Kinking Of Tube Research Articles

Kinking of endotracheal tube during posterior fossa surgery

Kinking of endotracheal tube during posterior fossa surgery

Cleft lip and palate surgery in children: Anaesthetic considerations

The Care of cleft patients is very challenging. Team cleft care is usually lacking in many developing countries due to shortage of qualified manpower. This study is aimed at highlighting anaesthetic challenges in the management of cleft in children. This was a study of cleft lip and palate patients who were managed during team cleft care activities at University of Maiduguri Teaching Hospital and Federal Medical Centre Nguru both in north eastern Nigeria from January to June 2009. One hundred and six cleft patients presented for surgical repair under general or local anaesthesia. Fifteen (14%) patients all of whom children were unfit for general anaesthesia due to various medical reasons. Ninety-one (86%) cleft patients comprising 53(50%) children and 38(36%) adults had cleft repair under halothane general endotracheal anaesthesia and local anaesthesia, respectively. There was no anaesthetic complications recorded under local anaesthesia. Fifteen percent of children who received general endotracheal anaesthesia suffered various anaesthetic complications which included hypoxia (3.8%), laryngospasm (1.9%), kinking of endotracheal tube (5.7%), inadvertent extubation (1.9%) and pulmonary aspiration (1.9%). There was no mortality or anaesthesia-related morbidity at the time of discharge in all the cases. We conclude that anaesthesia for cleft lip and palate repair in hospital based team-cleft care activities in our environment is relatively safe. We recommend general anaesthesia with controlled ventilation for children and local anaesthesia for adult and older children who can cooperate.

Initial Experience of Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

Purpose: Laparoscopic sleeve gastrectomy (LSG) is rapidly gaining ground as one of the surgical procedures in bariatric surgery with emerging long-term follow-up data. The aim of the present study was to report our initial experience of LSG in morbidly obese patients. Methods: Sixty-four consecutive patients underwent LSG from April 2009 to July 2010 at our bariatric surgery center. Patients eligible for LSG were those with a body mass index (BMI) of ＞37 ㎏/㎡, and ＞32 ㎏/㎡ with co-morbidities. LSG was performed using 5 trocars and endo-staplers with guidance of 34 Fr bougie. Perioperative management was standardized. The clinical data were prospectively collected and retrospectively analyzed. Results: Among 64 patients, 19 were male and 45 were female, mean age was 35 years (range 20∼57), mean preoperative BMI was 38.8 ㎏/㎡ (range 32∼57), and mean preoperative body weight was 108 ㎏ (range 75∼164). Mean operative time was 118 minutes (range 65∼340) and mean length of hospital stay was 3.4 days (range 1∼82). Staple line leak occurred in 1 patient, kinking of the gastric tube occurred in 2 patients. There was no open conversion and no postoperative mortality. After 170 days of follow-up, 24.4 ㎏ of body weight loss and 52.7% of excess weight loss (%EWL), on average, was noted. Conclusion: Though long-term follow-up is needed, our early operative outcome was satisfactory in terms of %EWL and safety of the procedure. LSG was a safe and effective treatment strategy for morbidly obese patients.

Endotracheal tube kinking during neurosurgical procedures

Endotracheal tube kinking during neurosurgical procedures

Kinked inner tube of coaxial Bain circuit—need for corrugated inner tube

mained patent, probably because of the corrugations, but the inner tube kinked most of the time and the Bain circuit got disconnected from the fresh gas fl ow outlet. There are no recommendations with regards to the type of tubing in a Bain circuit. Although the outer tubing is corrugated, the inner tubing is noncorrugated and is liable to kink. Also, the corrugated outer tubing may give false confi dence in the nonkinkabilty of such a coaxial breathing circuit; the inner tube may get kinked, and this is not noticed. In an earlier study, concerns related to the inner tube (disconnection of inner tubing from its seat at the machine end of the circuit), which were attributed to the fl exion of the coaxial circuit were reported, suggesting that redesign of the circuit was needed [1]. A problem of inner-tube disconnection during lateral displacement of the coaxial tubing of a circle system, has also been reported, suggesting the need for redesigning of the coaxial circuit [2]. Kinking of an overlong inner tube, forming a double angulation (“Z” shape) within the outer tube, leading to total occlusion, has also been reported earlier [3]. We want to highlight to readers the possibility of the kinking of the inner tube of a Bain circuit. The feasibility and respiratory mechanics of the use of a corrugated inner tube in the Bain circuit need to be evaluated.

