The goal is to prevent trauma to skin
and mucosal surfaces by appropriate positioning and padding. Because
shearing forces potentially cause the most damage, monitoring should not
include the use of adhesive gels or tapes. The sticky surround of the
electrocardiogram electrodes must be removed. Alternatively, needle
electrodes have been used successfully. Intravenous (and other) cannulas can
be sutured in place. Wrapping the limbs in soft padding prior to use of
automated blood pressure recording devices helps prevent skin lesions. The
pressure from an anesthetic face mask may be damaging, so it should be held
gently just above the face. Soft face masks with an air cuff seal and
generous use of Vaseline cream (to reduce shearing forces to the skin) may
be advantageous. Likewise, oropharyngeal airways should be used only if
absolutely necessary. Whenever possible, endotracheal intubation is avoided
because of the risk of inducing laryngotracheobronchial bullae formation,
which may result in proximal airway obstruction. If required, intubation
should be done as gently as possible with a well-lubricated, undersized
tube. Once intubated, any movement of the endotracheal tube must be
prevented (e.g., changing head position, coughing) and endotracheal
suctioning must be avoided, if possible. Use of intravenous ketamine (e.g.,
in combination with propofol or midazolam) in a spontaneously breathing
patient has been described, as have various techniques involving maintenance
of anesthesia via volatile agents delivered through head boxes or gently
applied face masks. Hypothermia may develop rapidly, so temperature should
be carefully monitored, and warming devices such as convective forced-air
warmers should be used.