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Table of Contents    
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1680-1681

Railroading Syringe Barrel for Intraoperative Endotracheal Tube Kink: A Bailout Procedure

1 Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India; National Institute of Health Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
3 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission29-Sep-2020
Date of Decision18-Feb-2021
Date of Acceptance26-Mar-2021
Date of Web Publication30-Aug-2022

Correspondence Address:
Manjul Tripathi
Associate Professor, Gamma Knife Radiosurgery, Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.355101

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How to cite this article:
Chauhan1 R, Tripathi M, Mohindra S. Railroading Syringe Barrel for Intraoperative Endotracheal Tube Kink: A Bailout Procedure. Neurol India 2022;70:1680-1

How to cite this URL:
Chauhan1 R, Tripathi M, Mohindra S. Railroading Syringe Barrel for Intraoperative Endotracheal Tube Kink: A Bailout Procedure. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1680-1. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1680/355101


Transoral surgeries pose unique challenges to neurosurgeons and anesthetists alike.[1] Surgery in this crowded space demands eye–hand coordination, instrument–tissue handling, and support from the anesthesia team. Nasotracheal intubation is not preferred because the tube passes near the midline further compromising the operative space. Dingman retractor additionally reduces the space. Oral endotracheal intubation (ET) with the tube pushed to one side of the corner of the mouth is a relatively better way to secure airway with minimal discomfort to the surgeon. Kinking of ET is a universal trouble with no visible solution. Reinforced/armored tube has been considered a solution for this trouble, but it is not foolproof, costlier, and not readily available.[2]

A 24-year-old male presented with complaints of compressive myelopathy secondary to basilar invagination and atlantoaxial dislocation. The patient was planned for transoral decompression followed by posterior fixation. The patient was kept in the supine position with an extended neck fixed on four pin fixators with endotracheal tube (ETT) of size 8.5 mm internal diameter (ID). Intraoperatively, there was evidence of increase in the airway pressure along with partial delivery of set tidal volume [Figure 1]b. The tube was getting kinked outside the mouth. At this stage of surgery, the tube could not be replaced. A syringe barrel of 10 cc having 17.7 mm outer diameter (OD) with an approximate length of 6 cm was cut from the nipple end and railroaded over ET having an OD of 11.6 mm after disconnecting the ET from connector. The tube was well supported from below with a saline plastic bottle [Figure 1]a. It served the purpose, and the tube remained patent throughout the surgery of 8 hours [Figure 1]c.
Figure 1: (a), Railroaded syringe barrel on endotracheal tube; (b), Intraoperative tube kink leading to partial delivery (in magenta colored box) of tidal volume (in cyan colored box), and high airway pressure (in yellow circle); and (c), Correction of the tube kink by railroading the syringe barrel ensuring delivery of tidal volume (in magenta colored box) and reduced airway pressure (in yellow circle)

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Polyvinyl chloride (PVC) ET is commonly used for surgeries in the supine position. Intraoperative indications of kinking of tube are high air pressure and inability to deliver the preferred tidal volume. The tube commonly gets kinked at the angle of mouth or at the connector.[3] Common endeavors to manage this situation are replacement of tube, readjustment of breathing circuit of anesthesia machine, reduction of the extra length of ET outside the oral cavity, or placement of extra soft gauge roll to support the tube. Published literature highlights external support with 18G needle cap or reinforcement with adhesive tapes.[4] External reinforcement of pediatric ETs has been described using bigger-sized ETs.[2],[3],[4],[5] However, in our case armored tube was not available, and replacement of tube at this stage of surgery was potentially dangerous in view of the difficult airway, application of Dingman retractor, and inability to mobilize the head fixed with four-point fixator. Compared with the PVC ET, the syringe barrel is made of polypropylene, which is much stronger than the PVC. This method of externally reinforcing an ET worked better than external reinforcement. We propose this technique as a bailout procedure in desperate situations of repeated compromise.

Financial support and sponsorship

Dr. Manjul Tripathi is supported by the National Institute for Health Research (NIHR) Global Health Research Group on Neurotrauma (16/137/105) using U.K. aid from the U.K. government. The views expressed in this publication are those of the author and not necessarily those of the NIHR or the U.K. Department of Health and Social Care.

Conflicts of interest

There are no conflicts of interest.

  References Top

Chauhan RB, Satapathy A, Mohindra S, Tripathi M, Batish A, Dave S. Transoral odontoidectomy: A time-honored rescue procedure. J Neurosurg Spine 2018;29:608-10.  Back to cited text no. 1
Aqil M, Al-Saeed A. A simple solution to unexpected kinking of endotracheal tube. Saudi J Anaesth 2013;7:344-6.  Back to cited text no. 2
Sivapurapu V, Subramani Y, Vasudevan A. Externally reinforced endotracheal tube in a pediatric neurosurgical patient. J Neurosurg Anesthesiol 2012:24:82-3.  Back to cited text no. 3
Wakamatsu T, Ishii H. The “wireless” portion of a wire-reinforced endotracheal tube may kink. JA Clin Rep 2019;5:22.  Back to cited text no. 4
Yamashita M, Motokawa K. Preventing kinking of disposable preformed endotracheal tubes. Can J Anaesth 1987;34:103.  Back to cited text no. 5


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