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Institute of Surgical Research „A” Modul - Surgical Techniques

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1 Institute of Surgical Research „A” Modul - Surgical Techniques
A1. MODUL - Asepsis and Antisepsis A2. MODUL - Surgical Deontology A3. MODUL - Wounds A4. MODUL - Operations A5. MODUL - Bleeding A6. MODUL - Clinical aspects of shock: endotracheal intubation use of laryngoscope + practical examination


3 Endotracheal intubation
Definition: introducing a tube through the mouth (or nose) into the trachea to secure open airways. Benefits as compared to extratracheal techniques: 1. Anatomic dead space is decreased by 50%; alveolar ventilation increasing (important in high risk surgical patients). 2. Air and anesthetic gas mixture could enter only the lungs and not the stomach. 3. Vomiting and aspiration can be avoided. 4. Suctioning will remove mucus from lungs. 5. Atelectasis can be eliminated in case of correct artificial ventilation. 6. Position of the patient (prone position) does not affect ventilation. 7. Different drugs can be given intratracheally.

4 Technique of endotracheal intubation
1. Preparing the equipments 2. Positioning the patient 3. General or local anesthesia 4. Oxygenization 5. Positioning the head, pharyx-larynx axis 6. Muscle relaxation Intubation with laryngoscope 8. Depth of intubation 9. Controlling 10. Fixation

5 1. Preparing the equipments
Ruben-balloon with valve and mask tube adaptors, adhesive tape suction catheter, suction pump laryngoscope laryngeal mask syringe Guedel-tube Magill-forceps endotracheal tubes

6 2. Positioning the patient
Most preferred: the patient is laid in supine position, the head is toward the person who is performing the procedure.

7 3. General or local anesthesia
Under General anesethesia, or local anesthesia should be induced in the patient’s pharynx and larynx. It is also practical to apply surface anesthesia: vagal excitation is less, the patient may tolerate the tube better, arrhytmias and laryngospasm after extubation are rare. Apply 10% Lidocain spray (2 or 3 spurts - 1 spurt=4.8 mg) If the distal end of tube is also sprayed with Lidocain before intubation, the patient will also tolerate the tube after recovering consciousness.

8 4. Oxygenization Deliver oxygen with a face mask for at least 3 min. If intubation fails (in short time - no more than 1 min) in the apnoic patient, apply ventilation through the mask, and then intubation should be performed again only in well-oxygenated patient.

9 5. Positioning the head 1. In supine position there is an oblique angle between the oral and pharyngeal axis. There are two positions for alignment of the two axes and making the passage of the endotracheal tube easier: 1. Jackson position: Patient is laid in supine position without a pillow. The palm is placed on the patient’s forehead and pushes it down, so the head is tilted backward at the atlanto-occipital joint (cervical spine is also turned backward).

10 6. Positioning the head 2. 2. Modified Jackson position: In supine position (short-necked, fat patient or in torticollis) a pillow (10 to 15 cm) is placed under the patient’s nape, and the head will be tilted so that the mouth should be opened. The oral axis coincides with the pharyngeal one, and the glottis can be seen with the laryngoscope underneath.

11 7. Intubation with laryngoscope 1.
- Grasp the laryngoscope by the left hand and insert the curved blade into the mouth along the median line of the tongue. - If necessary, push the tongue to the left with the blade. - The end of the blade is between the base of tongue and the epiglottis, in the plica glossoepiglottica (lifting the base of the tongue the epiglottis can also be elevated).

12 8. Intubation with laryngoscope 2.
… and the triangular glottis with its peak upward can also be seen. If the epiglottis and the front of trachea cannot be seen, the assistant will press down the base of thyroid cartilage and the cricoid cartilage (Sellick maneuver).

13 9. Controlling the intubation
Stethoscope auscultation over both axillar lines alternately. (If the tube is inserted too deeply, it is usually in the right bronchus, and ventilation on the left side cannot or slightly be heard.) We listen the chest at a point about the end of tube. Knock the chest wall gently at the upper part of thorax (thus the outflow of air can be heard through the tube). Insufflation through the tube induces a symmetrical moving of the thorax (rising and sinking). Oesophageal intubation could be avoided by the use of capnography (ETCO2 is zero);

14 10. Deepness of intubation
Can be read on the side of the tube. Distance of tracheal bifurcation from the upper incisor (nipper) is about 27 cm in males and about 23 cm in females. The distal end of tube has to be positioned in the trachea 1-3 cm above the bifurcation <= without this the ventillation is insufficient! Without blowing of cuff <= danger of aspiration! The balloon has an automatic valve, which shuts down after the removal of inflating syringe. The pressure of cuff could be max mmHg maximum.

15 11. Fixation A bite protector (in case of Guedel-tube) or a wet roller bandage in the mouth of the patient can be used to avoid biting of tube. The tube and the bite protector are fixed with an approx. 30 cm long strip of adhesive tape, which is sticked on the face of the patient in cross form <= the function of tube can be faulty without fixing.

16 Difficulties during intubation
12. SUMMARY I Difficulties during intubation 1. Patient Callused stricture of mouth, inflammatory lock-jaw, pouting and loose teeth, tumor in mouth, pharynx and tongue; deformed mandibula, tonsillar abscess, struma dislocating laryngx, stricture of trachea, short and thick neck, dental prosthesis. 2. Medical Lack of appropriate equipment, improper posture (laying), inappropriate muscle relaxation. In case of danger of aspiration avoid breathing through the mask; suck up continuously blood, mucus, regurgitating stomach content; Pressing the cricoid cartilage by finger (Sellick-maneuver) - the danger of regurgitation from the stomach can be reduced.

17 Complications of endotracheal intubation
13. SUMMARY II. Complications of endotracheal intubation Injuries: on lips, or tongue; teeth, mucosa of pharynx and larynx; vocal cord, bleeding of pharynx; Increased airway resistance: in case of narrow tube, especially children; Obstruction of lumen: by blood or excretion, foreign body; the end of the tube can be closed by the tracheal wall or by the cuff; Improper intubation: into the stomach or main bronchus; Slipping out: improper fixation Inappropriate sedation of patient can cause coughing, spasm consequent breathing difficulty.

18 Nasotracheal intubation (video)

19 Practical exam The practical exam consists of the execution of 3 exercises at 3 workstations. Place: outer and inner operating theaters Exercises Scrubbing and Dressing – workstation No. 1; 5 students; (max. 12 min); outer surgical theater; 2. Techniques of tying knots – workstation No. 2; 5 students; Demonstration of a surgical knot, method is optional (max 10 min); inner surgical room; 3. Suture techniques - workstation No. 3; 5 students; Applying simple interrupted or vertical mattress sutures (min. 3 stiches); (max 10 min); inner surgical room

20 Requirements 1. Scrubbing and Dressing
Taking on cap and mask, handwash with soap (from hands to at least 3 finger-breadth above the elbow), Rinse hands and arms with water regularly, Clean the nails with brush and rinse (1 min) Chemical disinfection: scrubbing with alcoholic detergent (5x1 min), From 3 finger-breadth under the elbow to distal on every surface, From middle arm to distal on every surface, From previous one to distal on every surface, On every surfaces of wrist and arm, On every surfaces of arms, Gowning, Glowing with assistant of nurse 2. Techniques of tying knots 3-4 min practice and then demonstration of an optional method of tying knots: two-handed square knot (sailor’s knot), surgeon’s knot or the Viennese knot. 3. Suture techniques Applying of a simple interrupted or vertical mattress suture (3 stiches); tying knot with an instrument.

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