Anesthesia C-s due to Intubation

Anesthesia Complications Related To Intubation : 

Anesthesia Complications Related To Intubation Dr. Askar Hamid, M.D, A.B.O.A, Anesthesiologist in KAUH, King Saud University 15/10/2008

History of intubation : 

History of intubation Hippocrates (460-380 BC) describes intubation of the human trachea to support ventilation. GA in infants and children w/ Endotracheal intub-n was rarely performed before 1940 due to the fear of this procedure (too dangerous and traumatic). The tubes available were potentially damaging to the airway (post- extubation tracheitis, subglottic stenosis, trauma to the mucosa and laryngeal spasm). Today intub-n is essential part of GA, mechanical ventilation, E medicine.

Indications for Intubation(Rule of 5P) : 

Indications for Intubation(Rule of 5P) Potency of airway required: ↓consciousness, facial injuries, epiglottitis, laryngeal edema (burns, anaphylaxis), tetanus. Protect the lungs from aspiration: absent protective reflexes (coma, cardiac arrest). Positive pressure ventilation: hypoventilation, apnea (GA), complicated RA (total spinal A), mechanical ventilation for pulmonary edema or status asthmaticus. Pulmonary toilet: pt unable to clear secretions (MG,C-S#). Provides a route for E drug administration: cardiac arrest (lidocaine, epinephrine, atropine, ventolin), maintenance inhalational anesthesia.

Confirmation of ETT position : 

Confirmation of ETT position Direct visual confirmation by laryngoscopy (subjective). Expiratory CO2 (objective) by capnog & detector.. Auscultation (subjective). Chest wall movement. Water vapor (fogging) seen in a clear plastic tube. Fiber optic laryngo – bronchoscopy. Radiological Image.

Slide 7: 

the tube passes along floor of the nose Coronal section Sagittal section ANATOMY OF the AIRWAY

Slide 8: 

Position of the tracheal tube

Types of intubation : 

Types of intubation Oral intubation Nasal intubation Intubation techniques Rigid Laryngoscopy. Fibro-optic laryngoscopy. Intubation through LMA. Intubation over the cook tube exchange catheter or gum elastic bougie. Blind intubation. Retrograde intubation.

Factors contributing in ↑ of c-s : 

Factors contributing in ↑ of c-s Emergency situations (full stomach, ACL's, Cs under GA). Unexpected difficult intub-n cases. Different types of difficult intub-n situations (obesity, pregnancy, genetic syndromes, acquired conditions). Loose teeth and prosthesis. light anesthesia on tracheal intub-n & extubation. Airway infection and tumors. Poor pre-op evaluation and preparation. Hurry and uncooperative surgeon. Tired or sick anesthetist.

Factors contributing in ↓ of c-s : 

Factors contributing in ↓ of c-s Good training & CME. Follow the work guidelines (A.B.C.D plans of Intub-n). Good pre-op pt evaluation and preparation. Review records of previous anesthesia. Sufficient number of anesthesiologists in theater. Advances in anesthesia instrumentation and drugs. Familiarity w/ alternative options of airway management.

Other options for airway management : 

Other options for airway management LMA, Laryngeal tube, Slipa airway. Comb tube. Flexible Fiber optic Scope. Fiber optic Intubation Scopes (Glide, Upsher, Bullard, Wu,..). Cook catheter, Gum Elastic Bougie. Jet ventilation. Cricothyrotomy devices. Retrograde intubation Surgical airway access

Slide 14: 

The LMA Ctrach Cook Airway Exchange Catheter

Nasotracheal intubation c-s : 

Nasotracheal intubation c-s Nasal bleeding. Resistance during insertion: (Glide Rite™ tracheal tube has a soft curved distal tip or immerge the tube in hot water before insertion). Dental injury. Injury of the pharyngeal wall, fracture of turbinate. Infective complications: nasal septal and parapharyngeal abscesses after short time of intub-n .® ®: Case reports by M. A. Hariria1 and P. W. Duncan

Bleeding : 

Bleeding Prevention: Choose correct size of the tube. 0.5-1.0% Neosynephrine and 4% Lidocaine, mixed 1:1 nasal drops. Generously lubricate the nares and endotracheal tube Proper (no aggressiveness) insertion of the tube.

