01Walk in with a checklist in your head
Nobody is born knowing how to set up an OR. The whole trick is doing it the exact same way every time so the routine — not your memory — catches the missing piece.
The classic mnemonic is MS-MAID (some say SOAP-ME). Run top to bottom before every case:
| Letter | Item | The "did I…" question |
|---|---|---|
| M | Machine | Passed self-test? Circuit connected, no leak? |
| S | Suction | Two working suctions, Yankauer on the one at the head? |
| M | Monitors | Pulse ox, NIBP cuff, ECG leads, capnography, temp ready? |
| A | Airway | Laryngoscope works, ETT cuff checked, backup sizes, LMA, bougie? |
| I | IV | Fluids spiked and primed, lines de-aired, pressure bag? |
| D | Drugs | Induction, paralytic, opioid, emergency pressors drawn & labeled? |
Set it up the same direction each time (e.g., left-to-right across your cart). Your hands will eventually do it on autopilot — which is exactly what you want at 6:45 AM.
- Set the room up the same physical order every time so a gap is obvious at a glance.
- Draw your emergency drugs (phenylephrine, ephedrine) FIRST, not after the patient destabilizes.
02The anesthesia machine check
Most modern machines run an automated self-test — start it at the beginning of the day before you do anything else. But the automated check does not verify everything. You still manually confirm:
- Backup ventilation available — a self-inflating bag (Ambu) and a way to give O₂ if the machine dies.
- O₂ cylinder present and adequate (don't rely only on wall supply).
- Pipeline pressures ~50 psi for O₂, air, N₂O.
- Vaporizers filled, caps tight, no leaks.
- CO₂ absorbent — not exhausted (watch for color change — purple/blue depending on brand).
- Circuit connected, correct size; breathing-system leak test and flow test pass.
- APL valve and ventilator both cycle.
- Scavenging connected.
Between cases you do an abbreviated check — leak test, circuit, fresh absorbent, suction, drugs — not the whole machine self-test again.
- Skipping the leak test "because the last case was fine" — circuits get swapped and bumped between cases.
- Assuming the green wall O₂ is enough and not checking the backup cylinder.
03Suction — you need it before you ever need it
You set up suction for the moment a patient vomits or bleeds on induction — there's no time to assemble it then.
- Two suction setups when you can: one at the head for the airway, one for the surgeons / a second line.
- Use a rigid Yankauer tip at the head.
- Turn it on and occlude the tip to confirm it actually pulls.
- Tuck it under the pillow or mattress edge on the patient's right so it's findable without looking.
- Test suction by covering the tip and feeling it grab — a setup that's connected but not pulling is useless.
04Airway cart — laid out, not buried
Before induction, have within reach:
- Laryngoscope — blade clicked on, light bright and white (Mac 3/4, Miller 2; video laryngoscope if planned/anticipated difficult).
- ETT of your chosen size with the cuff checked (inflate, confirm it holds, fully deflate) and stylet in, plus a size smaller as backup.
- LMA (rescue and primary).
- Oral/nasal airways, bougie, Magill forceps.
- Tape/tie, 10 mL syringe for the cuff, lube.
- Working face mask on the circuit.
Lay these out in the order you'll use them. A cart where you're digging for a bougie mid-desaturation is a cart that failed you.
- Not checking the ETT cuff before placing it — a leaking cuff means re-intubating.
- Only having one ETT size open.