Daily Operational Cognitive Aids
By: R. Christopher Call, M.D. and Monica W. Harbell, M.D.
updated May 5, 2020
The role of cognitive aids in the perioperative environment and healthcare in general has experienced a significant increase in focus and research interest over the past several years. While several advocates and studies suggest dramatic improvements with cognitive aid tools, other studies have shown little to no benefit in their application. Indeed, the proper usage and efficacy of cognitive aids in the operating room environment is still being investigated.
Despite the many unanswered questions regarding the role, design and implementation of cognitive aids, they are certainly not without value. One such value is their positive impact on long-term retention of training, such as the Advanced Cardiovascular Life Support pocket cards, or Circulation-Airway-Breathing (C-A-B) acronym of Basic Life Support training.
As anesthesiologists, we perform dozens of routine, multi-step processes daily. From the preprocedural machine check to preparing for cardiopulmonary bypass, our attention to detail helps mitigate risks in an inherently dangerous environment. This site is designed to introduce anesthesia providers to a selection of easy-to-implement, daily operational cognitive aids that may assist you in your clinical practice. These may prove especially useful for trainees who are still developing future practice habits. Please note these are not meant to be guidelines or standard of care and, in many cases, are not evidence-based checklists.
If you have a daily operational cognitive aid that you have found helpful in your practice, please feel free to share it with us at CPSE@asahq.org.
General Anesthesia Checklists:
- Airway Assessment
- LEMON
- L=Look externally
- E=Evaluate the 3-3-2 rule
- M=Mallampati
- O=Obstruction
- N=Neck Mobility
- Difficult Ventilation Prediction
- MOANS
- Mask seal (bushy beards, crusted blood on the face, or disruption of lower facial continuity)
- Obesity/Obstruction (Obesity, pregnancy, angioedema, Ludwig’s angina, upper airway abscess, epiglottitis)
- Age (> 55)
- No teeth
- Sleep apnea/Stiff lungs (COPD, asthma, ARDS, others)
- Room Setup
- MSMAIDS
- Machine
- Suction
- Monitors
- Airways
- Intravenous Lines
- Drugs
- Safety
- Preinduction checklists
- BESTOHIO
- Blood pressure
- EKG
- Stethoscope
- Tape
- preOxygenated
- Height of table/Head position
- IV open
- Other (special considerations)
- SOAPIMAM
- Suction
- Oxygen
- Airway equipment
- Pharmacy (induction meds, pressors)
- IV working
- Machine check completed
- Alarms Active and Audible
- Monitors working
Subspecialty Checklists
- Critical Care
- General Care of critically ill patients in ICU
- FAST HUG
Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Stress ulcer prevention, Glucose control
- FAST HUGS BID
Feeding, Analgesia, Sedation, Thromboprophylaxis, Head-up, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel movement, Indwelling catheter, Drug de-escalation
- Neuroanesthesia
- Transphenoidal Surgery
- SPHENOIDAL
Steroid supplementation, Packing of the oropharynx, Hormone levels/hypercarbia, Endotracheal tube to be fixed to opposite side, Normothermia, Observe for hemodynamic changes during tumor dissection, Infiltration of nasal mucosa, Diabetes insipidus, Airway, Lumbar drain
- Pediatrics
- Endotracheal tube size
- 4-3-2-1
- Size for uncuff ETT (ID) = Age/4+4
- Oral depth (cm) = ETT size x 3
- Nasal depth (cm): >1 year old = oral depth +2; <1 year old = oral depth +1
- Cardiac Anesthesia
- Initiating Bypass
- HAD2SUE
- Heparin: Always give prior to bypass.
- ACT: Always check before going on bypass (450 seconds).
- Drugs: Do you need anything (Nondepolarizing neuromuscular blocker).
- Drips: Turn off the inotropes, etc.
- Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture.
- Urine: Account for bypass urine.
- Emboli: Check the Arterial cannula for bubbles.
- HAD2SAVE
- Heparin: Always give prior to bypass.
- ACT: Always check before going on bypass (400 seconds).
- Drugs: Do you need anything (Nondepolarizing neuromuscular blocker, narcotic).
- Drips: Turn off the inotropes, etc.
- Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture.
- Alarms: Disable alarms tones (ECG, BP, CO2 etc).
- Ventilator: Turned off oncepatient is safely on bypass (“full flow”).
- Emboli: Check the Arterial cannula for bubbles.
- Coming Off Bypass
- WR MVP
- Warm: What is the bladder and blood temp?
- Rhythm: Are they in NSR or do you need to pace? Is the rate adequate?
- Monitors On: Turn them back on if you turned them off for bypass. Turn back on the alarms.
- Ventilation: Turn on the ventilator.
- Perfusion: What is the pump flow.
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