Management of the bleeding : 

Management of the bleeding Dependent on the severity of bleeding. Tomponade effect of the tube. Phynilephrine drops, tomponade with epinephrine Head position. Bp control. Oral intub-n in case of difficult nasal intubation.

Resistance during insertion : 

Resistance during insertion Glide Rite™ tracheal tube has a soft curved distal tip designed to prevent trauma to airway structures. (Parker tube). Generously lubricate the nares and endotracheal tube Immerge tube into hot water before insertion. Passing the tube over suction catheter after oral intub-n.

C-s : 

C-s C-s during laryngoscopy and insertion. While the tube is in place Trauma of the soft tissue Tube malfunction. C-s following extubation. Late C-s (ulceration, granulema and stenosis).

C-s during laryngoscopy and insertion : 

C-s during laryngoscopy and insertion Physiological reflexes: Tachycardia, bradycardia, PVC.    Hypertension. Laryngospasm, bronchospasm. ↑ ICP, ↑ IOP Hypoxia, hypercarbia, Risk factors: Light anesthesia Neonates and elderly pts. Pts w/ CVS and RS disease. Emergency situations. Pheochromacytoma. Difficult airway.

Prevention & Management : 

Prevention & Management Give pt usual morning medication (controlled). Good pre-op sedation. Rehydration before induction. Let pt reach sufficient depth of anesthesia. Spray the vocal cords w/ lidocaine. Lidocaine 1.5 mg/kg IV 1 – 2 min before intubation. Esmolol 0.5 mg/kg IV 1 -2 min before intubation. Lubricate the tube w/ lidocaine gel. Smooth & fast manipulation.

C-s during laryngoscopy and insertion : 

C-s during laryngoscopy and insertion Malpositioning: Esophageal intubation Endobroncheal intubation Laryngeal cuff position Airway trauma: Dental (malpractice claims). Lip, tongue, mucosal laceration Mandible dislocation, C-S injury, damage of spinal cord). Retropharyngeal dissection

While the tube is in place trauma of the soft tissue : 

While the tube is in place trauma of the soft tissue Mucosal inflammation and ulceration: (pressures exceed the capillary BP (approximately 30 mm Hg) cause tissue ischemia which lead to a sequnece of inflammation, ulceration, granulation and stenosis). minimum pressure that creates a seal during routine positive-pressure ventilation (usually at least 20 mm Hg) reduces tracheal blood flow by 75% at the cuff site. Further cuff inflation or induced hypotension can totally eliminate mucosal blood flow. Excoriation of the nose:

Tube malfunction : 

Tube malfunction Obstruction (secretion, kinking, biting by pt). Unintentional extubation (aggressive movement of the head by surgeon, improper fixation. Fire/explosion during laser surgery. Cuff perforation.

Dental injury : 

Dental injury The most common claim against anesthesiologist. Upper incisors most commonly injured during laryngoscopy. Risk of aspiration of the teeth after injury is high. Teeth protectors can prevent teeth injury, but can complicate already difficult intubation situation. Evaluation and documentation of teeth state is very important to avoid injury to loose teeth during elective surgery.

TMJ dislocation : 

TMJ dislocation TMJ dislocation is not uncommon. Laxity of supporting ligaments. Related to a jaw thrust maneuver during mask ventilation, placement of an oral airway or nasogastric tube, or in association with direct laryngoscopy. The first report of TMJ dislocation occurring during anesthetic induction with yawning as an isolated precipitating factor. A closed reduction of mandible was performed under fluoroscopic guidance and both TMJs were strapped with an elastic bandage.

