TEKNIK: GENERAL

BLIND NASAL INTUBATION

SINDY LEE AND BAHA AL-SHAIKH

First introduced by Rowbotham and Magill in the 1920s, it was originally described in
spontaneously breathing patients anaesthetised with an inhalational agent, but has been
modified for intubating awake patients – with or without sedation. Since direct vision of the
glottis is not necessary, it proved a useful technique in the management of patients with
difficult airways. Blind nasal intubation has largely been superseded by fibre-optic intubation
but remains a relevant and simple alternative in situations where a fibre-optic scope is not
available or fibre-optic intubation has failed.

INDICATIONS AND CONTRAINDICATIONS

The indications and contraindications are essentially the same as those for fibre-optic
intubation. The nasal route is indicated particularly where there are structural abnormalities in
the mouth or limited mouth opening.

SEDATION FOR AWAKE BLIND NASAL INTUBATION

For awake blind nasal intubation, just as for awake fibre-optic intubation, the patient must be
able to cooperate and respond to commands. Sedation, a topical vasoconstrictor and local
anaesthetic will facilitate improved tolerance of the procedure and reduce bleeding.

TECHNIQUE
• Check that all necessary equipment are functioning and that emergency drugs are available.
• Gain IV access.
• Have a trained assistant familiar with blind nasal intubation, in addition to a sedationist
where sedation is required.
• Ensure that the patient is spontaneously breathing at all times – this is key to success!
• Position the patient in the ‘sniffing the morning air’ position – with the neck flexed and
head extended at the altantoaxial joint. Where there is concern about C-spine stability, carry
out the procedure without neck manipulation (ideally with manual inline stabilisation).
• Identify a suitable nostril by assessing size, patency and history of epistaxis or polyps.
• Insert a well-lubricated 6–7 mm ID nasotracheal tube, which has been softened in warm
water. The bevel should face the septum to reduce trauma to the inferior turbinate.
• Direct the tube posteriorly along the floor of the nasal cavity. Gentle pressure and twisting
may be required to pop into the oropharynx.
• While keeping the other nostril and mouth closed, gently advance the nasotracheal tube into
the hypopharynx towards the glottis, taking care to stay in the midline.
• Listen for breath sounds as a guide to the position of the tube tip. As the tube approaches
the glottis, breath sounds get louder and misting of the tube may occur. Table 28.1 outlines
the expected clinical findings at different positions and provides hints for repositioning to
increase chances of a successful intubation.
• Once at the laryngeal inlet, ask the patient to take a deep inspiration to abduct the vocal
cords and intubate the trachea in one smooth motion. Transient coughing and a degree of
laryngospasm suggests correct tube placement where gag reflex is still intact – this should
quickly settle down.
• Confirm correct placement in the trachea with breath sounds through the tube, movement of
the reservoir bag when connected to the breathing system, inability to phonate and
capnography.
• Inflate cuff and secure tube.
• In awake patients, induce anaesthesia.

Table 28.1 Clinical findings for tube repositioning to increase chances of a successful
intubation

COMPLICATIONS
Complications can be classified into general, which are also associated with fibre-
optic intubation, and specific, arising from using the nasal route and a blind technique.
General complications are described in the section on fibre-optic intubation.
Relating to nasal intubation: epistaxis, turbinate or polyp fracture, retropharyngeal
laceration, retropharyngeal abscess and mediastinitis, intracranial placement in basal skull
fracture and
pneumocephalus.
Relating to the blind technique: trauma to the airway from multiple intubation
attempts (e.g. cricoarytenoid cartilage subluxation), obstruction caused by the epiglottis being
pushed into the glottic opening and oesophageal intubation. Unlike intubating under direct
vision, there may be a delay in recognition of these complications.

REFERENCES
Calder I, Pearce A. (Eds.). (2005). Core Topics in Airway Management. Cambridge:
Cambridge University Press.
Rao A, Srinivas M, Supriya R. (2015). Awake blind nasal intubation in difficult intubation
scenario.IOSR J Dent Med Sci 14(9): 49–50.

CROSS-REFERENCES
Difficult airway, Chapter 26
Fibre-optic tracheal intubation, Chapter 28
CLOSED CIRCLE ANAESTHESIA
SANJAY AGRAWAL AND BAHA AL-SHAIKH
When the current inhalational anaesthetic agents with low blood solubility were introduced,
their expense and the increasing awareness of environmental pollution led to a renewed
interest in the use of low flow and closed circle anaesthesia.

The circle system is so named because its components are arranged in a circular manner.
While it prevents rebreathing of CO2, it allows rebreathing of other gases and vapours. It
consists of:
• Fresh gas flow (FGF)
• Inspiratory and expiratory unidirectional valves
• Inspiratory and expiratory tubing
• Y piece connector
• APL valve
• Reservoir bag
• CO2 absorber
The most efficient arrangement of these components (Figure 28.1) is such that:
• FGF enters the system before the inspiratory unidirectional valve.
• APL valve and reservoir are situated between the expiratory valve and the CO2 absorber.
• CO2 absorber is situated before the FGF entry point.

DEFINITIONS
• Closed circle anaesthesia – FGF is just sufficient to replace the volume of gas and vapour
taken up by the patient (i.e. basal oxygen requirements, volatile agent uptake and N2O uptake
if used). No gas leaves via APL valve and the exhaled gases are rebreathed after CO2 is
absorbed. Significant leaks and gas losses are eliminated.
• Low-flow anaesthesia – FGF is less than the patient’s alveolar ventilation (usually below
1.5 L/min). Excess gases leave the system via the APL valve.
• Ultra-low-flow (minimal flow) anaesthesia – FGF is less than 0.5 L/min. Excess gases leave
the system via the APL valve.

