Cautionary Hints and Tips

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 90º. 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.

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Endotracheal Tube

My practical experience with endotracheal tubes...
Always maintain all sizes of endotracheal tubes for infants, small children and adult. Few adult cuffed endotracheal tubes are a must. Nasal soft tubes size 8, 9, 10 can be lifesavers. They should be sufficiently long. They can also be used for passing a Ryle’s tube in an unconscious patient. After threading the Ryle’s tube in a well-lubricated nasal tube is passed in Oesophagus and Ryle’s tube is threaded down into the oesophagus, the nasal tube is withdrawn. If it is difficult to pass the tube nasally, pass the tube orally push the threaded Ryle’s tube and withdraw the soft tube. The oral Ryle’s tube can be railroaded into the nose with the help of catheter fixed snugly in the end of Ryle’s tube. Push the Ryle’s tube, which is stiff. Do not pull the catheter.
In case of difficult intubation a soft portex tube is passed nasally which mostly enters the larynx. Sometimes it remains anterior to the epiglottis, which can be placed posterior to the epiglottis with Magill’s forceps and threaded to enter the larynx. Sometimes the tube gets hitched against the anterior commissure and cannot advance in the larynx and trachea. It can be manoeuvred by slightly flexing the neck, which corrects the angle between the advancing tube and the trachea.
All endotracheal tubes must be washed by you with soap and water and a jet of water forced down the tube to remove all the left over secretions and finally cleaned by brush and water and dried with a towel. This will save your embarrassment when a freshly boiled tube for use shows secretions of the previous case or a foreign body like a cotton swab or even a cockroach, even a nasal turbinate has been recovered.
Nasal endotracheal tube advanced before oral extubation in case of full stomach makes life easier. Sometimes solid food and big blood clots cannot be aspirated from the oropharynx when extubated and the patient struggle for breath. Nasal tube maintains the free airway and allows sufficient time for the patient to vomit out stomach contents if he is conscious and clear the oropharynx.
All tubes should be fitted with female Noseworthy’s connections. Cobb’s connection is only useful in cases with wet lungs when intermittent suction is mandatory. The connection must be tight fitting and of correct size. Do not try to fit bigger connection as it may tear the tube (rubber).
Cuffed ET should not be used all the time. It spares your cuffed tubes. With use of air it is hardly necessary if the bellows or respirator are used. As far as possible do not inflate the cuff. Pass the proper size tube. If the air leaks by the side of tube is more, replace the tube with the next size. Use of cuff can cause oedema and damage to the mucous membrane of the trachea in long duration cases. After placement of ET inflate the cuff yourself. Over zealous Assistants always tend to over inflate the cuff. The over inflated cuff becomes a very strong stimulus and in light plane of anaesthesia it can lead to intense bronchospasm endangering life if not detected. Cases are known where inflation becomes impossible due to bronchospasm and cyanosis start appearing in spite of oxygen rich mixture used to inflate the lungs thus produced by an inflated balloon. The bronchospasm produced by over inflated balloon does not respond to usual bronchodilator treatment like injection of drugs. It only responds to:
-Deflation of cuff
-Removing the ET
-Deepening the level of anaesthesia
The simplest in the situation is deflation of cuff. The remaining methods appear to be dangerous and are not productive. For conduction of cases always have 3 sizes ready. Also do not forget to keep a nasal tube of appropriate size always ready. It is specially important in cases who are overweight, short neck or where the mouth cannot open adequately. Nasal intubation can prove a life saving procedure in all difficult intubations. In a planned case always ascertain the freedom of breathing through each nostril separately. Lubricate the nasal tube thoroughly, do not use force at any stage. You can have two obstructions while passing a tube through the nose, one at the nasopharynx where it meets the Passavant’s ridge and secondly while the tube meets the larynx at its outlet. The first difficulty should be solved by putting a finger in the nasopharynx as you advance the tube to hook it and bring it out into the pharynx, and second difficulty can always be solved by flexing the neck so that the angle of the advancing tube corresponds with the trachea. The difficulty is due to the nasal tube hitching against the anterior commissure. Do not force the nasal tube. It can cause bleeding.
Rubber tubes last about a year or more and hence one should not hesitate to boil the tube for 2 minutes before each case. Discard the tube when the tube shows signs of perish. The boiled tubes before use must be cooled and in emergency cooled under tap water. A case of an adult female is recorded who had an intubation with hot tube. This patient for Thyroidectomy needed Tracheostomy in the postoperative period. This precaution is a must in case of children and infants.
Inspect the tube before giving it for boiling for any foreign body (Cockroach) or debris. Sometimes cotton swabs used for cleaning have been detected. So look down the tube after straightening to find the presence of any obstruction. Unimaginable objects have been accidentally found inside the tube. In small tubes and Oxford tubes run the water through the tube and pass a stillette to ensure perfect patency. One must possess all types of tubes like armoured, nasal, Oxford, infant and special for specific use. If one can obtain laryngeal mask airway all 3 sizes.
Endotracheal tube connectors
One should have sets of different connections like right angle, Cobb’s, and curved as in some situations one requires various angles and various other uses for the connector. A Cobb’s connection can be used when one has to resort to suction intermittently and for giving IPPR with thumb technique and for use as Ayre’s T piece if it is not available. For routine use it is better to have a plastic female nose worthy connection fitted to each tube and a male Noseworthy connection to the catheter mount or the various unidirectional valves can directly connected to Noseworthy connection with metal connectors check the catheter mount.

