This Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mahajan, R. Articles by Kumar, S. Search for Related Content PubMed PubMed Citation Articles by Mahajan, R. Articles by Kumar, S.

Another cause of obstruction of the endotracheal tube during laparoscopic cholecystectomy

Chandigarh, India

To the Editor:

Alteration of the tracheal tube position with endobronchial intubation has been reported during both gynecological laparoscopy in the head down position as well as during laparoscopic cholecystectomy in the head up position. This results in a decrease in SpO₂ and an increase in airway pressure.^1,2 We report another cause of partial obstruction of the tracheal tube in a patient undergoing laparoscopic cholecystectomy.

A 30-yr-female, physical status ASA I presented for laparoscopic cholecystectomy. The trachea was intubated with a 7.5-mm tracheal tube and the tube was fixed with adhesive tape on the right side of the mouth at the 21-cm mark. After intubation bilateral and equal air entry was confirmed. Mechanical ventilation was ensured using the circle system and anesthesia ventilator. The circuit was immobilized with the airway circuit-stabilizing device (ACSD). Pneumo-peritoneum was achieved and intra-abdominal pressures were satisfactory at 12 to 13 mmHg. Airway pressures and capnography remained within normal limits. A left lateral tilt of 30 to 35° was made to the operating table at the request of the surgeon to ease surgical access. About 10 to 15 min after making the tilt, peak inspiratory pressures increased above 40 cm H₂O and the high pressure alarm was activated. Capnography revealed prolongation of the expiratory upstroke of the end-tidal carbon dioxide trace, which was suggestive of obstruction to the gas flow. On changing to manual ventilation, a high resistance was encountered on attempting to ventilate the patient.

On close examination, it was found that the tracheal tube had migrated laterally between the right molars and was compressed. This could be attributed to a change in the position of the head, which initially was in the neutral position and had rolled to the left side after tilting the table. This led to dragging of the tracheal tube, which was relatively fixed, between the adhesive tapes and the ACSD, laterally between the molars. This was readily rectified by placing a support on the left side of the head to keep it in a neutral position with the torso and by readjusting the tracheal tube.

Although the head is usually supported during surgery in the lateral or semi lateral position, this is not routine practice during laparoscopic cholecystectomy. Accordingly, it is suggested that one should properly support the head during laparoscopic cholecystectomy especially if an increased degree of left lateral tilt of the operating table is anticipated. Further, a redundant length of anesthesia circuit between the tracheal tube and the ACSD may be desirable in these cases.

References

1 Joris JL. Anesthesia for laparoscopic surgery. In: Miller RD (Ed.). Anesthesia, 5th ed. Philadelphia: Churchill Livingstone; 2000: 2003–23.

2 Chen PP, Chiu PT. Endobronchial intubation during laparoscopic cholecystectomy (Letter). Anaesth Intensive Care 1992; 20: 537–8.

This Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mahajan, R. Articles by Kumar, S. Search for Related Content PubMed PubMed Citation Articles by Mahajan, R. Articles by Kumar, S.