ADMINISTRATION OF ANAESTHETIC AGENT

While it is possible to have vaporisers within the circle (VIC), it is more usual to have the
vaporizer outside the circle (VOC). A VIC vaporiser has low resistance to gas flow to
minimise the work of breathing required for spontaneously breathing patients. VIC systems
allow vaporisation of agent into recirculated gas already containing anaesthetic agent,
allowing rapid increases in concentration, especially when IPPV is used, potentially resulting
in risk of accidental overdose. The calibration of such vaporisers is impossible.
Direct injection of volatile agent into the circle system has also been described. It is
not recommended due to the great fluctuations of volatile concentration that result, and the
inability to guarantee even and rapid evaporation of the agent.
VOC systems utilise a conventional plenum vaporizer to add agent to the FGF.

PRINCIPLES OF LOW FLOW ANAESTHESIA

• If oxygen and N2O are used as the carrier gases, high FGF is needed initially to
denitrogenate the circle and the FRC. This is important to avoid build-up of nitrogen in the
system. In closed circle anaesthesia, this high FGF is needed for up to 15 minutes but in low-
flow anaesthesia only 5 minutes is required. If oxygen and air are used as the carrier gases,
denitrogenation is not necessary.
• Wash-in and wash-out curves for changes in vapour concentration within the closed system
are exponential. The time constant is the duration needed to reach 63% of the intended FGF
concentration in the system.

Time constant for circle Volume of circle system/FGF

Three time constants are required for 95% equilibration of FGF with circle gases. As
a result, it is normal to use an initial period of high flows to ‘prime’ the system and patient
during the period of high initial volatile uptake before lower flows are established. If large
changes in anaesthetic agent or carrier gases concentrations are required later it may be
necessary to temporarily increase FGF.
• Side-stream gas/vapour monitors remove between 150 and 200 mL min–1 of gases from the
breathing system for analysis. The sampled gas must be returned to the system for ultralow
flow or closed circle anaesthesia.
• For closed system, ultra-low and low-flow anaesthesia, a ventilator with rising bellows is
necessary which will collapse if there is leak in the system. With the descending type of
bellows, any leak may lead to entrainment of driving gas.
• FGF should be intermittently increased to aid removal of accumulated nitrogen (if oxygen
and N2O are used as carrier gases) and to remove other undesired gases which can
accumulate in the system such as carbon monoxide, methane, acetone, ethanol, hydrogen and
substance A.
• At the end of anaesthesia, anaesthetic gases are switched off and oxygen flows increased to
rapidly wash out the anaesthetic agents.
VOLATILE REQUIREMENTS
• To calculate the dose of an anaesthetic agent required, we need to know
• Minimum alveolar concentration (MAC)
• The amount of vapour needed to achievethis within the system and lungs
• The amount of vapour required for uptakeinto the circulation
• The amount required for uptake into the tissues
• The ED95 dose of a volatile agent is achieved at concentrations of 1.3 MAC and above.

• The amount of anaesthetic vapour required to achieve the target anaesthetic concentration in
the breathing system and lungs depends upon the volume of the system and lungs. This is
known as the ventilation-priming dose.

Ventilation-priming dose = Target concentration

x (Volume of system Volume of lungs)

This volume of system and FRC provides a large reservoir, within which the
anaesthetic gases are diluted at the beginning of anaesthesia.

Ventilation-priming dose= 1.3 MAC

x (Volume of system
Volume of lungs) /100
= mL of anaesthetic vapour

DENITROGENATION
• A 70-kg adult has approximately 2500–3000 mL of nitrogen, of which 1300 mL is
dissolved in the body (450 mL in the blood and 850 mL in the fat). The remaining 1200–1700
mL is contained in the FRC.
• With a high initial FGF of 10 L min–1, more than 95% of nitrogen is usually washed out of
the FRC and circle in approximately 5 min. Thereafter, nitrogen build up occurs slowly due
to release by tissues.

CO2 ABSORPTION
• CO2 absorbtion is achieved with soda lime (more common in the UK) or baralyme (more
common in the US).
• Soda lime consists of 94% calcium hydroxide, 2%–5% sodium hydroxide, 0.2% silica (to
prevent disintegration of the granules), an indicator dye and a zeolite which is added to
maintain a higher pH for a longer time. Older variants also contained 1% potassium
hydroxide, which acted as a catalyst for the reaction.
• Soda lime can absorb 25 L of CO2 per 100 g. However, in practice, small canisters
containing 500 g of soda lime appear exhausted with a CO2 load of 10–12 L 100 g–1 and
jumbo absorbers containing 2 kg of soda lime appear exhausted with a CO2 load of 17 L 100
g–1.
• Soda lime and its additives are made into granules to increase the surface area for
absorption and to minimize resistance to gas flow. The granule size is measured in ‘mesh’.
The usual size is 4–8 mesh.
• Baralyme consists of 80% barium hydroxide and 20% barium octahydrate. It is less efficient
than soda lime, but more stable in dry environments, and produces less heat.
• Absorber granules are consumed more rapidly the lower the FGF used because most of the
exhaled gases pass through the absorber with very little being discarded through the APL
valve.
• CO2 absorption by soda lime or baralyme is an exothermic reaction resulting in heat and
water vapour formation. The humidity generated by the reaction makes the use of a heat and
moisture exchanger unnecessary.
• Sevoflurane is partly degraded by soda lime forming compound A, which is nephrotoxic in
rats. The amount produced is proportional to the sevoflurane concentration and the
temperature of the absorber. The latter is higher with lower FGF. Sevoflurane use in humans
is safe although it is advisable that it should not be used with FGF of less than 1.5 L min–1
for more than 3–4 hours.
• Enflurane, isoflurane and desflurane can react with soda lime or baralyme to form carbon
monoxide. This is only significant when the water content is less than 1.5% in soda lime or
less than 5% in baralyme. Carbon monoxide is produced when the absorber has been flushed
with dry fresh gas for a considerable period of time without being attached to a patient before
the agent is used (i.e. dry absorber). Humidity prevents its production.
• The CO2 absorbant, Amsorb, does not contain a strong base (sodium or potassium
hydroxide) and does not produce compound A or carbon monoxide when used with
sevoflurane or desflurane.