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Your equipment is handled by you alone and no one can help you

Make sure that your equipment is full and complete and you are capable of conducting any case even in a village. You must be fully equipped with all your drugs for induction, maintenance, reversal, and also for resuscitation. Do not depend upon the nursing home to provide you with anything.
One of my colleagues never carried distilled water vials with him. One day he was faced with no saline, no water to dissolve Thiopentone. He probably used boiling water from the sterilizer and no wonder all patients developed hyperpyrexia.
When you paralyze a patient with long acting muscle relaxant you must possess the necessary prostigmine with you. Similarly if you intend to give spinal a vasopressor must be in your possession. While anaesthetizing an asthmatic patient check the immediate availability of aminophylline, cortisone, adrenalin etc. and the spray he may be using (salbutamide).
Laryngoscope
Laryngoscope is the most important piece of equipment. It must be in perfect condition. All spares must be readily available all the time. A spare bulb and pair of batteries (unused) must be at hand. Those who use rechargeable batteries, a note of caution, when the batteries are nearly discharged the bulb can fade away within seconds. A pair of batteries must always be in stock. The repairs and checking of all parts must be mastered for use in emergency. If the bulb is not working, check the following:
Change the batteries.
Check all contacts points and clean all the metal contacts with rough hard object or sandpaper if available.
Check the bulb by unscrewing from its place and checking it on the spring of the metal contact on laryngoscope handle and touching the body of the bulb to the body of the handle. If the bulb lights it means that laryngoscope handle, batteries, and bulb are O.K.
Clean the seating of the bulb in the blade and re-check the contact point on the blade and polish the same with sandpaper or even a metal file. The seating of the bulb can be cleaned by a needle and a drop of ether. Allow it to dry and replace the bulb.
Check the bulb. If it shows blackish discoloration change the bulb.
The insulation between the bulb body and contact points is only a small piece of paper, which gets wet while cleaning with water. Disengage the bulb and let it dry. Try to use it again. If it does not, pull the metal contact by a fraction of a millimetre. After constant use the insulation (paper) becomes useless and the contact and the bulb body touch directly and the bulb is short-circuited.
Checking the handle is easy. Unscrew the cap of the handle. Check the tension of the spring. Dry the handle from inside. Polish the contact of the spring with the metal body of the battery. Thus all metal contact points must be checked and cleaned of deposition of copper oxides. After use detach the blade, screw the bulb (if it is loose) and wash it with soap and water. The handle does not need cleaning unless smeared with blood during use in a difficult intubation. Minor points in repair of the laryngoscope must be known. Nobody teaches nor is it given in books. Check the light after cleaning.
If possible keep a spare Laryngoscope, cells and a bulb.
Extra long blade and special laryngoscopes can be useful.
Lastly do not loose your head. Insert the un-lighted blade in the patient’s mouth, give the correct position for intubation and pass a tube blindly. If the intubation for the same reason is difficult you may fail, otherwise in 90% cases you will succeed and carry the day.
Endotracheal tubes
The length of the endotracheal tube (ET) must not be longer than 2” of the size required. Longer ET may cause endobronchial intubation. The ET must have a nose worthy connection fitted permanently. So that it can be easily connected to the unidirectional valve for IPPR. Longer ET comes in the way for operations on the head and face and intra-oral surgery.
All tubes must be boiled for 2–3 minutes before use and re-checked as some debris only becomes apparent after boiling. The hard plastic tubes should be kept in warm water to make them soft and non traumatic (for nasal intubation).
Always check the temperature of the ET after it is taken out from the boiling water. Allow it to cool. Apply lubricant jelly after the tubes have cooled. In extreme emergency cool the tubes under tap water before intubating.
Keep all sizes of ET handy all times including OO size for new born resuscitation. Always have 3 sizes of ET ready. Apart from the proper size that you have selected have a smaller size and bigger size ready. Do not fumble at the last moment.
Special nasal tubes of sizes 6 mm to 10 mm must always be available for emergency use in failed oral intubation.
All endotracheal tubes must be secured with a good strip of sticking plaster. In cases of patient with beard or patient in prone position, it must be secured with additional bandage going round the neck. Chances of slipping of tube (which are quite high) are thus prevented. In case of infants it can be a disaster. In cases of children never pass a cuffed endotracheal tube. Avoid using cuffed tubes in cold cases. If at all used, inflate the cuff balloon yourself.
Other equipment

