Saturday June 30, 2007
Regarding Tracheostomy tube change

Tracheostomy tubes, frequently placed in critically ill patients who require prolonged airway access. It usually requires 7 days for maturation of the tracheal cutaneous tract. Changing tracheostomy tube prior to this may result in dissection between tissue planes, creating a false passage or lumen and loss of the airway. If situation arise to change tracheostomy tube before seven days (like due to cuff leak etc), it is always appropriate to keep backup measures with oxygen mask and endotracheal intubation in case tract get lost, desaturation or hemodynamic instability. Ideally, Bronchoscope should be kept handy too.

One trick in premature tracheostomy tube change is to do it over airway exchange catheter to avoid false lumen passage. You may use suction catheter, nasogastric tube or any tube to pass over.

Reference:

The tracheostomy tube change: a review of techniques - British Journal of Hospital Medicine, Vol. 62, Iss. 3, 14 Mar 2001, pp 158 - 163

Monday June 25, 2007
Regarding disposable plastic laryngoscope blade


Is disposable plastic laryngoscope blade acceptable ?


Answer is "No".
To save money and in some cases to decrease infection rate, there has been temptation in many institutions to use disposable plastic laryngoscope blade.

One study recently published from france 1 in which 284 adult patients requiring rapid sequence induction (for intubation) were randomly assigned to either plastic single-use or reusable metal blades.

In the case of failed intubation, a second attempt was performed using metal blade.

The primary endpoint of the study was the rate of failed intubations.
The secondary endpoint was the incidence of complications (oxygen desaturation, lung aspiration, and oropharynx trauma).

Results:

• On the first attempt, the rate of failed intubation was significantly increased in plastic blade group (17 vs. 3%).
• In plastic blade group, all initial failed intubations were successfully intubated using metal blade, but in metal blade group, 50% of failed intubations were still difficult after the second attempt.
• There was a significant increase in the complication rate in plastic group (15 vs. 6%).

Study concluded that in rapid sequence induction of anesthesia, the plastic laryngoscope blade should not be recommended for use.


Editors' note: Possible reasons of poor outcome from plastic blades include uneven curvatures, poor allignment or fitting with laryngoscope and chances of breaking down durin procedure.




References: click to get article

Comparison of Plastic Single-use and Metal Reusable Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia. - Anesthesiology. 104(1):60-64, January 2006.

Sunday June 24, 2007
Supraclavicular approach of subclavian central line (video)


Watch this very nicely done video of supraclavicular approach of subclavian central line (from EMPAR.TV)

supraclavicular approach of subclavian central line

(Total time 10:34 minutes)


Previous related pearl: Where is Subclavian vein ?

Saturday June 16, 2007
Changing double lumen endotracheal tube (ETT) to single lumen

Q; You have been asked to change double lumen endotracheal tube (DLT) on a patient after thoracic surgery. Due to excessive tapping, you cannot read anything but see 2 lumens - white and blue. Which lumen you will use to pass change over catheter ?

A; White color (Tracheal)

Double lumen endobronchial tubes are usually used in thoracic surgery. Double lumen tubes have 2 cuffed lumens

1. Endobronchial (usually blue) and
2. Tracheal (usually white)

DLT is less stable than single lumen ETT. DLT is of wide diameter and meant to be changed immediately post-operatively unless severe laryngeal edema prevents it. Tracheal port should be used to change the DLT to single lumen ETT over wire/catheter.