CONTROL OF MOISTURE
Prolonged use of the circle system results in significant condensation of water vapour. This
can result in sticking of the one-way valves due to surface tension, potentially turning the
entire volume of the system into dead space. This complication can be reduced by using a
hydrophobic filter (i.e. HME) at the end of the expiratory limb before the CO2 absorber, or
by changing the breathing tubing between cases.

MONITORING
The following monitoring is recommended for the use of closed circle, ultra-low flow and
low-flow anaesthesia, due to the possible variations between FGF composition, and inspired
and expired gas compositions.
• Inspired and end tidal oxygen
• Inspired and end tidal CO2
• Inspired and end tidal N2O
• Inspired and end tidal agent
• Tidal volume
• Standard monitoring

PRECAUTIONS AND SAFETY FEATURES

• Monitor inspired oxygen, end-tidal carbon dioxide and inhalational agent.
• Prevent the unidirectional valves from sticking because of water vapour condensation.
• Resistance to breathing is increased especially during spontaneous ventilation mainly due to
the unidirectional valves.
• Compound A: newer designs of soda lime claim less or no production of compound A;
baralyme is worse than soda lime and Amsorb© is the safest.
• Carbon monoxide production can occur when certain agents are used with very dry
granules; recent designs of soda lime claim less or no production of carbon monoxide.
• Methane, acetone, ethanol and hydrogen can accumulate but generally do not become
clinically significant.
• Uneven filling of the canister with soda lime leads to channelling of gases and reduced
efficiency.
• Because of many connections, there is an increased potential for leaks and disconnection.

ADVANTAGES OF LOW-FLOW
TECHNIQUES
• Economy of gases and inhalational agents
• Humidification of the inspired gases
• Reduced atmospheric pollution
• Greater understanding of breathing systems and the pharmacokinetics of inhalational
anaesthesia is claimed

DISADVANTAGES OF LOW-FLOW TECHNIQUES

• Capital investment for breathing systems and gas monitoring may limit use in poorer
countries
• Accumulation of unwanted gases although this is less of a problem with modern low flow
systems

REFERENCES
Al-Shaikh B, Stacey S. (2013). Essentials of AnaestheticEquipment, 4th edn. Edinburgh:
Churchill Livingstone, Elsevier.
Baum JA. (2000). Low Flow Anaesthesia, 2nd edn. Oxford: Butterworth–Heinemann.
Baum JA, Aitkenhead AR. (1995). Low flow anaesthesia. Anaesthesia 50: 37–42.
Baxter AD. (1995). Low and minimal flow inhalation anaesthesia. Can J Anesth 44: 643–52.
Mapleson WW. (1998). The theoretical ideal fresh-gas flow sequence at the start of low-flow
anaesthesia. Anaesthesia 53: 264–72.
White DC. (1992). Closed and low flow system anaesthesia. Curr Anaesth Crit Care 3: 98–
107. http://www.frca.co.uk/article.aspx?articleid=100143.

CROSS-REFERENCES
Awareness, Chapter 30
The anaesthetic machine, Chapter 27

FIBRE-OPTIC INTUBATION SINDY LEE AND BAHA AL-SHAIKH

Fibre-optic intubation is an essential skill in the management of difficult airways. It can be
performed either awake, with or without sedation, or asleep. Awake fibre-optic intubation
(AFOI) is the gold standard for anticipated difficult airways. Asleep fibre-optic intubation
may be suitable in patients with isolated difficult tracheal intubation.

INDICATIONS
• Known difficult intubation or previous awake fibre-optic intubation
• Anticipated difficult intubation
• After failed intubation in unanticipated difficult airway
• Known or suspected difficult mask ventilation
• Unstable C-spine

CONTRAINDICATIONS
ABSOLUTE
• Patient refusal or inability to cooperate

RELATIVE
• Lack of trained personnel
• Risk of impending airway obstruction
• Coaguloapthy or bleeding in airway
• Allergy to local anaesthetic
• Base of skull fracture (for nasal route)

PREOPERATIVE PATIENT ASSESSMENT

Refer to section on difficult airway management.

PREPARATION
• Ensure that all necessary equipment and emergency drugs are available and checked.
• Two anaesthetists – One to perform the intubation, one to provide sedation – and a trained
assistant familiar with fibre optic intubation.
• Intravenous access.
• Full monitoring throughout the procedure, including ECG, pulse oximetry, noninvasive
blood pressure, capnography and sedation level.
• Glycopyrronium (400 mcg IM or 200 mcg IV), atropine or hyoscine to reduce airway
secretions.

SEDATION
• Conscious sedation improves the level of comfort and cooperation. It is not essential as
local anaesthetic alone is adequate. If the airway is already acutely compromised, sedation
may lead to complete obstruction and might best be avoided.
• Appropriate methods of sedation include:
• Remifentanil – Target controlled infusion (TCI) at an effect site concentration of 1–5
ng/mL as sole agent or in conjunction with propofol or midazolam. Provides excellent
analgesia, anxiolysis and obtunds the laryngeal reflexes.
• Propofol – As an infusion or intermittent boluses either as sole agent or
incombination with fentanyl, remifentanil or midazolam. When used with a second
agent by TCI, an effect site concentration of 0.5–1 mcg/mL is usually adequate.
• Midazolam – 0.5–1 mg boluses to maximum of 0.05 mg/kg, usually in conjunction
with an opioid.
• Dexmedetomidine – Loading dose of 0.7–1 mcg/kg over 10–20 minutes and a
maintenance infusion of 0.3–0.7 mcg/kg/h, it offers analgesia, amnesia and anxiolysis
without respiratory depression.
LOCAL ANAESTHETIC
• Identify the preferred nasal passage based on assessment of patency and history of epistaxis.
• Administer supplemental oxygen at 4 L/min via nasal sponge in opposite nostril.
Alternatively nasal cannulae can be used for oral fibre-optic intubation. Administer local
anaesthetic to the airway in a stepwise manner. Do not exceed a maximum dose of topical
lidocaine of 7 mg/kg.

