Retrograde ion

8/8/2019 Retrograde ion

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RETROGRADERETROGRADE

INTUBATIONINTUBATION


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PremedicationPremedication::

1)1) AntisialagogueAntisialagogue hour prior to induction hour prior to induction

-- Allows better application of localAllows better application of local

anesthetic drugs.anesthetic drugs.-- Improves visualization by dryingImproves visualization by drying

secretions.secretions.

2) Minimal sedation may be given to decrease2) Minimal sedation may be given to decrease

anxiety. (Avoid deep sedationanxiety. (Avoid deep sedation))


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Preparation:Preparation:

Nasal patency checked.Nasal patency checked.

XylometazolineXylometazoline drops put in thedrops put in the

nostrils.nostrils.

Adrenaline soaked pack inserted in the sameAdrenaline soaked pack inserted in the same

nostril using forceps. ( causes decongestion andnostril using forceps. ( causes decongestion and

vasoconstriction hence minimizes bleedingvasoconstriction hence minimizes bleeding

during intubation.)during intubation.)

For awake patient airway is anesthetized as inFor awake patient airway is anesthetized as in

fibreopticfibreoptic intubationintubation..


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AirwayAirway AnaesthesiaAnaesthesia

Oral cavityOral cavity 2%2% LignocaineLignocaine viscousviscous

NoseNose -- 4%4% LignocaineLignocaine + Decongestant+ Decongestant

NasopharynxNasopharynx -- 4%Lignocaine4%Lignocaine


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Preparation:Preparation:Main sensory supply is 5Main sensory supply is 5thth , 9, 9thth and 10and 10thth

cranial nerves.cranial nerves.

-- Nose andNose and nasopharygealnasopharygeal airway anesthetized by usingairway anesthetized by using

4%4% lignocainelignocaine nebulizationnebulization..-- 10%10% lignocainelignocaine spray instilled through nose orspray instilled through nose or

directly intodirectly into oropharynxoropharynx..

-- Gargles with 2%Gargles with 2% lignocainelignocaine viscous solution toviscous solution to

achieve anesthesia ofachieve anesthesia of oropharynxoropharynx..

-- GlossopharyngealGlossopharyngeal nerve and superior laryngeal nervenerve and superior laryngeal nerve

blocks are given to eliminate gag reflex and minimizeblocks are given to eliminate gag reflex and minimize

response to intubation.response to intubation.


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GlossopharygealGlossopharygeal nerve blocknerve block

(lingua

l branch

of

9(

lingua

l branch

of

9thth

nerve)nerve)

Tongue gently retracted exposingTongue gently retracted exposing palatoglossalpalatoglossal arch. Thearch. Thearch is pierced approximately 0.5arch is pierced approximately 0.5 cmscms from the lateralfrom the lateral

margin of the rest of the tongue at the point at which itmargin of the rest of the tongue at the point at which itjoins floor of the mouth.joins floor of the mouth.

2ml of 2%2ml of 2% lignocainelignocaine injected using 25 G spinal needle oninjected using 25 G spinal needle oneither side. Length of the spinal needle allows the syringeeither side. Length of the spinal needle allows the syringe

to be outside the mouthto be outside the mouth..


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S

uperiorlaryngea

lnerve

block

S

uperiorlaryngea

lnerve

block

External approachExternal approach TransoralTransoral approachapproachUsing 23 G hypodermic needleUsing 23 G hypodermic needle LignocaineLignocaine soakedsoaked pledgetpledget

2ml of 2%2ml of 2% lignocainelignocaine injected kept ininjected kept in pyriformpyriform fossafossa..on either side at the greateron either side at the greater cornucornu

of hyoid bone.of hyoid bone.

2ml 2% lignocaine


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TranstrachealTranstracheal injection :injection :

Trachea is anesthetized byTrachea is anesthetized by transtrachealtranstracheal injection.injection.Cough induced by injection produces excellentCough induced by injection produces excellentspread of drug below vocal cords.spread of drug below vocal cords.

2ml 4

%

2ml 4

%lignocaine

lignocaine


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RETROGRADE INTUBATIONRETROGRADE INTUBATION::

Patient is able to open mouth partially justPatient is able to open mouth partially justenough to retrieve catheter by finger.enough to retrieve catheter by finger.

Preparation of the airway as discussed.Preparation of the airway as discussed. Neck is scrubbed.Neck is scrubbed.

