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Safety is in the details

The Challenges of Intubation in the OR and the ICU

elcam medical safety

The process of intubation might seem like a routine task in hospitals, but in fact it’s a critical procedure that requires special care and attention. In this article, we are going to discuss the challenges CRNAs face before, during, and after intubation, as well as the role of ICU nurses when they receive intubated patients.

Before Intubation Challenge – Airway (and Patient) Resistance

One of the most common intubation challenges for CRNAs is intubating a patient that is obese. Excess body mass, and especially additional soft tissue in the upper airway, increases airway resistance.

In many cases, the CRNA will need to position the patient slightly upright to shift the abdominal contents away from the diaphragm. This will reduce the pressure around the airway, making it easier to insert the tube, as well as ensuring proper ventilation while the patient is intubated.

A similar situation arises when patients simply have a narrow airway. In this case, CRNAs sometimes struggle to see if the tube is inserted correctly. Whenever this happens, the CRNA is usually required to ask for a second opinion to verify that the tube is placed properly, and in special circumstances, an X-ray can be performed to confirm proper placement.

Intubation Innovations

The ideal situation would be to have a small, lighted camera on the end of the Laryngoscope. This would improve accuracy and save the need for an X-ray to confirm the placement. The companies Infinium and Covidien (Medtronic) are only two of the companies that offer such a product. Verathon’s Glidoscope is even available on Ebay. Video Laryngoscopy and fiberoptics were documented as assisting tracheal intubation. You can read more about this case in the Medscape website.

As tracheal intubations are always a challenge, various developments of intubating devices are emerging in an effort to resolve the issue or at least make intubation a bit easier for medical staff. The MK intubating Airway claims that while standard procedure is maintained the new rigid, non-crushable conduit and bite guard improved on long standing airways that provide limited functionality by permitting removal of the airway without disturbing a placed bronchoscope. Another device still under development, the Esophocclude can be used to prevent pulmonary aspiration (yet another challenge of intubation). The Esophocclude is an encapsulated self-expanding stent that resembles a pill,  which is intended to be swallowed by patients before intubation. It expands and prevents the flow of gastric acids into the lungs.

New in Intubation Training

Swansea innovations have developed a unique training device for CRNAs as a means of improving the psychomotor skills involved in the manipulation of a fibreoptic endoscope, which today is considered a necessary skill in the anesthesia arsenal. The C-MAC Tip system from Karl Storz Endoscopy-America, Inc. is a great teaching tool, allowing learners to perform direct laryngoscopy while providing reassuring visualization to the instructor of the intubation on the screen.

Code Blue

The most common situation for ICU nurses that makes intubation challenging is during a Code Blue when a patient is thrashing around. It’s virtually impossible to insert the tube alone and this scenario requires collaboration between the team of nurses to restrain the patient before intubating. It would be great if nurses had some type of vest they could quickly toss over a patient and attach to the bed to restrain their upper body so they could start intubation with less people. Innovative spirit is demonstrated once more as a team led by Spectrum Health Innovations created a device to prevent self-extubation. The new approach led to the design of a retaining block to keep the tube in place. The block is held in place by headgear modeled after a scuba mask.

During Intubation – Monitoring is Key

While the patient is intubated, the vast majority of problems are easily prevented by an attentive CRNA who is monitoring their patient. The CRNA performs regular vital signs’ monitoring during anesthesia to ensure the patient remains in a healthy, stable state at all times. They also ensure proper airway management and anesthesia management throughout the procedure.

After Intubation Challenge – Sedative Weening and Patient Awakening

Following a procedure, a CRNA or ICU nurse will start the process of weening the patient off of their sedative. During this time, it’s critical to monitor sedation levels so a patient doesn’t wake up on their own and start choking on the tube.

Once the sedative has mostly worn off, the CRNA or ICU nurse removes the tube and briefly wake the patient to confirm that the patient can breathe on their own. If the patient needs to remain intubated because they won’t be able to breathe on their own, a nurse will be there when the patient wakes up to explain why they are intubated and how important it is for them to remain intubated.

A common problem in the ICU is when the floor is understaffed and all of the nurses get so busy that they don’t notice a patient is waking up from their sedative. This is an example of where telemedicine can help. Having an extra set of eyes on patients increases the level of care patients receive without requiring more nurses on duty.

It’s imperative for ICU nurses to continually monitor sedation levels, vital signs, and to be in the room when the patient wakes up to explain where they are and why they are intubated. If the patient isn’t restrained, they will often panic and remove the tube.

Even in scenarios where patients are restrained, they still find ways to get past restraints and remove their tube. This is a nightmare for ICU nurses because, during their state of panic, patients often end up disconnecting IVs and other tubing.

This is when innovative medical devices like the Safe2 Rotator are especially useful. The Safe2 Rotator has a luer lock connection that prevents disconnections when a patient pulls at tubing or moves around erratically.

If for whatever reason a patient does wake up while intubated, the Safe2 Rotator can help ensure they are still receiving the medications they need until a nurse can get to them and get them properly intubated again.

Daily challenges continue to be faced by ICU nurses and CRNAs, but technology and innovations are not far behind, assisting medical staff in giving enhanced patient care, while keeping staff and patients safe.


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