An unusual site of intraoperative kinking of an endotracheal tube

An unusual site of intraoperative kinking of an endotracheal tube

Maneuver to Relieve Kinking of the Endotracheal Tube in a Prone Patient

We would like to report a case of intraoperative kinking of the endotracheal tube (ETT)1in a prone patient and a unique maneuver to restore its patency.A 52-yr-old female was undergoing craniotomy for tumor resection in the prone position. A 7.5-mm polyvinyl ETT was placed without difficulty and secured at 21 cm at the teeth. The esophageal temperature was 36.6°C when peak airway pressures began to rise. Examination revealed an ETT that would not allow passage of a small flexible suction catheter beyond 19 cm, the point at which the pilot balloon line inserts. Extubation over a tube changer and then reintubating was considered, but rejected, because it was believed that even a smaller diameter tube changer would not fit through the kinked ETT. Given that the patient was prone and in pins with an open cranium, we felt it would have been difficult to return the patient to a supine position to troubleshoot the ETT obstruction.A Berman intubating airway (Vital Signs, Totowa, NJ), often used as an aid to fiber-optic intubations, was spread longitudinally, lubricated, passed over the ETT, then slowly pushed into the mouth until the kinked area of the ETT was approximately in the middle of the Berman airway, thereby immediately relieving the kink. The case proceeded without further difficulty.One need not remove the ETT connector, but should be careful not to pinch or tear the pilot balloon line. As can be seen in the figures, the Berman airway has a “hinged” side (fig. 1) and an open side. A partially inserted ETT is shown in figure 2. Because of dependent edema in airway tissues, lips, and tongue that often occurs after prolonged time in the prone position, one may deflate the ETT cuff and extubate through the Berman airway, leaving it in place to aid ventilation. The Berman airway comes in multiple sizes to accommodate larger or smaller ETTs.*University of Utah School of Medicine, Salt Lake City, Utah. rachael.choza@hsc.utah.edu

Decreased hemodialysis circuit pressures indicating postpump tubing kinks: A retrospective investigation of hemolysis in five patients

The source of hemolysis during hemodialysis must be quickly identified to avoid life-threatening complications. At a single clinic, over a 10-day period in which 550 treatments were performed, 5 case-patients were retrospectively identified for experiencing acute hemolysis (4 deaths) from an unknown origin. The investigation focused on the postpump arterial tubing as the pressure was not monitored in this region, and the segment was shorter than required and could kink if overly stressed at bend points (i.e., tubing support clips, dialyzer inlet). To determine whether the circuit pressures indicated kinked tubing, a relative comparison between each case-patient's recorded arterial (prepump) and venous circuit pressures throughout their adverse event treatment and their immediately preceding treatment was conducted. Treatment pressure-time traces showed that sustained, significant decreases (>25 mmHg) in both of the circuit pressures occurred only on the hemolytic event dates. While direct observations of kinked tubing were not reported, the circuit pressure decreases could only be explained by severe postpump tube kinking causing a decrease in the blood flow rate. While postpump obstructions and hemolysis can occur without causing noticeable changes to the prepump arterial and venous blood line pressures (due to the highly occlusive setting of the roller blood pump), recognizing sudden and/or sustained decreases in the circuit pressures during treatment may help to prevent adverse patient events. This analysis reinforces the importance of regularly checking the blood tubing set for kinks and for monitoring the circuit pressures for atypical trends within and between treatments.