CricothyroidCricothyroid puncture done under LA with 18 Gpuncture done under LA with 18 G

tuohytuohy needle.N

eedle is angledneedle.N

eedle is angled cephaledcephaled andanddirected towards pharynx.directed towards pharynx.

18 G epidural catheter is inserted into trachea via18 G epidural catheter is inserted into trachea vianeedle.needle.


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The catheter retrieved from pharynx either byThe catheter retrieved from pharynx either bypatient himself or anesthesiologist.patient himself or anesthesiologist.

TuohyTuohy needle retrieved keeping the catheter inneedle retrieved keeping the catheter in

situ.situ. Soft rubber catheter introduced through theSoft rubber catheter introduced through the

nose and brought out through mouth.nose and brought out through mouth.

Epidural catheter and the rubber catheter tied to

Epidural catheter and the rubber catheter tied toeach other tightly.each other tightly.


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The epidural catheter is pulled out of the noseThe epidural catheter is pulled out of the nose

by pulling the suction catheter and the suctionby pulling the suction catheter and the suction

catheter is detached once the epidural cathetercatheter is detached once the epidural catheter

comes out of nose.comes out of nose.

ETT is inserted over the epidural catheter byETT is inserted over the epidural catheter bykeeping the catheter taut.keeping the catheter taut.

Once the tip of the ETT reachesOnce the tip of the ETT reaches cricothyroidcricothyroid

membrane , epidural catheter cut near the skinmembrane , epidural catheter cut near the skinand removed from above and the ETT isand removed from above and the ETT is

advanced into trachea.advanced into trachea.


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CricothyroidCricothyroid puncturepuncture


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Threading of epidural catheterThreading of epidural catheter


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Railroading ofETTRailroading ofETT


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SUBMENTAL INTUBATIONSUBMENTAL INTUBATION

It is the route of intubation used in cases ofIt is the route of intubation used in cases ofmaxillofacial surgeries where both nasal and oralmaxillofacial surgeries where both nasal and oral

intubation are contraindicated.intubation are contraindicated.


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Example: In case ofExample: In case of LeforteLeforte I & II fracturesI & II fractures

surgeons requiresurgeons require maxillomaxillo--mandibularmandibular fixationfixation

intraoperativelyintraoperatively..

Oral intubation is obsolete in such cases.Oral intubation is obsolete in such cases. Nasal intubation is avoided in fear of displacingNasal intubation is avoided in fear of displacing

the fractures or causing CSFthe fractures or causing CSF rhinorrhoearhinorrhoea oror

meningitis.meningitis. InitiallyInitially tracheostomytracheostomy was the only optionwas the only option

available in such cases but now a days withavailable in such cases but now a days with

submentalsubmental intubation technique, the morbidityintubation technique, the morbidity


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Procedure :Procedure :

Induction done by conventional method.Induction done by conventional method.

OrotrachealOrotracheal flexometallicflexometallic tube used for intubation.tube used for intubation.

Throat packing done.Throat packing done.

CutaneousCutaneous incision in theincision in the submentalsubmental region which isregion which is

extendedextended intraorallyintraorally,, safegaurdingsafegaurding thethe submandibularsubmandibularglands duct.glands duct.


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LaryngoscopyLaryngoscopy done and the tube disconnecteddone and the tube disconnectedfrom circuit. The universal connectorfrom circuit. The universal connectordisconnected.disconnected.

The proximal end of the tube held withThe proximal end of the tube held with magillsmagillsforceps and the end taken out from theforceps and the end taken out from the

submentalsubmental incision outside the oral cavity andincision outside the oral cavity andreconnected to the circuit. The pilot balloon alsoreconnected to the circuit. The pilot balloon alsotaken out.taken out.


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Tube position confirmed with end tidal CO2Tube position confirmed with end tidal CO2monitoring and chest auscultation. Now themonitoring and chest auscultation. Now thetube doesnt come in way oftube doesnt come in way of interdentalinterdentalocclusion.occlusion.

At the end of surgery theAt the end of surgery the interdentalinterdental occlusionocclusionreleased and tube again brought out from thereleased and tube again brought out from theoral cavity andoral cavity and submentalsubmental incision sutured.incision sutured.

PatientPatient extubatedextubated after reversal.after reversal.


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COMPLICATIONSCOMPLICATIONS

InfectionsInfections

OrocutaneousOrocutaneous fistulafistula

CONTRAINDICATIONCONTRAINDICATION

Infection atInfection at submentalsubmental sitesite..


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THANK YOUTHANK YOU

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