Clinical Quiz: Bite Blocks

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Not so much of a quiz, really...perhaps a poll on practice. I was given a break by an MDA on an adult case; he said..."Oh..you nurses and your soft bite blocks..." then went on a mini-tirade about soft bite blocks being useless with ET's. I asked him to elaborate on it a little. His feeling was that nobody used to insert soft bite blocks instead of oral airways with ET's; when LMA's came along and soft blocks were being used, folks started using them with their intubations, as well. "After you take out the tube, can you ventilate through a mass of soggy gauze?" he went on..... (I didn't tell him my patients were usually awake and cooperative on extubation, and let me take out both their ET and bite block at the same time...!) BUT...he made me think a little about this, and I'm leaning in his direction in practice; I like his thinking. Almost everybody I know uses soft bite blocks with ET's - some folks talk about lip injury (ischemia?) during long cases, or patients breaking their teeth on the oral airway, as reasons to use a soft bite block. I can't find any evidence for either of those claims....and I think if you injure a lip or inflict pressure enough to cause ischemia to lips...you probably are not gentle enough with the insertion or are inserting it wrong!

Anyway...thought I would throw this out to all under a "how do you practice" discussion....Thanks.

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piper....

i worked with many CRNA's who never used bite blocks they were very good at waking patients nicely...but then they had a whole run of people who bit on the tube...

so...what i learned from them was to insert a soft bite block tightly rolled and taped prior to waking and remove when they open their mouth for the ETT to come out. i dont' use a hard bite block unless absolutely indicated (those muscular young guys) because they tend to bite hard enough that a soft bite block doesn't do the trick...but no matter - i still don't put them in until the very very end to prevent damage due to longer times of use.

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I see this happen in the units all the time. People come down with hard oral airways, basically being utilized as bite blocks. I would tend to think that maybe a little sedation would go a long way in these cases.

In the OR, I know some CRNAs will put OAs in on intubated patients as a knee jerk mechanism, even at the start of a long case. That doesn't make sense to me. I asked one CRNA one day and she said "because I don't want him biting on the tube". Mind you this was a projected 4 hour case.

HELLO.......We are utilizing anesthesia here and maintaining paralysis with norcuron. My thought was something along the line of: do your job and you won't have to rely on an oral airway as a bite block during the case. Yes, on long cases I do worry about lip, tongue, and palate pressures with putting OAs in as bite blocks.

My practice is to use OAs, esp on young muscular males towards the end of the case if I am concerned about them biting. If we are still deeply paralyzed, then I go ahead and put it in. If the patient is borderline relaxed, then 80-100 mgs of propofol will do wonders for inserting a OA.

I really don't use a soft roll for LMAs, but that is me. Some CRNAs use them every time they insert a LMA. I tend to pull my LMAs deep anyways, so biting is a non-issue.

Different strokes, different folks. I DO question the people that insert OAs as bite blocks at the start of medium to long cases. Can't exactly figure that one out.

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piper....

i worked with many CRNA's who never used bite blocks they were very good at waking patients nicely...but then they had a whole run of people who bit on the tube...

so...what i learned from them was to insert a soft bite block tightly rolled and taped prior to waking and remove when they open their mouth for the ETT to come out. i dont' use a hard bite block unless absolutely indicated (those muscular young guys) because they tend to bite hard enough that a soft bite block doesn't do the trick...but no matter - i still don't put them in until the very very end to prevent damage due to longer times of use.

Very nice. :cool:

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Ok, you'll receive alot of differing replies to this question, so here it goes:

I use oral airways for all my ETT cases. I would prefer that my patients do not bite down and occlude their airway during extubation. (yes, amazingly,not all your patients wake up calmly and gently! Especially those young, healthy males) This is a safety issue in my book. Those homemade soft bite blocks will not help you if your patient needs ventilating after extubation (again, amazingly everyone's patients don't wake up calmly, and laryngospasms do happen, I know you're shocked at this revelation!) If your patient laryngospasms, it may be very difficult to place an oral airway to assist in generating positive pressure. I have not had an issue with ischemia of the lip or numbness of the tongue during longer cases with an oral airway in place though I put it in at the beginning, remove during the case and then place it at the end. Breaking of teeth has not been a concern of mine unless the teeth are in bad shape to begin with or if the patient has front caps or veneers.

