Intubation in the OR

Hey guys as perioperative nurses its important to understand the use of intubation in the OR. I’m excited to talk to you a little bit about that today!

Ok guys what is intubation?  Intubation is the insertion of a tube into the trachea during surgery when the patient is under general anesthesia.  Because general anesthesia causes muscles to be paralyzed, including the diaphragm, the patient is unable to breath on their own, the tube connects the patient to a ventilator which will do the breathing for the patient making sure the patient is properly ventilated and oxygenated while protecting the patient’s airway.  Guys check out the specific lesson we have on general anesthesia!

So the tube can be inserted into the mouth to the trachea or into the nose to the trachea.  The most common mouth to trachea tube is known as the endotracheal tube, another intubation tube is the LMA or laryngeal mask airway, which you can see here, an LMA is a cross between a mask and a endotracheal tube.  The LMA will be used on general anesthesia surgical patients who will not be intubated for an extended amount of time, do not have a history of reflux, and do not need to be repositioned a lot during surgery. The nasotracheal tube is inserted into the nose instead of the mouth and we use this during surgeries where a tube can’t be placed in the mouth like oral or facial surgeries.

So as perioperative nurses, specifically the circulating RN, they have an important role during intubation of a patient. It’s super important that we assist anesthesia during this process because the patient is vulnerable as after anesthesia is administered the patient is no longer breathing on their own so it’s race against the clock so to speak to get that patient oxygenated and we have to do that through intubation.  So during this time the circulating RN will support the patient and assist anesthesia during this process. In addition, the circulating RN is going to assess the patient before intubation and we will talk a little bit more about that on the next slide.

So additionally as the circulating RN we want to assess and document some specific things before intubation. Take a look at the patient’s teeth are they cracked, chipped, or loose?  Take a look at their mouths do they have any cuts, abrasions, sores, anything like that? It’s important to document that these issues were recognized before intubation took place.  Also, are they wearing partials or dentures because these need to be removed before intubation as they can cause issues during the process for anesthesia.  Finally guys assess your patient for any visible issue that could make intubation difficult, like a thick neck or limited neck extension.

So let’s take a look at the intubation process. So anesthesia will be positioned at the head of the OR table looking at the patient’s feet. The patient’s position will be supine or on their backs. The patient will be sedated by the anesthesia team so that their mouth and neck relaxes and then the mouth gently opened.  The laryngoscope, which we see here in the picture will be inserted so that the anesthesia team can visualize the vocal cords while protecting the tongue and teeth. Also guys you can see that there are different handles and different blades used with the scope depending on the patient.

So continuing on with the intubation process after the specific landmarks are visualized the tube which we see here and this picture is inserted and is advanced into the airway.  The balloon or cuff which is part of the endotracheal tube is inflated which holds the tube in place. Placement of the tube is verified by listening to equal breath sounds, making sure that there are no sounds in the stomach area, also by capnography which has to do with CO2 levels, and then also seeing that there is condensation in the breathing circuit.  Guys I also want to mention that this is for placement verification in the OR. In most other settings placement of a tube will be verified by x-ray but not necessarily during surgery. After anesthesia has verified the placement of the tube it’s going to be tied or taped in place to secure it.

Okay so let’s talk about the extubation process a little bit. So the surgery is complete, anesthesia has been reversed, or it has worn off.  Anesthesia is going to verify that the patient is breathing on their own, they’re able to maintain their own airway, they’re able to lift her head and follow commands. Typically at this point they are ready to be extubated.

Continuing with the extubation process.  The tape or tie is going to be removed, that balloon that was inflated to keep the tube in place will now be deflated and the tube will be gently removed.  Anesthesia team at this point will monitor the patient very closely and apply oxygen.

So what are some risks of intubation?  Trauma can occur to the mouth, teeth, tongue, larynx, really any structure that will come in contact with that tube.  Aspiration, bleeding, hoarseness, sore throat are all additional risks. I would say that most patients when they wake up complain of having a sore throat so this is a pretty common risk.   Extubation issues like being unable to wean the patient from a ventilator is also a risk of intubation.

So what are some nursing concepts that we can apply to intubation in the OR?   Oxygenation and perfusion of the surgical patient are obviously very closely associated with the safety of a patient who is intubated so these would be the most obvious nursing concepts that we can relate to intubation of patient.

Okay some key points to take away with you regarding intubation in the OR. The purpose of intubation is obviously going to provide the patient ventilation and oxygenation and protect their airway while under anesthesia.   Types of intubation include the endotracheal tube, nasotracheal tube, and laryngeal mask airway. The process of intubation includes anesthesia being initiated which causes the patient’s mouth to relax, inserting the laryngoscope, insertion of the tube, verifying placement of the tube, and securing the tube.  So once the surgery is complete and anesthesia is reversed and it’s verified that the patient can maintain their own airway, the tape will be removed, the cuff will be deflated, the tube will be removed and oxygen will be applied. The nursing role during intubation you’re going to assess the patient’s mouth and teeth condition before intubation, also remove any partials or dentures, we’re going to support anesthesia and the patient.

Okay guys I hope you enjoyed this lesson on intubation in the OR!  Make sure you check out all the resources attached to this lesson, as well as the rest of the lessons in this course. Now, go out and be your best self today. And, as always, happy nursing!