General Anesthesia:

Intubation

Neuraxial Anesthesia
Topics For Discussion
 Basic anatomy and
physiology.
 Advantages of
endotracheal intubation.
 Indications of intubation.
 Contraindications of
intubation.
 Complications of
intubation.
 Equipment required for
intubation.
 Technique of
endotracheal intubation.
 Rules of endotracheal
intubation.
 Tube sizes.
 Rules and principals of
suctioning.
 Other airway adjuncts.
 Conclusion.
 Difficult intubations.
Anatomy and Physiology
The airways can be divided in to parts namely:
 The upper airway.

 The lower airway.

The Upper Airway
The Lower Airway
Advantages of Endotracheal
Intubation
 Cuffed E.T tubes protect the airway from aspiration.
 E.T tube provides access to the tracheobronchial
tree for suctioning of secretions.
 E.T tube does not cause gastric distention and
associated danger of regurgitation.
 E.T tube maintains a patent airway and assists in
avoiding further obstruction.
 E.T tube enables delivery of aerosolized medication.
Indications for Intubation
 Inadequate oxygenation(decreased arterial
PO2) that is not corrected by supplemental
oxygen via mask/nasal.
 Inadequate ventilation (increased arterial
PCO2).
 Need to control and remove pulmonary
secretions.
 Any patient in cardiac arrest.
Indications for Intubation
 Ant patient in deep coma who cannot protect his
airway.(Gag reflex absent.).
 Any patient in imminent danger of upper airway
obstruction (e.g. Burns of the upper airways).
 Any patient with decreased L.O.C, GCS <= 8.
 Severe head and facial injuries with
compromised airway.
Indications Cont…
 Any patient in respiratory arrest
 Respiratory failure
1. Hypoventilation/Hypercarbia
A. Paco2 > 55mmhg
2. Arterial hypoxemia
refractory to O2
A. Paco2 < 70 on 100% O2
Contraindications for Intubation
 Patients with an intact gag reflex.
 Patients likely to react with laryngospasm
to an intubation attempt. e.g. Children
with epiglottitis.
 Basilar skull fracture – avoid naso-tracheal
intubation and nasogastric/pharyngeal
tube.
Complications Associated With
Intubation
 Trauma of the teeth, cords, arytenoid cartilages, larynx
and related structures.
 Nasotracheal tubes can damage the turbinates, cause
epistaxis, and even perforate the nasopharyngeal
mucosa.
 Hypertension and tachycardia can occur from the
intense stimulation of intubation; This is potentially
dangerous in the patient with coronary heart disease.
 Transient cardiac arrhythmias related to vagal
stimulation or sympathetic nerve traffic may occur .
Complications Continued…
 Damage to the endotracheal tube cuff, resulting
in a cuff leak and poor seal.
 Intubation of the esophagus, resulting in gastric
distention and regurgitation upon attempting
ventilation.
 Baro-trauma resulting from over ventilating with
a bag without a pressure release
valve( phneumothorax).
Complications Continued…
 Over stimulation of the larynx resulting in
laryngospasm, causing a complete airway
obstruction.
 Inserting the tube to deep resulting in unilateral
intubation (right bronchus).
 Tube obstruction due to foreign material, dried
respiratory secretion and/or blood.
Equipment Required for
Successful Intubation
Equipment Cont…
 Laryngoscope with relevant size blades.
 Magill forceps.
 Flexible introducer.
 10-20 ml syringe.
 Oropharangeal airways – all sizes.
 Tape or adhesive plaster.
 E.T tubes – relevant sizes.
 Bag-valve-mask with oxygen connected.
 Suction unit with Yankauer nozzle and endotracheal
suction catheter.
Technique of Endotracheal
Intubation (in a ideal setting)
Technique Cont…
 Position the patient supine, open the airway with
a head-tilt chin-lift maneuver.(Suspected spinal
injury, attempt naso-tracheal intubation, spine in
neutral position.).
 Open mouth by separating the lips and pulling on
upper jaw with the index finger.
 Hold laryngoscope in left hand, insert scope into
mouth with blade directed to right tonsil.
 Once right tonsil is reached, sweep the blade to
the midline keeping the tongue on the left.
Technique Cont…