NOSE
The aim is to reduce bleeding and oedema with a vasoconstrictor and provide topical
anaesthesia:
• Co-phenylcaine (0.5% phenylephrine + 5% lidocaine) given via mucosal atomiser to each
nostril.
• Co-phenylcaine, xylocaine (2% lidocaine + adrenaline) or 4% lidocaine soaked cotton
buds/ribbon gauze inserted into nasal cavity and left for 3 minutes.
• 2 mL of 4% lidocaine via nebuliser.

OROPHARYNX
• 10 sprays of 10% lidocaine to tongue and posterior pharynx.

LARYNX
• 4% lidocaine sprayed above vocal cords under direct vision during endoscopy. This is
achieved by advancing an epidural catheter through the working channel of the fibrescope, or
attaching a syringe with lidocaine and 1 mL of air directly onto the working channel (Spray
As You Go technique).

TRACHEA
• Either 4% lidocaine sprayed below the vocal cords under vision during endoscopy or
cricothyroid injection of 2 mL of 2% lidocaine via 20G cannula or 22G needle (immediately
remove needle after injection to avoid trauma caused during coughing).

TECHNIQUE
• Place the patient in a semi-recumbent position.
• Check orientation of the fibrescope and perform white balance.
• Load the scope with a lubricated 6 mm ID endotracheal tube and fix with tape in a way to
allow rapid release.
• Pass epidural catheter down suction port if using Spray As You Go technique. Ensure tip of
catheter is not protruding out of the distal end of scope when not administering local
anaesthetic.
• Insert the fibrescope through the nostril or mouth depending on chosen route. For oral
intubation,
use a Berman airway or Breathesafe as a bite block and to maintain the scope in the midline.
• Once in the oropharynx, identify the epiglottis and slowly advance towards the glottic
opening. Visualisation may be improved by asking the awake patient to stick out their tongue.
In asleep patients, ask your assistant
to pull the tongue with a swab or provide jaw thrust.
• Keep black air cavity in the centre of the screen to assist with orientation. When the whole
screen is pink, the tip of the scope is against mucosa – withdraw slightly until relevant
anatomy can be identified before advancing further.
• Spray local anaesthetic onto the laryngeal inlet. Warn the patient that this will cause them to
cough.
• Enter the subglottic space to identify the trachea and spray a further dose of local
anaesthetic.
• Advance the scope until the tip is just proximal to the carina.
• Release the endotracheal tube and railroad this gently over the fibrescope. In the event of
hold-up, do not use force but rotate the tube as it is advanced.
• Confirm that the tip of the endotracheal tube is in the trachea on removal of the fibrescope
under vision.
• Connect to breathing system and check for correct placement with capnography.
• Proceed with induction of anaesthesia with inhalational or intravenous induction agents.
• Inflate endotracheal tube cuff.
• Plan for difficult extubation as per Difficult Airway Society guidelines.

COMPLICATIONS
• Oversedation, respiratory depression, airway obstruction, apnoea.
• Trauma, bleeding, airway obstruction, laryngospasm, vomiting in unstarved patient.
• Local anaesthetic allergy, toxicity, risk of aspiration due to loss of laryngeal reflexes.

REFERENCES
Allman K, Wilson I. (Eds.). Oxford Handbook of Anaesthesia, 3rd edn. Oxford, UK: Oxford
University Press.
Kritzinger S, Van Greunen M. (2010). Awake fibreoptic intubation – the basics. Anaesthesia
tutorial of the week 201. www.totw.anaesthesiologists .org.
Leslie D, Stacey M. (2015). Awake intubation. Contin Educ Anaesth Crit Care Pain 15(2):
64–7.

CROSS-REFERENCE
Difficult airway management, Chapter 26

ONE-LUNG ANAESTHESIA DANIEL LAKE, NESSA DOOLEY AND SIMON STACEY

One-lung anaesthesia is the process of complete functional separation of the two lungs. It
facilitates certain types of thoracic surgery but causes significant physiological disadvantages
in regards to pulmonary gas exchange.

INDICATIONS
• Protective isolation.
• To prevent contamination or spillage of infectious material – pus or secretions from
the contralateral lung.
• To prevent massive hemorrhage.
• To control the distribution of ventilation between the two lungs in the presence of:
• Bronchopleural fistula
• Giant unilateral cyst/bulla
• Surgical opening of major airway
• Tracheo-bronchial tree disruption
• Unilateral bronchopulmonary lavage, e.g. for alveolar proteinosis.
• VATS.
• To facilitate surgical exposure for pulmonary surgery (e.g. pneumonectomy, lobectomy or
thoracoscopy) or non-pulmonary surgery (e.g. oesophageal surgery, thoracic aneurysm,
thoracic spinal surgery). Many thoracic procedures can be accomplished with a normal
tracheal tube.

TECHNIQUES OF LUNG SEPARATION

• Double lumen tube – Allow rapid transition between one-lung ventilation and two-lung
ventilation, permitting either lung to be suctioned and CPAP applied to the non-ventilated
lung.
• Bronchial blockers – Do not facilitate ventilation or suction distal to the blocker.
• Uncut tracheal tube – Can be advanced into the relevant main bronchus. Not ideal, but
useful in an emergency situation.
• Papworth BiVent tube – A new double lumen tube designed to enable rapid and reliable
lung isolation using a bronchus blocker without endoscopic guidance. Allows suctioning of
the collapsed lung through a central opening in the bronchial blocker but not ventilation.

