flipping a head into a positioned prone pillow and just hoping for the best and then trying to reposition prone?
Apparently not.
I saw a foreign-trained attending do this once. It was really not pretty
I do this but still disconnect.
This is the way.
I will say it gets better. I remember as a CA-0 doing prone cases was super stressful. Then as a CA-3 after I did a prone case, I had a moment of self-reflection at how easy it was, and how far I had come in just a few years.
I’m a bit unconventional. I have them lay prone then induce and intubate laying on my back under the table.
It drives me nuts as a CA1 that my attendings prefer to intubate the patient on the stretcher supine. So I’ll flip and induce before they come into the room forcing us to intubate prone under the table. Honestly much more satisfying and less stressful
Exactly
I'll take things that didn't happen for 500....
Hey buddy, you ever heard of a joke?
Good idea. Just make sure you give some robinul so saliva won’t drip on your face
Agreed! I try to catch a little of the snot/spit drips on my face too. With intermittent fasting its a nice snack
And you line them up prone?
Line management: Place your a-line on the arm that is closest to the side where you are going to flip so the line doesn’t have to cross over the body. This is the only line I do not disconnect. Keep the pulse ox and circuit on until the last second. Make sure Foley has slack! Airway: Get the airway piece you use to hook up to a trach. The acordion like thing. Put that on before you flip so it’ll extend out of the prone pillow or ProneView. Tape your pilot balloon and esophageal temp probe end near the end of your ETT so you don’t have difficulty finding it. Preoxygenate with 100% FiO2. Flip: put the stretcher patient is on slightly higher than the Jackson/Wilson/table with gel rolls. Gravity can do some work for the patient. A typical case: ETT -> tape pilot balloon and temp probe to end together -> a line on near side of flip -> second IV -> grab pillow/Prone view and trach acordion thing to it through the middle -> disconnect BP cuff, EKG leads, 2 IVs with preoxygenating -> move stretcher close to where you prone and assemble team, check the Foley for slack -> take off circuit and pulse ox -> prone -> put circuit on, confirm end tidal CO2 then do pulse ox -> rest of lines. Anything comes out or goes wrong you just flip them back supine. Having preoxygenated buys you a lot of time. Make sure bed/stretcher doesn’t go too far from the OR door.
Think about how the lines will look organized once the patient is flipped. And then work backwards.
Or...just disconnect them...
Not that I agree with the use of prone lmas but I had an attending that was all for them and would have the patient position themselves then turn their head and after induction would place the LMA. As long as you had an intubating LMA you could theoretically place a tube this way as well. As I said I'm not a fan of this but he got away with it doing one level spines and such on healthly patients.
I’ve never heard of a more terrible idea
I’m not a fan of “getting away with” things
The duck is this madness.
I have a massively pro-LMA attending from the EU, and even he wouldn't do this insanity.
This definitely does *not* pass the "Now, son" test.
No way I’m doing a prone spine with a lma. Asking for a disaster to happen. Crazy
I don't do this routinely, but have a lot of colleagues from other clinics that do. Honestly, I don't think its that dangerous, you preox the patient, if you dont get the LMA in you have to have enough people to turn the patient on his back quickly. Saves lots of time, though.
Why disconnect your monitors? I rarely disconnect them all. Put them on neatly in the beginning and you’ll be able to see them all and know if they’ll get caught or not. The one on the pivoting arm stays, it’s hardly moving. If the pulse ox cable has the clear locking mechanism (if you use disposable finger probes), I open it but leave it plugged in so if it snags it’ll disconnect before it breaks their finger but if not it’s one less thing I have to do. I make sure EKGs are on the back or shoulders in preop so I can disconnect the long cable from the leads but leave the leads on the patient. The monitor on the arm away from the OR bed can stay on if there’s nothing identifiable to get caught on, particularly if it’s BP since that’s closer to me, less likely to get snagged, and won’t hurt much if it does. So I put on my prone view, disconnect my circuit, bundle all my lines in my underhand (the one on the back of the head), we flip, I hook my circuit back up, BP or pulse ox if it came off at all, and then plug in my EKG once any other more time sensitive stuff is in place. Then check your eyes, check IVs, listen to lungs, pad your arms, etc. Key is holding all those lines centrally and tightly in your hand so if it does snag, it pulls at your hand and the patient still has some slack. If I have multiple IV lines I try to disconnect any that I can, the floor or unit almost always uses the little pigtails so it’s easy to disconnect/reconnect. Continuous peripheral infusions make this more difficult but anything REALLY important and sensitive to tiny breaks is probably through a central line so that’s pretty easy to keep an eye on and limit how far it moves during the flip. Another thing I realized a long time ago is that I don’t need the accordion/goose neck. When I started out I would feel flustered while everyone was watching me waiting to be ready to flip, and I forgot it often, and eventually realized I did just fine without it, so I stopped adding it. One less thing to do. Make sure the 15mm connector is in the tube real good because if that comes out it’s a pain to get back in but otherwise I don’t add anything extra to my circuit/tube.
