Endotracheal tube related cautionary hints and tips...
- After intubation turn the face of the patient on the side which is kept on arm board, based on the surgeon’s preference, with right arm out. The problem does not exist except for over extension of arm beyond 90ยบ. Prevent it by putting the IV stand on the head end side of the arm board. Hyper abduction, arm below the table level and head rotated on the opposite side can lead to bronchial palsy. In my observation, maximum number of accidents occur with head rotated on left side (right mastoid)
- due to linking of the ET over the airway or the bite block and
- excessive oozing during surgery.
- In oedentous (patients with beard) patients and infants do not depend on sticking tapes to the ET. Always use a tape or bandage to tie the tube round the face. Stitching tapes easily give way and come out due to salivation, making it easy for the ET to come out.
- On operation on neck where extension is needed with a bolster under the shoulder, tape the eyelids with small tapes to prevent the eyelids coming apart due to gravity and draping, which pulls the upper eyelid down towards the table causing exposure keratitis and corneal ulceration. Fix the tube only after final position is given with bolster under the shoulder. If fixed earlier to the angle of the mouth, the tube can come out of trachea .
- In ophthalmic procedures, to prevent the sterile drapes from becoming wet, surgeons put a waterproof sheeting on top. In patients who are not intubated and the airway is not in place, patients find it difficult to breathe. Fresh air cannot enter under the waterproof plastic sheet and the patient becomes restless. Carbon dioxide accumulates under the drape and they start hyperventilating. This can be prevented by putting a 1 meter (approx.) corrugated hose under the drapes, which is communicating with the theater air. Ventimask is a must.
- Always fix the ET in patients with hyperextension of the neck after the position is given and it is confirmed that the ET is in the trachea and not abutting at the commissure or has come out.
- Keep a watch on the arm kept by the side of the patient is well tucked in with a tape keeping the arm close to the body. A loose arm and the surgeon or assistant leaning against the table can press the ulnar nerve against the edge of the table.
- Extravasation of 5% Thiopentone or other irritating drugs can cause median nerve palsy. Use 2.5% solution and inject under vision. Inj. Diazepam outside the vein can cause sloughing and ulceration. In the event of extravasation, inject normal saline at the site to dilute the extravasated drug and its effect.
- Confirm that the injection to be given is in the vein and not an abnormal artery.
- For a patient in prone position check and make sure that the abdomen is free from the operation table and is well supported on bolsters. Make sure that the face and head are in a comfortable position and well supported and that the ET is not kinking and is well fixed with a tape or bandage to the head. Manual IPPR should be continued till the final prone position is given. If connected to a ventilator, check it manually for good ventilation and then switch on the ventilator.
- For a patient in a sitting position, involve the neurosurgeon in fixing the head. After fixing check the ET, and tie the ET to the head support to prevent it from slipping with movements of head during surgery.
- After cannulating a vein do not forget to remove the tourniquet. A case is recorded where the anesthesiologist forgot to remove the tourniquet and went on injecting more and more of 5% Thiopentone to meet the requirement for surgery. The tourniquet was detected when the patient was shifted to the ward. In the evening when the surgeon visited the patient it was found that arm, forearm and palm had turned black, pulse good volume and all muscle movements normal. After slight exfoliation of epidermis the extremity was normal. The cause– diffusion of Thiopentone into the tissues with intact tourniquet; fortunately it was a venous tourniquet.
- In all patients operated under tourniquet, make a note of the tourniquet time and see that it is removed at the end of surgery. Check again when the patient is being moved to the ward.