 This brings the epiglottis into view.” DO NOT LOOSE
SIGHT OF IT!”
 Advance the blade until it reaches the angle between the
base of the tongue and epiglottis.( volecular space)
 Lift the laryngoscope upwards and away from the nose –
towards the chest. This should bring the vocal cords into
view. It may be necessary for a colleague to press on
the trachea to improve the view of the larynx.
 Place the ETT in the right hand. Keep the concavity of
the tube facing the right side of the mouth.
 Insert the tube watching it enter through the cords.
Technique Cont…
 Insert the tube just so the cuff has passed the
cords and then inflate the cuff.
 Listed for air entry at both apices and both
axillae to ensure correct placement using a
stethoscope.
Rules of Intubation
 Always have a suction unit available.
 An intubation attempt should never exceed 30
seconds.
 Oxygenate the patient pre and post intubation
with a bag-valve-mask.(100% O2).
 Have sedative medication available if needed.
(e.g. Midazolam 15mg/3ml)
 Always recheck tube placement manually
guided by oxygen saturation readings.(Spo2).
Tube sizes
 Newborn – to 4 kg - 2.5 mm (uncuffed).
 1-6 months 4-6 kg – 3.5 mm (uncuffed).
 7-12 months 6-9 kg – 4.0 mm (uncuffed).
 1 year 9 kg – 4.5 mm (uncuffed).
 2 years 11 kg – 5.0 mm (uncuffed).
 3-4 years 14–16 kg - 5.5 mm (uncuffed).
 5-6 years 18–21 kg – 6.0 mm (uncuffed).
 7-8 years 22-27 kg – 6.5 mm ( uncuffed).
Tube Sizes
 9-11 years 28-36 kg – 7.0 mm(cuffed).
 14 to adults 46+ kg – 7.0 – 80 mm (cuffed).
 Adult female 7.0 – 8.0mm (cuffed).
 Adult male 7.5 – 8.5 mm (cuffed).
 The size of the tube may also be determined by the
size of the patients little finger.
N.B patients below the age of 8 require uncuffed ETT
due to damage caused by the cuff in younger
patients. Always monitor the ECG activity during
intubation.
4 Rules of Suctioning
 Never suction further than you can see.
 Always suction on the way out.
 Never suction for longer than15 seconds.
 Always oxygenate the patient before and
after suctioning.
Other Airway Adjuncts
 Kombi-tube.
 Oropharangeal airways/tubes.
 Nasopharyngeal airways/tubes.
 Oro-tracheal tubes.
 Naso-tracheal tubes.
Conclusion
 Always oxygenate patient before and after
intubation.
 Do not attempt intubation unless you are
totally skilled, rather perform bag-valve-
mask ventilation.
 Always monitor the spo2 readings.
 Always reconfirm tube placement from
time to time.
Neuraxial techniques
Spinal anesthesia
 Patient position
 Approachs: Midline & Paramedian
 Technique
 Monitoring during spinal anesthesia
 Single dose spinal anesthesia
 Continuous spinal anesthesia
 Complications
 Contraindications
 Common local anesthetics for spinal anesthesia
 Lidocaine, Bupivacaine, Tetracaine, Ropivacaine
 Position
• Sitting position
Sit straight first
Chin on chest
Arms resting on knees
Footstool/table to support feet
Back curving like banana or shrimp
• Lateral position
Shoulders perpendicular to bed
Positioned with hips on edge of bed
Knee chest position and back curving
Midline approach to subarachnoid space
Procedure
 Common local anesthetics

LA & Concentration T10 level T4 level Duration Duration

upper abd lower abd plain with epi
Bupivacaine 0.75% 12-14mg 12-18mg 90-120min 100-150min

Tetracaine 1% 10-12mg 10-16mg 90-120min 120-240min

Lidocaine 5% 50-75mg 75-100mg 60-75min 60-90min

Ropivacaine 02-1% 12-16mg 16-18mg 90-120min 90-120min

Factors affecting spread of LA solution
• Baricity of LA solution
• Position of patient
• Concentration volume injected
• Level of injection
• Speed of injection
Assessing the level of block
 Epidural Anesthesia
• Position
• Approach: midline & paramedian
• Location: cervical, thoracic, lumbar
• Technique
• Monitoring
• Single dose - pain management
• Continuous epidural - anesthesia & analgesia
• Complication
• Contraindication
• Common LA for epidural anesthesia & analgesia
Bupivacaine and ropivacaine
Epidural Approach
Loss of resistance technique
Epidural Catheter Placement
Epidural Catheter placement
Epidural Catheter Placement