PHYSIOLOGICAL EFFECTS OF THE LATERAL DECUBITUS POSITION

Awake, closed-chest: Gravity causes a vertical gradient in the distribution of pulmonary blood
flow with the dependent lung better perfused. The dome of the lower diaphragm is pushed up
into the chest and hence can contract more efficiently. Thus, the better perfused dependent
lung is better ventilated regardless of the side on which the patient is lying.
Anaesthetised closed-chest: There is no difference in the distribution of pulmonary
blood flow between dependent and non-dependent lung when compared to an awake patient.
Ventilation is now switched from the dependent to the non-dependent lung. This is due to a
loss of FRC with induction of anaesthesia which leads to the dependent lung moving to a less
favourable portion and the non-dependent lung moving to a more favourable portion on the
pressurevolume curve. The high curved lower diaphragm no longer confers any advantage in
ventilation. The weight of the mediastinum, abdominal contents and the chest wall all impede
lower lung ventilation.
Anaesthetised, open-chest, paralysed: The dependent lung is less compliant, poorly
ventilated and overperfused whereas the non-dependent lung is over-ventilated and
underperfused resulting in a considerable degree of V/Q mismatch. When onelung ventilation
commences, the preferential distribution of ventilation to the upper lung is completely
eliminated. Perfusion to this lung continues and this results in increased shunt. At this stage,
the dependent lung receives the entire minute volume and a high proportion (about 60%) of
the cardiac output.
Hypoxic pulmonary vasoconstriction increases the pulmonary vascular resistance of
the collapsed lung; however, its effects and the effects of anaesthetic agents on it are usually
of little clinical importance in routine thoracic practice.

PREOPERATIVE ASSESSMENT AND INVESTIGATIONS

• Full blood count; urea and electrolytes.
• Chest X-ray: assess the anatomy of the airways to see if endobronchial intubation is
possible. Often a CT of the thorax is also available.
• Arterial blood gases.
• Pulmonary function tests and CPET.
• ECG.

PERIOPERATIVE MANAGEMENT
MONITORING
• Routine standard monitoring with direct arterial pressure.
• Airway inflation pressure; flow/volume loops are also useful.
• Fluid balance and blood loss.
• Core temperature.
• Central venous pressure (insert ipsilateral to the thoracotomy).
• Nerve stimulator.

ANAESTHETIC TECHNIQUE
• Premedication if necessary.
• General anaesthesia (TIVA or inhalational agent) with muscle relaxation and controlled
ventilation.

DOUBLE LUMEN TUBES

Robertshaw double-lumen endobronchial tubes are available in three sizes (small, medium
and large). The PVC derivative (Bronchocath) is more malleable but more likely to migrate
and suffer cuff damage by teeth during insertion. They are available in a wide range of right
and left. Care must be taken not to over-distend the bronchial cuff since bronchial rupture
may be catastrophic.
Right-sided endo-bronchial tube placement should be avoided where possible because
of the high risk of right upper lobe occlusion and lobar collapse.
The correct positioning of a double-lumen tube is traditionally confirmed by
observation of chest expansion and auscultation while each lumen in turn is occluded.
However, reliance on clinical signs alone will miss a significant number of malpositioned
tubes. NCEPOD 1998 highlighted the morbidity and mortality associated with malpositioned
double
lumen tubes. The use of a flexible fibre-optic bronchoscope allows direct visual confirmation
of tube position and is now the method of choice. The new VivaSight-DL double lumen tube
has an integrated high resolution camera for continuous monitoring of tube position, but there
is a limited range of sizes and only a left-sided version exists.

ARTERIAL HYPOXAEMIA
Hypoxaemia is one of the most important problems encountered during one-lung anaesthesia.
The elimination of carbon dioxide during one-lung ventilation is not a problem if the minute
volume is maintained at the amount previously delivered to the two lungs. Two-lung
anaesthesia should be maintained for as long as possible.

MANAGEMENT OF HYPOXAEMIA DURING ONE-LUNG VENTILATION

• Increase inspired oxygen to 100%.
• Check position of tube with fibre-optic bronchoscope. Suctioning of secretions may be
required.
• Ensure adequate blood pressure and cardiac output.
• PEEP 5–10 cmH2O to the dependent lung to decrease atelectasis and increase FRC.
Excessive PEEP increases pulmonary vascular resistance and may increase shunt.
• CPAP 5–10 cmH2O with 100% oxygen to the non-ventilated lung to facilitate oxygen
uptake in this lung whilst not adversely affecting the surgical conditions.
• Abandon one-lung ventilation and intermittently ventilate the collapsed lung after warning
the surgeon.
• Early clamping of the appropriate pulmonary artery will stop the shunt.

POSTOPERATIVE PERIOD
Adequate pain relief, physiotherapy and high dependency care are important factors for
reducing the incidence of postoperative complications and hospital stay.
REFERENCES
Eastwood J, Mahajan R. (2002). One-lung anaesthesia.Br J Anaesth CEPD Rev 2: 83–7.
Ghosh S et al. (2008). The Papworth BiVent tube: A new device for lung isolation.
Anaesthesia 63: 996–1000.
Miller RD. (2006). Anaesthesia for Thoracic Surgery, 6th edn. New York: Churchill
Livingstone, Elsevier.
Pennefather SH, Russell GN. (2000). Placement of double lumen tubes – time to shed light
on an old problem (editorial). Br J Anaesth 84: 308–11.
The Report of the National Confidential Enquiry into Perioperative Deaths 1996/1997.
(1998).
London: The National Confidential Enquiry into Perioperative Deaths, pp. 57–61.
Vaughan RS. (1993). Double-lumen tubes (editorial). Br J Anaesth 70: 497–98.

CROSS-REFERENCES
Breathing systems, Chapter 27
Thoracic surgery, Chapter 15
Pneumonectomy, Chapter 15
Lobectomy, Chapter 15

PROLONGED ANAESTHESIA
GREGORY WAIGHT AND BAHA AL-SHAIKH
Adequate preparation, good management and close attention to details reduce the risks
associated with prolonged anaesthesia. It contributes to perioperative complications which in
turn may lead to delayed hospital discharge.

