A simple solution to unexpected kinking of endotracheal tube
A 2-month-old male baby, of weight 4 kg, was scheduled for emergency repair of bilateral inguinal hernia and right hernia was incarcerated. We planned general anesthesia with ET intubation, along with caudal block for this patient. The baby was placed over forced air warming blanket (Bair Hugger®) set at 40°C. Intravenous (i.v.) induction of anesthesia (modified rapid sequence) was done with propofol 2 mg/kg, fentanyl 3 μg/kg, and rocuronium 1.0 mg/kg. We accomplished ET intubation (oral) with 3.5-mm-internal diameter ET tube (Portex non-cuffed, PVC) and connected to anesthesia machine (Drager Zeus). The lungs of the baby were being ventilated with 2%-3% sevoflurane and 40% oxygen in air mixture. The mode of ventilation was volume control with tidal volume 20 ml and respiratory rate 30/min. Caudal block was placed with 4 ml of 0.25% bupivacaine. After the block, the baby was turned to supine position and handed over to surgical team which shifted the baby downward to middle of the operating table (as their final operating position). We re-confirmed neutral position of head, equal air entry, and fixed the breathing circuit on the supporting arm of the anesthesia machine. After 10 min of start of surgery, we heard an audible alarm from the anesthesia machine and noticed a decrease in expired tidal volume and rise in peak airway pressure. We checked the ET tube and found that it was kinked at a point between the angle of the mouth and the connector of the ET tube. We repositioned the support arm of anesthesia machine for breathing circuit close to the patient and placed some pieces of the cotton gauze under the tube to support it from below (arrow 1 in ) which resulted in straightening of the ET tube. We confirmed equal air entry on auscultation of chest, and measured expired tidal volume, and airway pressure returned to the previous readings. After a few minutes, we heard the same alarm again, with concomitant decrease of tidal volume and rise in peak airway pressure, and noted that the ET tube had kinked again at the same point. We manually supported the ET tube to straighten it and the chest expansion became adequate once again and ventilatory parameters also returned to acceptable range. To solve the problem of repeated kinking of ET tube, we wrapped an ordinary paper tape (Micropore 3M, 1 inch wide) around the ET tube (about 10 circles) at the point of frequent kinking (arrow 2 in ) and noted that there was no kinking during the rest of the procedure which lasted for more than 1 h after our reinforcement.