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REPLACES: JUNE 1993

DATE: MAY 1999

FOR REVIEW: MAY 2002

REFERENCE: ASSOCIATE CLINICAL NURSE MANAGER, HIGH DEPENDENCY UNIT

a.) protection from gastric aspiration and secretions

b.)access and maintenance-in difficult airway and difficult surgical positions/procedures

c.) provide positive pressure ventilation- can be done for shorter periods with a mask or Oxylog

d.) oxygenation- to provide a controlled concentration of oxygen up to 100%, also provides for complete scavenging

e.) secretions- facilitates removal of secretions via suctioning

a) to allay the anxiety of the patient

b) to assist the Medical Officer a required

c) to prepare the equipment required

REQUIREMENTS

cardiac monitor

pulse oximeter

laryngoscope (check light)

Adult blades No. 3 & No. 4

Magill forceps

lubricant

connector- Bodi Y / elbow (may be required)

Flexible introducer

Syringe 10 ml

Clamp

Guedel airway Nos. 2 or 3

Tape for ties

licorice stick

Endotracheal tubes: usually 8 mm for women; 9 mm for men ; age/4 + 4 for children. e.g. age 8 - a 6 mm tube

Means of inflating lungs - Air Viva, anaesthetic machine

With face mask: size 3 for women; size 4 for men

Suction apparatus with Yankauer nozzle and endotracheal suction catheter

Receptacle - dirty dish for used laryngoscope, face mask.

TECHNIQUE OF ENDOTRACHEAL INTUBATION

Position of the patient: Supine

Pillow under head

Flexion of the neck.

Extension of the atlanto-occipital joint.

(This is the position sometimes called "sniffing the morning air")

Open the mouth by separating the lips and pulling on the upper jaw with the index finger.

Hold the laryngoscope in the left hand. Insert the laryngoscope into the mouth with the blade directed to the right tonsil. Once the right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.

This brings the epiglottis into view. DO NOT LOSE SIGHT OF IT.

Advance the laryngoscope blade till it reaches the angle between the base of the tongue and the epiglottis.

Lift the laryngoscope upwards and away from the nose - towards the chest. This manoeuvre should bring the vocal cords into view, but it may be necessary for an assistant to press on the trachea to improve the direct view of the larynx.

Take the endotracheal tube in the right hand. Keep the concavity of the tube facing the right side of the mouth. This causes least interruption to the view of the vocal cords. Watch the tube entering the larynx and insert it through the cords only till the cuff is just below the cords.

Inflate the cuff to provide a minimal leak when the bag is squeezed.

Listen for air entry at both apices and both axillae to ensure correct placement, using a stethoscope.

Precautions:

Wear protective clothing: gloves; gowns; goggles.

Disposal of apparatus:

Face masks, Guedel airways, contaminated laryngoscopes, suction nozzles should be put into a "dirty dish" and removed from the theatre promptly for cleaning. Used endotracheal tubes should be discarded into a container for contaminated waste.

INTUBATION MEDICATIONS

Specific Agents

Sedatives-Hypnotics: rapid onset of unconsciousness (0.5 to 1 minute) and short duration of action

Thiopentone sodium (Pentothal)

· a barbiturate

· 2-5 mg/kg

· increased venous capacitance _ decreased preload___CO and _BP

· Hypovolemic patients and those with poor cardiac reserve are prone to hypotension with induction

· Increased HR

· Useful as induction agent and brief sedation

· Respiratory depression can be significant

Propofol (Diprivan)

· an isopropyl phenol

· 1-2.5mg/kg

· more rapid and complete awakening compared to barbiturates

· reduces blood pressure more than thiopental

· exaggerated hemodynamic effects in hypovolemic patients

· pain with injection into non-antecubital, small vein

Antianxiety agents

Amnestic, anticonvulsant, hypnotic, and sedative effects. Useful sedation for procedures and toleration of mechanical ventilation.

Benzodiazepines

Midazolam

· sedation: 0.5-1 mg increments

· induction: 0.15-0.35 mg/kg

· amnestic: 50 mcg/kg

· mild vasodilatation

· respiratory depression: increased in the elderly and when combined with narcotics

· onset 1 - 2 mins. and recovery 30 - 120 mins.

Diazepam

· sedation: 2 - 10mg (adults)

· onset 1 -2 mins. and recovery 2 - 4 hrs.

Muscle relaxants

FULL VENTILATORY SUPPORT IS MANDATORY

Suxamethonium chloride

· depolarising muscle relaxant

· indications: facilitate tracheal intubation, provide skeletal muscle relaxation during surgery or mechanical ventilation

· intubation: 0.5-1.5 mg/kg

· onset: 60 seconds

· recovery time: 3-10 minutes

· Cardiac dysrhythmia including sinus bradycardia, junctional rhythm, and sinus arrest have been reported. May cause tachycardia in adults and bradycardia in children

· significant hyperkalemia may result in patients with skeletal muscle myopathy, neurologic deficits, prolonged bed rest, multiple trauma, major burns (safe within first 24 hours of burn)

· risk of hyperkalemia peaks at 7-10 days post burn, neurologic injury or multiple trauma

· Use in children should be reserved for emergency intubation or instances where immediate securing of the airway is necessary.

· Increases intraocular, intragastric and intracranial pressure

Vecuronium bromide (Norcuron)

· steroidal analogue of pancuronium

· intubation: 0.08-1 mg/kg

· onset: ~ 3 minutes

· duration: 20-35 minutes

· hemodynamically benign

Pancuronium bromide

· Intubation: 0.1 mg/kg

· onset: 3-5 minutes

· duration: 60-90 minutes

· 10-15% increase in HR, arterial BP and CO

Local Anesthetics

Lignocaine Spray (Xylocaine Spray)

· goals: topical anaesthesia to increase patient comfort, control hemodynamics and facilitate tracheal intubation via oral or nasal routes.

· Amide local anaesthetic, metabolized by the liver.

· elective nasotracheal intubation: 3-5 cc of 2% lidocaine in an atomiser inhaled into each nares or 4 cc of 4% lidocaine nebulised into the oropharynx; both techniques completely anaesthetise the vocal cords in ~ 5 minutes

· Intravenous route may be effective in blunting the response to laryngoscopy and intubation

NURSING POINTS TO NOTE:

1. With the exception of life threatening emergencies the patient should be nil orally for four - six hours prior to the procedure.

2 The Anaesthetist may request the Registered Nurse to apply Cricoid pressure during the intubation to prevent aspiration during the procedure. To apply Cricoid pressure, the nurse must place her fingers on the cricoid cartiledge and apply pressure to obstruct the oesophagus. This pressure must be maintained until specifically requested by the Anaesthetist to stop after the cuff of the endotracheal tube has been inflated.

3. The patient must never be left alone whilst intubated

4. The patients dentures may be left in situ depending on the preference of the Anaesthetist. If removed, dentures should be placed in a correctly labelled container.