Kinking of a tube in the pharynx

Kinking of a tube in the pharynx

Unusual complication of ventriculoperitoneal shunt: Anal extrusion

The diversion of cerebrospinal fluid (CSF) for hydrocephalus is an established surgical practice, after its feasibility was demonstrated in the early 1900s [1]. Various valve assemblies have been devised and we use valve regulated ventriculoperitoneal shunt with a slit lower end [2]. More than 100 shunts have been placed for congenital/post meningitis hydrocephalus in children, at our centre. Many abdominal complications have been described which include fibrous encasement of the peritoneal tip, blocking or kinking of the distal tube, slipping out through the surgical wound or migration of the shunt or its component parts into the various abdominal cavities [2]. Other complications are infection, CSF fistula, paralytic ileus in the immediate postoperative period, failure of peritoneal absorption of the diverted CSF, perforation of the bowel by the abdominal tube, development of hydrocele, appearance of a peritoneal cyst and spontaneous extrusion of the tube through the umbilicus [3, 4]. We highlight an unusual complication of this procedure with two of our cases developing spontaneous extrusion of the lower end of the tube through the anal opening. The possible predisposing factors for this complication are discussed.

Endotracheal Tube Obstruction by Tooth of Facial Trauma Patient - A case report -

Difficulties in ventilation are sometimes encountered in intubated patients. In these cases, endotracheal tube kinking, or an obstruction by secretion or foreign bodies should be considered. We experienced an endotracheal tube obstruction by a foreign body. The patient was a 36 year old woman who had a traffic accident. She had already been intubated when entering operating room. However, ventilation was difficult, which was presumed to be caused by an endotracheal tube obstruction. The endotracheal tube was examined by fiberoptic bronchoscopy and the patient's broken tooth was found inside the endotracheal tube. The endotracheal tube was exchanged and ventilation was normalized. (Korean J Anesthesiol 2007; 53: 641∼4)

Intraoperative Kinking of Polyvinyl Endotracheal Tubes

To the Editor: Kinking of an endotracheal tube (ETT) during anesthesia and surgery is generally uncommon (1), but may occur more commonly if the position of the head and neck overbends the ETT (2,3). If strong bending forces are expected or if the ETT cannot be easily accessed during surgery (e.g., neurosurgery or maxillo-oral surgery), anesthesiologists may choose flexometallic ETTs. We present a small series of intraoperative ETT kinking incidents discovered through our anonymous critical-incident reporting system. Within the last several months, three anonymous critical-incident reports have described intraoperative kinking of polyvinyl ETTs at our institution. All cases involved patients in the supine position undergoing lower limb surgery. Their tracheas were intubated orally with polyvinyl ETTs (Mallinckrodt, Tyco Healthcare Deutschland, NeustadtJDonau, Germany). Approximately one hour after intubation, sudden increases in airway pressures made ventilation impossible. Examination of the circuit revealed kinked ETTs, with the kink hidden in the mouth. Repositioning the ETTs restored luminal patency and adequate ventilation. Polyvinyl ETTs come with preformed bending. Further bending along the concave curve does not compromise the tube’s stability (Fig. 1). Even bending up to reasonable angles into the opposite direction initially does not cause kinking (Fig. 2). However, if the ETT’s temperature is increased to 36°C, the tube softens and kinking occurs at astonishingly low angles (Fig. 3). The kinking typically occurs where the cuff line exits, 18 cm from the tube’s tip, a spot usually hidden in the oral cavity. The outer side of the ETT’s bend, usually marked by the manufacturer, should face nasally. Manufacturers should ideally consider changing the ETT’s design, so that the cuff line exits the tube outside the oral cavity.Figure 1.: Bending of the polyvinyl endotracheal tube along the concave curve does not compromise the tube’s stability.Figure 2.: Bending of the polyvinyl endotracheal tube into the opposite direction at room temperature hardly compromises the tube’s stability.Figure 3.: At body temperature kinking occurs at a low angle if the polyvinyl endotracheal tube is bent in the wrong direction.Matthias Hübler, MD, DEAA Frank Petrasch Department of Anesthesiology and Intensive Care Medicine Carl Gustav Carns University Hospital Technical University Dresden Dresden Germany [email protected]

Volume-targeted modes of modern neonatal ventilators: how stable is the delivered tidal volume?

