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• W4313268517 abstract "Dear Editor, Endotracheal intubation in the prone position is technically demanding and more difficult after unintentional extubation. If the airway is not immediately reestablished, it can result in hypoxia and cardiac arrest. The prevalence of unintentional extubation in the perioperative context ranges from 0.5% to 35.8%.[1] The authors sought to address the issue of endotracheal intubation during accidental extubation in the prone position by the use of non-channeled (McGrath) video laryngoscope (VL) and its demonstration on a mannequin simulation. A Stepwise Approach of the Technique is Discussed It should be kept in mind that the VL technique in the prone position is inverse of that in the supine position. 1) Detection of extubation is confirmed by the absence of adequate airway pressure or visual inspection. One should immediately seek expert help and attach nasal prongs. 2) Gain access to the patient’s head from downwards (if the headrest is used) [Figure 1a]. In case of no headrest, try shifting the patient toward the edge of the table so that the shoulders rest on the edge. Now ask an assistant to stabilize the head and neck in a straight line, that is, in the neutral position. 3) Next, widen the mouth opening using the scissoring technique and use the right hand to introduce the VL in the inverted position (blade directed downwards). Use of the right hand is advocated because it is easier to introduce the endotracheal tube (ET) by the left hand as the left side of mouth is free when VL is introduced in inverted position [Figure 1b]. Gently move the blade in the midline along the curvature of the tongue while keeping an eye on screen. 4) On visualizing the epiglottis, pull it downwards (instead of lifting it) to elevate the epiglottis to make the vocal cords visible. 5) Introduce the appropriately size ET with the stylet inside and angled at 90° through the vocal cords. The direction of the ET should be facing downwards [Figure 1c]. 6) Take out the stylet, inflate the ET cuff, and fix the tube. Figure 1: (a) Assistant is asked to stabilize head in neutral position in absence of head rest. (b) Visualizing the vocal cords via McGrath VL held inverted by the right hand. (c) Endotracheal tube with stylet facing downwards passed through the vocal cordsLogically thinking, management of sudden extubation in an anesthetized patient in the prone position should require repositioning the patient to the supine position and reintubation, but this may lead to complications during the ongoing surgery and possible hypoxia during repositioning. Baer and Nyström,[2] suggested routine intubation using a standard Macintosh laryngoscope in the prone position. However, the technique is difficult to master and can be performed effectively only by experienced anesthesiologists. For prone position, VL is relatively easier to master than direct laryngoscopy, as one is able to visualize everything on the side screen. Abrishami et al.[3] concluded that evidence regarding the use of Supra glottic airway device (SGAD) in the prone position is sufficient in elective settings but lacking in emergency settings like unintended tracheal extubation. In contrast, ET intubation by this method is more secure and definitive during a long duration surgery; also SGADs can’t guarantee aspiration prevention. Although the use of fiberscope and intubating Laryngeal mask airway (LMA) for prone position intubation has been documented,[4] VL-guided intubation, once mastered, is more viable than fiberscope due to its easier availability as compared to a fiber optic device. The use of VL for prone position intubation is still a relatively unexplored area. There has only been one case report till date by Gaszynski describing the use of an AirTraq Avant VL (channeled type) in prone position.[5] In the prone position, however, mouth accessibility is limited and the degree of mouth opening is uncertain and mostly limited. In limited mouth opening scenarios, a non-channeled VL takes up less space and is thus easier to insert than a channeled VL.[6] Endotracheal intubation in a prone position can be difficult due to limited access to the patient’s head and a lack of space around the mouth due to the use of a head holder. Given the neutral head position and limited mouth opening while prone, a non-channeled VL is preferred because it is easier to introduce. The intubation technique described here is simple and can be used with the majority of non-channeled VL models. The final decision on which method to use is based on the immediate availability of resources in the operation theater (OT) and the anesthetist’s personal preference and skill level in such situations. We tried this technique on various prone position mannequins and were successful each time. This technique is simple to learn and master with a little practice. In prone-position surgeries, we recommend keeping this technique on hand as a viable backup plan in case of accidental extubation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest." @default.
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• W4313268517 date "2022-01-01" @default.
• W4313268517 modified "2023-09-27" @default.
• W4313268517 title "Simulation-based illustration of non-channeled (McGrath) video laryngoscopy and intubation in prone position" @default.
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• W4313268517 doi "https://doi.org/10.4103/joacp.joacp_629_20" @default.
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