Esophageal intubation : 

Dramatically decreased incidence after routine ETCO2 and SPO2 Monitoring & improving airway instrumentation. Present w/ no ETCO2, or low rapidly extinguished and hypoxemia (delayed by preoxygenation). Absent breath sounds over chest, gurgling sounds in epigastrium. Abnormal resistance on hand ventilation. Regurgitation of gastric contents up the ETT. Esophageal intubation

Management of esophageal intubation : 

Management of esophageal intubation Stop ventilating down ETT once the diagnosis is suspected. Recheck location of ETT by direct Laryng-y ____ if in doubt, take it out. Ventilate w/ 100% O2 by face mask and restore saturation. Re-attempt to intubate and verify tube position by Direct observation of passage of ETT through VC, auscultation, capnograph or Wee detector. Secure the ETT when tracheal position confirmed. Decompress the stomach w/ NG tube.

Endobronchial Intubation : 

Endobronchial Intubation Presents as high PIP and a ↓ breath sounds usually over left side. Sometimes presents as bronchospasm and ↓ SPO2. Deflate the cuff and withdrew ETT & fix after Bil auscultation. Flexion and hyper-extension of the head can move tip of the tube by 2.5 cm and rotation by 0.5 cm. Children 16–19 m of age: full flexion displaced the ETT tip 0.9 cm toward the carina, whereas full extension displaced the ETT tip 1.7 cm toward the vocal cords.

C-s of endotracheal intubation(Con’t) : 

C-s of endotracheal intubation(Con’t) Obstruction: from kinking , secretion or over inflation of cuff (Compression of the lumen). Disconnection from breathing circuit: alarm system with continues vigilance can prevent bad outcome. Accidental extubation: minimized by good fixation and secure during head movement.

Stretching of the tracheal wall : 

Stretching of the tracheal wall Caused by over-inflation of the cuff. This may lead to tracheitis, pressure necrosis of the tracheal wall or tracheal rupture. Use of low pressure -high volume tubes. Adjust pressure in the cuff after 15 minutes if N2O used©. ©: Migration of N2O into the cuff

C-s following extubation : 

C-s following extubation Laryngospasm. Bronchospasm. Vocal cord trauma (extub-n w/ inflated balloon). Sore throat. Aspiration: blood, gastric content. Edema and stenosis (glottic, subglottic, or tracheal). Hoarseness (vocal cord granuloma or paralysis)

Sore throat and hoarseness : 

Sore throat and hoarseness Etiology: Due to mechanical presence of the tracheal tube The most frequent subjective complaints after tracheal intubation. Incidence : 40% {higher in fem/ mal (44% vs. 33%)}. Risk factors: (female sex, duration of anesthesia, history of smoking, postoperative nausea, throat pack, laryngoscopy attempts). The average duration: 16 ± 11 h.

Laryngospasm : 

Laryngospasm Types: partial, complete. Known and unknown (recurrent) etiology. Incidence: 8.6/1000 in adults, 27.6/1000 in children. Causes: light A extub-n, secretions, blood, surgical debris, L blade, suction catheter, inflated balloon during extub-n. Pathogenesis: prolonged glottic closure reflex mediated by the superior laryngeal nerve Symptoms and signs: difficulty in breathing, vocalizing, inspiratory stridor and paradoxical respiration, Intercostal retraction, ↓SaO2 .

Laryngospasm : 

Laryngospasm High risk groups: smokers, obese patients, the presence of underlying airway disease, difficult intubation cases, light anesthesia extubation. Complications of Laryngospasm: severe hypoxia, Hypercarbia, pulmonary aspiration, negative pressure pulmonary edema, cardiac arrest. Prevention: deep or fully awake extubation, good suction, smooth removal of the tube.

