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  Table of Contents 
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 53-55

Increase in airway pressure after application of fishhook retractors in a neurosurgical patient in the supine position

Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication6-May-2019

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_64_18

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How to cite this article:
Singh S, Dwivedi D, Kiran S, Paul D. Increase in airway pressure after application of fishhook retractors in a neurosurgical patient in the supine position. Indian Anaesth Forum 2019;20:53-5

How to cite this URL:
Singh S, Dwivedi D, Kiran S, Paul D. Increase in airway pressure after application of fishhook retractors in a neurosurgical patient in the supine position. Indian Anaesth Forum [serial online] 2019 [cited 2020 Jan 25];20:53-5. Available from: http://www.theiaforum.org/text.asp?2019/20/1/53/257686


Intraoperative increased peak airway pressure due to endotracheal tube (ETT) kinking may be explained by many reasons. We report an unusual occurrence of ETT kinking in a patient undergoing intracranial surgery in the supine position.

A 26-year-old male patient, a known case of the right insular glioma, was posted for craniotomy and excision of tumor in the supine position with head position fixed by Mayfield three-pin system in a neutral position. Medical history and physical examination were unremarkable except for symptoms and signs of focal seizures on the left side of the face and arm for 1 year. Standard intraoperative monitoring and invasive blood pressure monitoring were applied, and the patient was induced with intravenous (IV) fentanyl 1.5 μg/kg and thiopentone 5 mg/kg. Rocuronium 1 mg/kg IV was administered to facilitate intubation with an 8-mm internal diameter cuffed polyvinyl chloride (PVC) ETT. It was fixed on the left side at the angle of the mouth at 22-cm length after confirming its position by five-point auscultation and obtaining a sustained capnograph. Twenty minutes after incision, we noticed the sudden increase in peak airway pressures from baseline of 16 cmH2O to 41 cmH2O. The capnograph tracing showed an increased end-tidal CO2 of 54 mmHg with the shark fin pattern, and the expired tidal volume also decreased from 480 to 260 ml. However, the oxygen saturation was maintained, with a SpO2 of 99%. Auscultation over the chest revealed vesicular breath sounds. On manual ventilation, we noticed the decrease in compliance of the reservoir bag. To check the patency of ETT, a suction catheter was inserted in, which could not be advanced beyond 8 cm. The surgeons were alerted, and the drapes were removed. Exposure of the patient revealed kinking of the ETT at the angle of the mouth [Figure 1]a. The traction of the fishhook retractors applied by the surgeon for better exposure had inadvertently compressed the ETT at the angle of the mouth, below the surgical drape leading to high airway pressures [Figure 1]b. After removal of the fishhook retractors, the airway pressure dropped from 41 cmH2O to 18 cmH2O. End-tidal CO2 decreased to 28 mmHg and was maintained in the same range thereafter. Surgeons reapplied the retractors away from ETT under aseptic precautions after draping again. The remaining intraoperative period was uneventful, and the patient was shifted to intensive care unit after extubation.
Figure 1: (a) Endotracheal tube kinking at the angle of mouth. (b) Fishhook retractor compressing endotracheal tube over surgical drape

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Kinking of ETT intraoperatively can be catastrophic if not noticed in time.[1] It is difficult to diagnose kinking of ETT and secure the airway, with head and neck draped in sterile drapes during the craniotomy. The high peak airway pressures and poor compliance of reservoir bag correlate well with the ETT kinking or obstruction of the larger airways. Softening of the PVC ETT due to exposure to oropharyngeal temperature for prolonged duration may also result in kinking at the angle of the mouth.[2] Kinking can also occur intraorally at the junction of the oral and pharyngeal axis, caused by thermal softening and overbending of the PVC ETT due to the temperature inside the oral cavity. Intraoral kinking presents a greater difficulty in the diagnosis than kinking of the ETT at the angle of the mouth.[3] Reinforced ETT can be useful in the situation where kinking is anticipated. A part of additional large ETT tube can also be fixed over an existing PVC ETT at the angle of mouth which can prevent kinking.[4] In an incident reporting by Dube et al., traction by the fishhook retractors with the head fixed with neck flexed, on a horseshoe, resulted in kinking of the ETT.[5] In our case, however, the head was fixed on a pin in a neutral position. Emphasis should be laid upon the proper application of fishhook retractor at the time of application by the surgeon. The use of reinforced and nonkinking ETT may be considered in patients where fishhook retractor is to be used, even with surgeries in a supine position.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Szekely SM, Webb RK, Williamson JA, Russell WJ. The Australian incident monitoring study. Problems related to the endotracheal tube: An analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:611-6.  Back to cited text no. 1
Ayala JL, Coe A. Thermal softening of tracheal tubes: An unrecognized hazard of the bair hugger active patient warming system. Br J Anaesth 1997;79:543-5.  Back to cited text no. 2
Ahluwalia C, Kiran S, Chopra V, Kar S. Airway obstruction during one lung ventilation: A shocking twist in the tube. Indian J Anaesth 2014;58:497-9.  Back to cited text no. 3
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Yamashita M, Motokawa K. Preventing kinking of disposable preformed endotracheal tubes. Can J Anaesth 1987;34:103.  Back to cited text no. 4
Dube SK, Rath GP, Gupta N, Sokhal N. Tracheal tube kinking during craniotomy in supine position after application of fish hook retractors. Neurol India 2011;59:647-8.  Back to cited text no. 5
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