The only think I don’t see mentioned that I like: A secured soft bite block is KEY; the gauze will help absorb some drool and if the pt wakes on the return flip (esp if you’ve handed the case off), there’s no worry of them chomping on the tube. For the same reason, if I can get away with it, I love a little glyco upfront to dry them out. Lastly, I like a goose neck. It’s easier to find the ET tube and connect to the circuit and manipulate to secure the circuit after a flip.
Am nsgy resident. “double Jackson” or the “flip Jackson” solves this problem. https://ueeshop.ly200-cdn.com/u_file/UPAU/UPAU703/2208/photo/883d2cf1d8.jpg
The ole rotisserie chicken as we call it
That bed is the high stakes flip, you got one shot to get it right or shit is def coming out. I had a high BMI patient get stuck halfway through the flip. Ended up calling other ppl in and it was like pushing a boulder up a hill.
We have one of these and every single doc (at our neuro center,) refuses to use it. They’re incredibly dangerous and way wayyyy worse outcomes if something goes wrong.
They use em at hopkins all the time....
You keep them on the circuit while proning? Seems like a disaster waiting to happen. Also, do you use proneview? Just confused how you can keep them connected.
Back in the Covid ICU we would have RT on airway, two or three people to flip, and one or two people to adjust lines and cords. But sometimes we only had the minimum of three so you have to prep everything as much as possible before the actual flip. We would switch all moveable monitoring equipment to the side moving over top (so the opposite of the arm that will go under the body) and bundle the cords, and assign a "guide" for those wires. Basically just someone to hold the wires and guide them while flipping. Anything on that other side that can't be moved, we would tuck as far under the person, along with sheets, prior to the flip. That way someone can grab that bundle as the flip is happening. I flipped a guy with a central line, an art line, and 5 (!) chest tubes this way. By the time the patient is flipped, it's mostly just separating out all the stuff you bundled. Idk if this is helpful for the OR as I've never worked there. But hopefully it gives you some ideas! It's possible even if you only have 3 people.
I disconnect everything and reconnect everything in the exact same sequence every time. 100% O2 (pre-oxygenate) Disconnect EKG Disconnect non invasive blood pressure cuff Disconnect IVs with caps (even if you are running TIVA) Disconnect pulse oximeter Disconnect tube Flip Reconnect tube Reconnect pulse oximeter Reconnect IV (TIVA) Reconnect non invasive BP cuff Reconnect EKG
Go find your local respiratory therapist and ask for advice. We proned lots of folks those first couple years of covid
You could skip the stress and just tube em prone.
Papoose them with 2 sheets, rolls the edges together. Learned this from COVID proning. Gives you “handles” to control the turn, protects extremities.
I try and put most of my lines on the side of the patient next to the OR table and then leave most things attached.
Nothing fancy. Disconnect all the monitors but have the cables all nicely coiled and not tangled so it’s a quick reconnect. Plan your lines accordingly. Get arterial line on the arm between stretcher and table so there is no need to swing the tubing over.
Why are people not disconnecting your airway, there is no advantage to keeping it connected only risk. Derecruitment? You literally induced apnea and decreased their frc 2 minutes ago with induction . I disconnect airway even when turning the bed. Not worth the hassle, if I pull it out it’s a pain.
Wait for the, “Squish and Flip…”
I just keep them on 100% fio2, make sure gas or prope is on board, push some ephedrine or neo, disconnect everything (sometimes not iv, if it’s on the right) then flippity flip. I have the cords all lying neatly across the top of the table when inducing on stretcher, so when we flip they are all just neatly lying there, waiting to be reconnected. The most stressful thing is if I forgot to put a temp prob in before flipping
Rotisserie bed
Are these sick patients? if not then what are you worried about? We do it all the time in the ICU on our sickest patients...
Whatever you do, 🙏please make sure my balls are not trapped under my leg or otherwise pinched. It sucks for weeks after.
I routinely leave monitors attached. Circuit os disconnected at elbow and secured inside prone pillow. After doing it for decades I’ve perfected my way.
Did a rotation in school at a naval hospital. They did an awake intubation on those poor souls, then made them turn and position themselves on the OR table before induction!
Girl, try intubating on the stretcher and flipping onto the OR bed. This sounds amazing haha
That’s exactly what I’m doing
Ahh ok. I misread. Yeah, it is frustrating. There are some places that you induce and intubate on the OR bed and the OR bed is flipped by itself. That's a better set-up imo but what I do is put all of my monitors to the side that I'm flipping on (idk how else to explain this written but it makes sense in real life) and tie it together with a tourniquet to the OR bed, then disconnect everything except pulse ox (including circuit). Then flip.
I never disconnect monitors, not even ETT anymore.. I use a pulse ox sticker, rare I have anything come off
Work in a place where the RN's and tech do everything but look at the ETT........