Immediate management : 

Immediate management Stop the stimulus that precipitate largospasm. Open & clear the airway as much as possible and remove airway devices that may be stimulating the larynx Forcible jaw thrust or anterior pressure on the posteriosuporior mandibular rami just anterior to the mastoid process (Larson’s point) may break laryngospasm due to a combination of stimulation & and airway clearance. Apply CPAP w/ 100% O2 via bag & Mask. If SPO2 continues ↓ call for help . Deepen anesthesia w/ IV agent (Propofol 20 – 40 mg increments) & continue CPAP.

Immediate management : 

Immediate management If SPO2 continues ↓, give Sux in sub paralytic doses (0.1 mg/kg I.V). If ventilation becomes easier, oxygenation improves, & the airway does not require protection, bag & mask ventilation may be sufficient ton maintain adequate oxygenation, if not, an airway should secured w/ LMA Or Reintub-n. In the exceptional cases of severe laryngospasm causing life threatening hypoxemia despite Tx , surgical airway is life saving.

Management of recurrent Laryngospasm (alternative methods). : 

Management of recurrent Laryngospasm (alternative methods). Propofol in sub hypnotic dose (0.25mg/kg ). Lidocaine spray(2ml of 2% solution). Nitroglycerin (4 µg/kg IV bolus). Diazepam (1mg I.V increments; up to 3mg). Use of a bilateral superior laryngeal block will interrupt the reflex arc.

Laryngeal Notch : 

Laryngeal Notch Larson’s point

Aspiration : 

Aspiration Presentation: direct visualization of foreign material in oropharyngx entering laryngeal inlet. Intraoperatively: laryngospasm, unexpected rise in AWP, Hypoxemia. Post-op: material present in the suction, unexpected hypoxemia, tachypnea/ dyspnea, bronchospasm, intercostal/ suprasternal recession, wheeze, crackles, reduced air entry.

Risk factors for aspiration : 

Risk factors for aspiration Full stomach. Pregnancy & up to 48 h post-partum. Obesity. DM (autonomic neuropathy). Significant trauma & opioid analgesia. Upper GI bleeding. Intestinal obstruction, Diaphragmatic hernia. Esophageal pathology (stricture, achalasia, hiatus hernia, incompetent lower esophageal sphincter.

Precipitating factors : 

Precipitating factors Ineffective cricoid pressure or inexperienced application/ premature release during mask ventilation. Difficult manual ventilation w/ inflation of the stomach. Vomiting during induction and recovery w/ deep extubation and excessive suction (pharyngeal stimulus). Straining, coughing, & bucking on a supraglottic airway, hiccups. Tracheal extubation during light planes of A.

Management of aspiration : 

Management of aspiration If soiling of the trachea is recognized and material is emerging from esophagus, apply cricoid pressure to limit further aspiration. If actively vomiting, turn the pt to Lt lateral position w/ Head down tilt, Avoid cricoid pressure while active vomiting to reduce risk of esophageal rupture. Clear the pharynx w/ rigid sucker. Do not ventilate during these maneuvers within the limits of O2 desaturation.

Management of aspiration : 

Management of aspiration When airway cleared and protected, ventilate w/ O2 100%. PEEP may be required to maintain adequate arterial sat. Empty stomach w/ large-bore gastric tube after intubation. Cancel elective surgery and quick proceed of E surgery.

C-s Associatedwith Repeated Laryngoscopic Attempts : 

C-s Associatedwith Repeated Laryngoscopic Attempts (Anesth Analg 2004;99:607–13) May Change situation from Can ventilate, can not intubate to Can not ventilate, Can not intubate.

Special notes : 

Special notes Repeated attempts at laryngoscopy during a difficult intubation may lead to periglottic edema then inability to ventilate with a face mask or LMA, thus turning a bad situation into a life-threatening one. Risk of gastric inflation is high if PIP > 20-25 cmH2O ▲ risk of pulmonary aspiration. Don’t hesitate & lose time, Call for help. Don’t Panic, Relax, recently you have many options to secure the airway. Remember: و من يتق الله يجعل له مخرجا. Who is obeying Allah, who will get safe exit in difficult situation.