Anesthesia 5th year, 5th lecture (Dr. Gona)

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The lecture has been given on Nov. 30th, 2010 by Dr. Gona.

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Anesthesia 5th year, 5th lecture (Dr. Gona)

  1. 1. Surgical airway: <ul><li>If the upper airway is obstructed because of foreign body or massive trauma or if ventilation cannot be accomplished by other means, surgical entry into the trachea is required. </li></ul>
  2. 2. Cricothyrotomy <ul><li>Can establish an emergency airway, the patient lies supine, shoulders raised by pillows or sheets, and neck extended </li></ul><ul><li>After sterile preparation, the larynx is grasped with one hand while a blade is used to incise the skin of the neck just below the &quot; Adam's apple &quot;, or thyroid cartilage,, subcutaneous tissue, and cricothyroid membrane precisely in the midline. An appropriately sized tracheostomy tube is advanced through the opening into the trachea. In an out-of-hospital, immediately life-threatening airway obstruction, a knife handle, disposable pen barrel, or other hollow object can be used to keep the airway open. </li></ul>
  3. 3. Cricothyrotomy <ul><li>If other equipment is unavailable, a 12- to 14-gauge IV catheter can be passed into the trachea through the cricothyroid membrane. The larynx is grasped with one hand while the sterile needle-catheter is inserted percutaneously through the precise midline of the cricothyroid membrane, pointing the needle tip slightly inferiorly, aspirating while advancing, and taking care not to perforate the posterior tracheal wall or to stray out of the midline into large vessels. Once tracheal position is confirmed by aspiration of air, the catheter is advanced into the trachea. A 3-way stopcock and an O2 pressure source provide oxygenation but limited ventilation </li></ul>
  4. 5. Complications <ul><li>Complications include hemorrhage, subcutaneous emphysema, and pneumomediastinum. </li></ul>
  5. 10. Tracheostomy <ul><li>Tracheostomy is a more complex procedure involving surgical exposure and opening of the trachea. It is preferably performed in an operating room by a surgeon. In emergencies, the procedure has a higher rate of complications than cricothyrotomy and offers no advantage. It is, however, the preferred procedure for a long-term (> 48 h) surgical airway. </li></ul><ul><li>Percutaneous tracheostomy is an attractive alternative for critically ill patients who should not be moved to the operating room. This bedside technique uses a simple skin puncture and single or multiple dilators to insert a tracheostomy tube </li></ul>Uses for a tracheotomy The conditions in which a tracheotomy may be used are: Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, e.g. branchial cyst , acute inflammation of head and neck, and Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the head and neck.
  6. 11. Uses for a tracheotomy <ul><li>The conditions in which a tracheotomy may be used are: </li></ul><ul><li>Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, e.g. branchial cyst, acute inflammation of head and neck, and </li></ul><ul><li>Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the head and neck. </li></ul>
  7. 12. Completed tracheotomy : 1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff
  8. 13. Complications: <ul><li>Tracheostomy insertion can rarely cause hemorrhage, thyroid damage, pneumothorax, recurrent laryngeal nerve paralysis, injury to major vessels, or late tracheal stenosis at the insertion site. </li></ul><ul><li>Erosion of the trachea is uncommon. It occurs more commonly from excessively high cuff pressure. Rarely, hemorrhage from major vessels (eg, innominate artery), fistulas (especially tracheoesophageal), and tracheal stenosis ensue after intubation. Using high-volume, low-pressure cuffs with tubes of appropriate size and measuring cuff pressure frequently to maintain it at < 30 cm H2O decrease the risk of ischemic pressure necrosis, but patients in shock, with low cardiac output, or with sepsis remain especially vulnerable. </li></ul>

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