Now, with LMAs, I do use a rolled up piece of gauze and place it by the back molars. If you've seen the original LMA video with Dr. Archie Brain, he used the same method. Good enough for me. Of course there are the plastic bite blocks that cover one molar on either side. These work well too.

If you choose what's safe and what's in the best interest of the patient, I don't think you'll go wrong.

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One advantage to soft bite blocks is that they sponge up oral secretions. And I agree that it has never made much sense to me to be told to insert a bite block of either variety at the beginning of the case; if your patient is biting during surgery, you have a problem with your anesthetic as opposed to a lack of things stuffed in the oral cavity. I've been putting mine in at the end of the case, usually when I d/c the OG tube and/or eso thermometer.

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Specializes in CRNA, Finally retired.
One advantage to soft bite blocks is that they sponge up oral secretions. And I agree that it has never made much sense to me to be told to insert a bite block of either variety at the beginning of the case; if your patient is biting during surgery, you have a problem with your anesthetic as opposed to a lack of things stuffed in the oral cavity. I've been putting mine in at the end of the case, usually when I d/c the OG tube and/or eso thermometer.

I never use anything with the exception of peds when I'll put an oral airway in before extubating. Other exception is pumpkin heads who will get an oral airway before extubation. Using enough narcotics and keeping the patient warm precludes any need for more crap in their mouths.

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I am not a crna yet. Maybe beyond my realm to comment. But as a CSU nurse I recover intuebated patients and none of them have bite blocks of any type. If I have trouble when they wake up I will stick one in if I can't calm them verbally, or with additional sedation until they wake up cooperative.

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again with the nevers.....

i use alot...alot...alot of narcs... but every great once in awhile you get that person who doesn't react the way one would predict... lately i haven't been using anything...but i am sure it will bite me in the a$$ soon enough.

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Funny, we were just talking about this today.

This would be a great (and simple) research project. Im experimenting, always used OA's as bite blocks on emergence, just recently started using a "soft gauze" bite block, and I seem to have noticed less gagging on emergence. This is what I LOVE about anesthesia, there are a million ways to do things, and it never gets boring!!!:smiley_aa

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i use alot...alot...alot of narcs... .

My main facility is heavy with the narcotics and I love it. One MD actually intubates most hearts with 30mls Fentanyl followed by 10mg norcuron, then a good 30ml flush of Fentanyl. Now I have never used drugs in my life, nor do I want to, but I honestly wonder what these people experience when induced in this manner.

What I probably like most is heavy MACs with versed, fentanyl, and propofol boluses. Our facitlity is not too big on Ketamine and sometimes I wish I could administer it more. I wish I could mix the gtt that Yoga talked about, by my OR pharmacist I believe would have a stroke. People talk about heavy MACs like it isn't a big deal. What BS. The BIS will read anywhere from 47-low 60s on these patients. They will go through an entire operation (hernia repair) and never move. Pulling off a beautiful MAC is a wonderful challenge.

Fentanyl is king here in the southeast. I have friends at very low narcotic areas, we sit and trade stories. They can't believe the amount of narcotics we give.

A couple of weeks ago I gave my as-yet-to-date biggest dose of Fentanyl: 97 mls during a 12 hour cardiac-related procedure. I hated to return the last three, but I could not justify administration.

For those of you having trouble conceptualizing this dose, yeah, I said 97 mls.

97 mls @ 50 mcg/ml = 4850 mcg of fentanyl.

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Specializes in Theatre.

In the land of OZ where I work bite blocks are not used with ETTs. Occassionally a guedel might be inserted if problems are anticipated on extubation. We use thick gauze bite blocks inserted between the molars if possible during ECTs.

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