PROBLEMS ASSOCIATED WITH PROLONGED ANAESTHESIA

• Accumulation of anaesthetic agents leads to delayed emergence depending on
pharmacokinetics of the drugs used:
• Volatile anaesthetics with a high blood: gas solubility coefficient, e.g. isoflurane
(1.4) will have a longer wake-up time compared to agents with a lower value, e.g.
desflurane (0.4).
• Fentanyl duration of action is prolonged with increasing length of infusion. This is
in contrast to remifentanil, which displays a relatively constant clearance profile
independent of duration of infusion.
• Potential toxicity of administered agents:
• Degradation of inhalational agents by CO2 absorber may lead to accumulation of
toxins, e.g. sevoflurane to compound A. In the US, the use of sevoflurane with fresh
gas flow rates of at least 2 L min–1 is recommended for procedures lasting more than
1 hour.
• Inorganic fluoride production from hepatic metabolism of sevoflurane and enflurane
may be nephrotoxic in patients with chronic renal impairment.
• Prolonged exposure to nitrous oxide may result in acute vitamin B12 deficiency with
megaloblastic anaemia and neurological deficit. Toxic manifestations may occur in
susceptible individuals after shorter exposures. Risk is increased in pernicious
anaemia, exposure to DNA synthesis inhibitors (e.g. methotrexate), pre-existing bone
marrow depression, folate deficiency, diseases of the ileum and malabsorption.
Nitrous oxide also causes expansion of air spaces.
• Impairment of gas exchange and respiratory mechanics, notably development of
hypoxaemia and hypercarbia secondary to slowly developing dependent atelectasis.
• The influence of anaesthetic agents on renal function can lead to water and salt retention.
Disturbances in intermediary carbohydrate metabolism promotes the development of
metabolic acidosis.
• Retention of anaesthetic agents in the body can extend untoward effects into the
postoperative period.
• Decreased carbohydrate metabolism results in intraoperative hyperglycaemia.
• Problems exist with accurate management of fluid and electrolyte balance.
• Inadvertent perioperative hypothermia, defined as a core body temperature below 36°C, can
lead to:
• Increased wound infection
• Surgical bleeding
• Impaired immune function
• Increased incidence of myocardial ischaemia and infarction
• Malignant arrhythmias
• Postoperative shivering
• Prolonged immobility can lead to:
• Increase risk of deep vein thrombosis
• Nerve damage and pressure sores
• Bilateral compartment syndrome
• Rhabdomyolysis
• Corneal damage if eyes are left open
• Postoperative delirium.
• Immunosuppression and increased susceptibility to infections.
• Increased opportunity for human error due to fatigue.

PREPARATION
• Discuss the risks of prolonged procedures with the theatre team prior to the case and plan
appropriately.
• Position the patient with meticulous attention to detail, including:
• Padding of pressure areas
• Neutral joint positioning and support of the lower back
• Avoid traction on at-risk nerves, e.g. brachial plexus
• Ensure documentation of these Interventions
• Adequate scavenging to protect the theatreteam: in the UK, recommended maximum
accepted concentrations over an 8 hour timeweighted period are
• 100 parts per million (ppm) for N2O
• 50 ppm for enflurane and isoflurane
• 10 ppm for halothane
• Use a low-flow circle system to reduce consumption of gases and vapours.
• Maintain body temperature (theatre temperature, forced air warmer, warming blanket, fluid
warmers, humidification of inspired gases, clothing/limb wrapping, hat).

MONITORING
• Minimal monitoring with direct invasive BP
• Core and skin temperature
• Blood loss
• Bispectral index analysis
• Tracheal tube cuff pressure
• Peripheral nerve stimulator
• Blood gases, electrolytes, glucose, coagulation
• Pressure-volume loop and lung compliance
• Inspiratory and expired concentration of oxygen, nitrous oxide, anaesthetic vapour and CO2
concentration
• Fluid balance (central venous pressure, hourly urine output via urinary catheter)
• Cardiac output

ANAESTHETIC TECHNIQUE
The technique chosen is dependent on the surgery proposed, anticipated blood loss and the
chronic health status of the patient. Controlled ventilation provides the ability to manipulate
oxygenation and carbon dioxide. There have been case reports of healthy patients having
prolonged surgery on the extremities breathing spontaneously via a laryngeal mask for 8
hours with no adverse effect. Regional anaesthesia may be used for surgery on the lower
extremities, but prolonged immobilisation often necessitates light general anaesthesia or
sedation for patient comfort.
• Consider using oxygen/air technique, omitting nitrous oxide with minimum FiO2 to achieve
an acceptable oxygen saturation or tension.
• Consider TIVA/TCI.
• Use high-volume low-pressure cuff with regular tracheal tube suctioning.
• Pay careful attention to body positioning with frequent repositioning of the head.
• Passive movement of joints through their range of motion periodically may reduce
incidence of arthralgia postoperatively.
• Cover exposed body surfaces.
• Eye protection (lubrication, tapes, padding or eye shields).
• DVT prophylaxis.
• Be aware of the risks of fatigue amongst the theatre staff, and the increased likelihood of
errors.

POSTOPERATIVE CARE
Consider:
• ITU/HDU stay for continued ventilation until warm and stable; awaken slowly.
• Regular physiotherapy.
• Maintenance of DVT prophylaxis.
• Ensure adequate fluid input and output.

REFERENCES
Brimacombe J, Shorney N. (1993). The laryngeal mask airway and prolonged balanced
regional anaesthesia. Can J Anaesth 40: 360–4.
Dodds C. (1996). Prolonged anaesthesia for plastic and reconstructive surgery. Curr Anaesth
Crit Care 7(1): 20–4.
Girgis Y, Broome IJ. (1997). Monitoring failure and awareness hazard during prolonged
surgery. Anaesthesia 52: 504–5.
Higuchi H, Sumikura H, Sumita S et al. (1995). Renal function in patients with high serum
fluoride concentration after prolonged sevoflurane anesthesia. Anesthesiology 83: 449–58.

CROSS-REFERENCES
Monitoring, Chapter 27
Awareness, Chapter 30
TOTAL INTRAVENOUS
ANAESTHESIA (TIVA)
MAUREEN BEZZINA AND BAHA AL-SHAIKH
TIVA is a technique where intravenous drugs are used to induce and maintain general
anaesthesia, avoiding the use of inhalational anaesthetics. A continuous intravenous infusion
is used commonly in the form of a target controlled infusion (TCI) pump.