Volume-targeted modes are designed to deliver a constant tidal volume (V(t)) at lowest possible pressure independently of changes in compliance, resistance, and leak of the respiratory system. We examined whether these volume-targeted modes respond rapidly enough to sudden changes in respiratory mechanics (e.g., selective intubation, surfactant administration, endotracheal tube kinking, de-kinking, obstruction), resulting in insufficient or excessive V(t) delivery. Bench study of six neonatal ventilators in the volume-targeted mode simulating preterm and full-term infant settings on a test lung. Breath-to-breath expiratory V(t) were measured after rapid compliance, resistance, and leak changes. Under our test settings all ventilators showed important volume overshooting following rapid increase in compliance or decrease in resistance. Between one and 16 inflations were required to return to the set V(t). Some ventilators delivered inaccurate V(t) under steady state condition while others showed considerable breath-to-breath V(t) variability. We observed inaccurate V(t) delivery under specific conditions as well as immediate and sometimes prolonged volume overshooting after a rapid respiratory system compliance increase or resistance decrease in volume-targeted modes of modern neonatal ventilators. Similar discrepancies between the set V(t) and the delivered inflations can be harmful in clinical situations, especially in newborns. Their clinical relevance needs to be clarified with safety studies in the neonatal population and we encourage manufacturers to further improve the ventilators algorithms.

Anaesthesia for cleft palate surgery

Cleft lip and palate repair are common surgical procedures in paediatric centres. With careful attention to detail (e.g. watching for tube kinking and endobronchial intubation with gag insertion) anaesthesia should be relatively straightforward in most cases. Associated problems such as Pierre Robin or Treacher Collins can make airway management very difficult. These associated syndromes are mostly seen with isolated cleft palate. Postoperatively, close monitoring of airway patency is required. If this is likely to be a problem, a nasopharyngeal tube can be inserted for the first 24–48 hours. This can be done best in theatre by the surgeon using a cut short endotracheal tube. If necessary, this may be done carefully in recovery or on the ward by an experienced doctor. Airway monitoring should involve direct nursing observation and saturation monitoring while breathing air. This should take place in an high-dependency unit setting for the first 24 hours after palate surgery.

A Test to Detect Chest Tube Kinking

To determine whether the Mac-technique test can detect kinking of the chest tube upon thoracostomy tube placement. This was a prospective observational study that was conducted October 2000 through October 2001 in an urban Level 1 trauma center. There were 103 consecutive nonrandomized adult trauma patients who required immediate tube thoracostomy during their initial resuscitation who were entered into the study. The Mac-technique test was performed during standard tube thoracostomy insertion to the appropriate depth. The test involved grasping the external portion of the thoracostomy tube, turning it clockwise 180 degrees, and then releasing the tube. If the tube spontaneously spun back to its original position, the test was considered positive, and the tube was considered kinked. If the tube did not spontaneously spin back and stayed in position upon release, the test was considered negative. Regardless of the results of this test, the tube was secured, and a postprocedure chest radiograph was obtained. The criterion standard for determining a kinked chest tube was its appearance on this chest radiograph. A total of 103 chest tubes were placed by using the Mac-technique test. The test was positive in eight placements; four tubes were kinked on chest radiograph. The Mac-technique test was negative in 95 placements; four tubes were kinked on chest radiograph. The Mac technique had a sensitivity of 50% (95% confidence interval [CI] = 15.7% to 84.3%), a specificity of 95.8% (95% CI = 89.6% to 98.8%), a positive likelihood ratio of 11.9, a negative likelihood ratio of 0.52, and an odds ratio using Yates correction of 20.3 (95% CI = 4.1 to 102.1). On the basis of this study, a positive Mac-technique test is useful to detect chest tubes that are likely to be kinked after insertion and before securing.

A Test to Detect Chest Tube Kinking

A Test to Detect Chest Tube Kinking

Preventing the kinking of sampling tube of capnography apparatus

Preventing the kinking of sampling tube of capnography apparatus

Using the Circuit Elbow to Prevent Capnometer Tube Kinking

Using the Circuit Elbow to Prevent Capnometer Tube Kinking

A Test to Detect Chest Tube Kinking

A Test to Detect Chest Tube Kinking

Intraoral tracheal tube kinking in a child

Intraoral tracheal tube kinking in a child