• A set of airways: Apart from serving as airway it can be good bite block and can also be used for fixing the endotracheal tube. The modern anaesthesiologist is neither trained nor he believes in open drop anaesthesia. Airway becomes mandatory equipment in both open drop anaesthesia and total intravenous technique.
  
• Magill's forceps: One size (big one) is mandatory. In difficult intubation it can be useful. If not used carefully it can cause trauma e.g. mucous membrane can be picked up by mistake.
  
• Flexo Metallic Stillette: Is mandatory. In difficult intubation it can be useful. Remember it can be traumatic if not used carefully.
  
• Ethyl chloride spray and ether drop bottle with Schimelbusch’s masks of all sizes. If spray is not available use Halothane in 5cc syringe with needle size 20G, 22G and 25G for induction depending on the age of patient.
  
• 3 sizes of Scalp vein needle.
  
• A cannula of the size needed for the patient.
  
• Endotracheal Tube connections
  All tubes should be fitted with Noseworthy connections of proper size so as to avoid searching for a connection and fitting of wrong connection (small) in a bigger endotracheal tube (by the assistant or ward boy) the Nose worthy connection takes up the unidirectional valve directly and does not need any other connection or catheter mount. In some cases of facio maxillary surgery (cleft lip and palate) use the Magill’s connection going to the endotracheal tube (especially the Oxford tube) with extra length of arm going out. This makes the job of the plastic surgeon of fitting the Boyle Davis gag easy and leaving some length of connection for fitting Ayre’s T piece.
  
• Ayre’s T piece: Keep it ready with both arms fitted with pieces of rubber tubing to take up the connection on the machine or the bellows. Have a half-meter long plastic tube fitting on the inlet of Ayre’s connection. The other side of this tube should have a permanent adapter to go directly on the Boyle’s machine or the exit of the Bellow unit.
  Bellows Unit: Always open the bellows from the lock instead of fumbling. Never keep cotton swabs and gauze pieces on the table as they are likely to get sucked in and block the inlet of the bellows and after a time may not allow any air in the bellows. These foreign bodies are not easily spotted unless you expect them. If the rubber shows signs of perishing get it changed immediately.
  
• Oxygen: In case you need to use oxygen, administer it with RR attachment and not through tap provided. Tap should only be used for IPPR and not for anaesthesia as it dilutes the vapour and lower concentration is delivered to the patient.
  It is always preferable to use the bellow unit with unidirectional valve situated under the bellows than separate disc valve set. Like in Oxford inflating bellows. It makes the equipment lighter.
  
• Hoses: Hoses connecting the vaporizer and the patient should be lightweight and not the heavy rubber as they can drag the endotracheal tube out in case one is not careful. The male and female connections at the end of hoses must be well fitting.
  
• Unidirectional valve: Any valve, which functions well and has not got the leak, is acceptable. Minor difference does not matter much. The Reuben valve material is damaged with continuous use of ether and should be replaced (replacement should be kept ready) as soon as one sees opaque patches or cracks. If it falls it crumbles to pieces easily. In the absence of unidirectional valves one can carry IPPR with a thumb technique.
  
• Tourniquet: Always carry a 1 foot long latex tubing with you. Help may not be available. One should palpate the vein in case one is suspicious of it being an artery. I have demonstrated abnormal superficial arteries in many cases.
  
• Draw over Bottle or Modified Flagg's can: A very convenient apparatus to use after induction with open drop ether and intubation in children. The size of the container (Glass bottle or can) should be small. The level of ether should be well below the lid and the inlet ports provided should have total cross sectional area equal to adult Trachea. It is better if is glass. Cooling of ether is very fast and in cold weather does not deliver adequate concentration. Even then one should resist the temptation of dipping in hot water. Remember boiling point of ether is only 35º C. Tap water jacket is all that one needs.
  Disconnect the delivery tube whenever one leaves the bottle or the patient. Always keep the palm loosely over the lid which keeps you informed about the respiratory rate and volume and it steadies the vaporizer. So many accidents have been recorded due to aspiration of pure liquid ether in the respiratory passage which results in pulmonary oedema and death. At one time this technique was supposed to be the safest. However if taken lightly it can cause deaths.

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