CHARACTERISTICS OF THE IDEAL AGENT

 Both hypnosis and analgesia can be achieved using an intravenous technique. At the
present time, propofol is the hypnotic of choice for TIVA. Analgesia can be achieved using
the short acting opioids such as alfentanil and remifentanil. More recently, TCI has been
widely used, although TIVA can also be achieved using intermittent bolus injection or
manual
infusion techniques.
TIVA must achieve the following goals: smooth induction, reliable and titratable
maintenance and rapid emergence. Achieving these has been possible with TCI.

DOSE–RESPONSE RELATIONSHIP
In order to compare TIVA with inhalational anaesthesia, CP50m has been used. This is the
plasma concentration required to prevent 50% of patients from responding to painful stimuli
– similar to MAC for volatile anaesthetics. It is important to note, however, that at present, no
method for measuring drug concentration directly in the plasma is commercially available
and so CP50m values are based on calculated data only.

TARGET CONTROLLED INFUSION (TCI)

As there is no method that allows real-time measurement of plasma concentration of a drug,
sophisticated TCI syringe drivers are used. These incorporate real-time pharmacokinetic
models that deliver the appropriate dose of the drug to achieve and maintain the requested
target concentration. For this to be achieved, the appropriate infusion rates needed to produce
a required target concentration are continuously calculated by the microprocessor within the
syringe driver.
A bolus/elimination/transfer principle is used by TCI pumps to maintain an
appropriate plasma level of drug. Anaesthesia is induced by the syringe driver infusing
propofol rapidly, giving a bolus calculated to achieve the required plasma concentration. This
is followed by a progressively decreasing infusion rate calculated to match the transfer of
drug in and out of the peripheral compartments and elimination of drug from the body (and
therefore maintain the required plasma concentration). Once the compartments reach steady
state concentration, the infusion rate slows to match elimination only.
To increase the target plasma concentration further, the syringe driver delivers another
bolus to achieve the desired concentration and then maintains this higher concentration with a
higher infusion rate. To decrease the target plasma concentration, the syringe driver stops
infusing until the microprocessor calculates that the new target has been achieved. The new,
lower level is then maintained.
The predicted concentration in the brain, which is displayed as the effect site
concentration, increases slower than that of the plasma (plasma site concentration). Modern
TCI pumps have software allowing titration to a choice of either plasma site or effect site
concentrations, depending on the mathematical pharmacological model used.
As there is considerable variation in uptake and effect of drugs between individual
patients, it has been proposed by many that depth of anaesthesia monitoring (such as
bispectral index [BIS]) be used during TIVA used for hypnotic purposes on paralysed
patients.

PROPOFOL
Propofol (a phenolic derivative – 2,6 diisopropylphenol) is highly lipid-soluble and is
available as either a 1% or 2% lipid–water emulsion (with soya bean oil and egg
phosphatide), as its water solubility is low. It is cleared from the body mainly by hepatic
metabolism. It has, however, been successfully used in patients with liver cirrhosis, and the
pharmacokinetics
are not significantly affected.
The pharmacokinetics of propofol may be influenced by age. Values for clearance and
plasma concentration
on awakening are higher in children than adults. Children require significantly higher doses
of propofol than do adults.
The rapid recovery from propofol is due to its short distribution phase, high clearance rate
and short elimination half-life.

PROPOFOL TCI MODELS

Currently there are four common propofol TCI models in use. These are Marsh and Schnider
for adults and Kataria and Paedfusor for paediatrics.
The Marsh model bases its calculations on the assumption that the central
compartment volume is proportional to the weight of the patient, ignoring the age. Therefore,
it administers the same bolus dose to all patients of a given body mass for any chosen plasma
concentration regardless of their age (and hence their pharmacodynamic response). The
Marsh model requires age to be inputted into the pump but only to ensure that the age of the
patient is >16 years. It assumes that the central compartment volume is 19.4 L for an 85 kg
patient.
The Schnider model was developed later and requires age, height and body weight to
be inputted. The pump then calculates a sex-specific lean body mass and works out the
dosages accordingly. It assumes that the fixed central compartment volume is 4.27 L for an
85 kg person and therefore there is a fourfold difference in calculated peak plasma
concentration when compared to the Marsh model. Lower doses of propofol are required to
achieve a given plasma concentration and therefore this model is used more commonly in the
elderly population.
The Schnider model allows for effect site concentration to be targeted specifically,
whereas the Marsh model was designed primarily for targeting plasma site concentration
(although effect site concentration is also calculated).
 The Paedfusor model is a variant of Marsh kinetics for patients between 1 and 16
years of age. It uses the weight to calculate target plasma concentration and it features a
nonlinear scaling of central compartment volume as age exceeds 12 years.
The Kataria model can be used for patients 3–16 years of age with a minimum weight
of 15 kg. It also uses weight to calculate target plasma concentration.
Propofol TCI allows easy control and rapid change of the target propofol
concentration. In unpremedicated
adult patients under the age of 55 years, a target propofol concentration of 4–8 μg mL–1 is
usually adequate for the induction of anaesthesia. Induction is smooth and usually takes 60 to
120 seconds. When co-administering an analgesic, anaesthesia can be maintained using
propofol concentrations of approximately 3–6 μg mL–1. Lower target concentrations are used
in elderly patients reducing the risks of side effects. Due to the differing pharmacokinetic
profile in children, propofol TCI has not been used extensively in the paediatric population.

MANUAL INFUSION AND MANUAL INTERMITTENT BOLUS TECHNIQUES

Manual infusion can be achieved by a bolus dose for induction using a syringe driver
with a rapid bolus facility. Anaesthesia is maintained using a stepdown sequence of infusion
rates. Before the advent of TCI, a popular method was to administer a 1 mg/ kg propofol
bolus followed by 10 mg kg−1 h−1 for 10 min, 8 mg kg−1 h−1 for 10 min, and 6 mg kg−1
h−1 thereafter – the Bristol model. This model was originally described, however, to include
premedication with fentanyl and co-administration of nitrous oxide.
A manual intermittent bolus technique has also been used but leads to wide variations
and fluctuations in the plasma concentrations and the anaesthetic effects. The majority of
anaesthetists now prefer to use a TCI system due to its simplicity and reliability.

ANALGESIA
Since propofol has no analgesic properties, TIVA is generally achieved by combining
a propofol infusion
with a regional local anaesthetic block or supplemental opioids. The shorter-acting opioids
are often suggested as an ideal complement to propofol. Of these, remifentanil, alfentanil and
sufentanil are widely used.

REMIFENTANIL
Remifentanil (a fentanyl derivative and pure μ agonist) has a unique metabolic and
pharmacokinetic profile. It undergoes rapid methyl esterase hydrolysis by tissue and plasma
esterases to relatively inactive metabolites. Its effect is terminated by rapid metabolic
clearance (elimination half-time is 3–10 minutes) rather than redistribution, unlike fentanyl
and alfentanil, resulting in rapid reduction in plasma concentration even after prolonged
infusion. It does not accumulate in either hepatic or renal failure.
The time required for the drug concentration to fall by 50% (context sensitive half
time) is always the
same at about 3 minutes, leading it to be described as context insensitive. This is independent
of age, weight, sex or hepatic and renal function, making it ideal for a continuous intravenous
technique since it
does not accumulate even after prolonged infusions.
Remifentanil can be given via TCI using the Minto pharmacokinetic model. This is
easy to use and allows easy titration based on patient age, gender, weight and height.
Remifentanil has become the opioid of choice in TIVA for many anaesthetists, certainly in
longer or more stimulating procedures. A target plasma concentration of 3–8 ng/mL is
usually required for induction and intubation and this can be increased to up to 15 ng/mL in
stimulating procedures. Care must be taken, however, to ensure adequate analgesia after
remifentanil has worn off. This can be ensured either by local/regional techniques or by
judicious administration of an alternative opioid toward the end of the case.

ALFENTANIL
Alfentanil (a μ agonist) has a short onset of action of 90 seconds and can be used effectively
in TCI for analgesic purposes. The Maitre model is mostly used for alfentanil TCI and it
bases its calculations on age, gender and weight.

SUFENTANIL
Sufentanil is a much more potent opioid than remifentanil but it has a longer duration of
action and therefore tends to accumulate if infused for a prolonged time. Two TCI models
were developed for sufentanil: Gepts and Bovill. The Gepts model uses a fixed compartment
volume which is not dependent on weight. The Bovill model bases its calculations on the
assumption that the central compartment volume is proportional to the body weight.

USE OF TCI IN THE ELDERLY AND PAEDIATRIC POPULATION

Patients at the extremes of age have different physiological factors that may affect the
pharmacokinetics of drugs. Elderly patients have a smaller central compartment volume,
decreased clearance, increased volume of distribution and altered metabolism. Lower
concentration of drugs is required to induce and maintain anaesthesia, and they are more
sensitive to the effects of drugs on the cardiorespiratory system.
TCI use in the paediatric population is less popular. Children tend to have a larger
central compartment volume and a higher clearance rate than adults.

SAFE PRACTISE DURING USE OF TIVA

The NAP5 (2014) highlighted problems during the use of TIVA which led to accidental
awareness with the following recommendations:
• Making sure the cannula is visible and accessible at all times and checked regularly to
prevent disconnection or tissuing.
• Checking pump setup regularly to make sure tubing disconnection accidents do not occur,
clamps are open/closed accordingly, pump alarms are rectified and no backtracking of drug
occurs.
• Ensuring that the concentration of drug matches that programmed.
• Ensuring correct drug syringe is placed in the correct syringe driver programmed for it.

The Safe Anaesthesia Liaison Group in 2007 also recommended the use of anti-reflux and
anti-siphon valves with clamps in a multilumen tubing for safe delivery of a continuous
intravenous infusion.

INDICATIONS FOR THE USE OF TIVA

1. Malignant hyperthermia susceptibility
2. Long QT syndrome
3. History of severe PONV
4. Surgery requiring neurophysiological monitoring
5. Anaesthesia in non-theatre environments
6. Transfer of anaesthetised patients between different locations
7. Sedation in intensive care
8. Tubeless ENT procedures and rigid bronchoscopy
9. Thoracic surgery
10. Intracranial surgery
11. Procedures requiring sedation, e.g. endoscopy, cardioversion

ADVANTAGES OF TIVA
• Avoiding the use of nitrous oxide with its effect on air emboli and pneumothoraces, bone
marrow suppression.
• Elimination of volatile agents along with their possible toxicity to the liver and kidney,
potential rise in intracranial pressure, their effect on the uterus and possible environmental
effects.
• Elimination of the need for accurately calibrated vaporizers.
• Superior quality recovery with less hangover.
• Propofol is a powerful anti-emetic.

DISADVANTAGES OF TIVA
• Pharmacokinetic and pharmacodynamic variability of response to the injected drug.
• Lack of ability to accurately assess actual blood levels.
• Variations in the haemodynamic state of the patient.
• Requirement for dedicated IV access, and risk of disconnection.
• Risk of accidental awareness.

REFERENCES
Al-Rifai Z, Mulvey D. (2016). Principles of total intravenous anaesthesia: Basic
pharmacokinetics and model descriptions. BJA Educ 16(3): 92–7.
Naidoo D. (2011). Target controlled infusions. Available at:
http://anaesthetics.ukzn.ac.za/Libraries /Documents
2011/D_Naidoo_Target_Controlled_Infusion.sflb.ashx.
NAP5. (2014). Fifth National Audit Project of the Royal College of Anaesthetists in
collaboration with the Association of Anaesthetists of Great Britain and Ireland.
Safe Anaesthesia Liaison Group. (2009). Guaranteeing drug delivery in total intravenous
anaesthesia. Available at: https://www.rcoa.ac.uk /system/files/CSQ-PS-2-Safety-
notification-TIVA
.pdf.

CROSS-REFERENCE
Awareness, Chapter 30