Common Procedures in Anaesthetics

• Common Procedures in Anaesthetics
• Endotracheal tube (ETT)


  A flexible plastic tube with an inflatable cuff at one end and a connector at the other, inserted through the mouth, throat, larynx, and vocal cords into the trachea
• Endotracheal tube sizes


  • Different sizes available, with the diameter written in mm (e.g., 7-7.5mm for women, 8-8.5mm for men)
• Inflating the cuff of an endotracheal tube

  Use a syringe to inflate the cuff via the pilot line, check pressure with a manometer, and assess inflation with a pilot balloon
• Murphy’s eye


  Provides an extra hole on the side of the tip of the endotracheal tube for gas flow in case the main opening becomes blocked
• Laryngoscope


  A metal blade with a light attached, used to visualise the vocal cords and guide the endotracheal tube into position in the trachea
• McGrath laryngoscope


  A high-tech version of a standard laryngoscope with a camera and screen for visualising the vocal cords via a live video feed
• Bougie


  A device to help with intubation, especially when vocal cords cannot be visualised, by guiding the endotracheal tube into position
• Intubation


  1. Bougie is inserted into the trachea

  2. Endotracheal tube slides along the bougie into the correct position in the airway

  3. Bougie is then removed, and the endotracheal tube remains in place
• Stylet


  • A stiff metal wire (with a plastic coating) that is inserted into the endotracheal tube before intubation is attempted
  • Can be bent to hold the endotracheal tube in a specific shape
  • Usually used to bend the tip of the endotracheal tube anteriorly towards the trachea
• Awake fibre-optic intubation


  1. Endotracheal tube is inserted with the patient awake, under the guidance of an endoscope

  2. Endoscope is inserted through the nose or mouth, down to a position below the vocal cords

  3. Endotracheal tube is then inserted over the top of this tube into the correct position

  4. Endoscope is removed, leaving the endotracheal tube in position

  5. Used where there is restricted mouth opening or difficult anatomy
• Putting the patient to sleep prior to inserting the endotracheal tube is more risky, as a delay in intubation can lead to hypoxia
• Trismus


  • Refers to pain and restriction when opening the jaw
  • Can make intubation more difficult and might need awake fibre-optic intubation
• Supraglottic Airway Devices (SAD)

  • Alternative to endotracheal intubation for ventilation
  • Commonly used in both elective and emergency scenarios
  • First option if intubation fails in a difficult airway scenario
  • Tip located at the top of the oesophagus
  • Cuff fits around the opening of the larynx, forming a seal between the device and the airway
  • Cuff can be inflatable or non-inflatable
  • SADs with inflatable cuffs are called laryngeal mask airways (LMA)
  • I-gel is a type of non-inflatable SAD that uses a gel-like cuff that moulds to the larynx
• Oropharyngeal (Guedel) airways


  • Inserted into the oropharynx
  • Rigid and create an air passage between in front of the teeth and the base of the tongue
  • Maintain a patent upper airway
  • Inserted upside down, then rotated into position once the tip is past the tongue
  • Most often used when ventilating the patient via a face mask and bag prior to inserting an SAD or ETT
  • Size measured from the centre of the mouth to the angle of the jaw
• Nasopharyngeal airways


  • Slightly flexible tubes inserted through the nose
  • Create an air passage from outside the nostril to the pharynx (throat)
  • Size measured from the edge of the nostril to the tragus of the ear
  • Often used in emergency scenarios, for example, in A&E or at cardiac arrests
  • Carry a risk of nosebleeds (epistaxis)
  • Base of skull fracture is a contraindication for inserting a nasopharyngeal airway
• Tracheostomy


  1. Creating a new opening in the trachea

  2. Hole is made in the front of the neck with direct access to the trachea

  3. Tracheostomy tube is inserted through the hole into the trachea and held in place with stitches or soft tie around the neck (trach tie)

  4. Tracheostomies may be temporary or permanent, depending on the indication
• Tracheostomy


  Inserting a tracheostomy tube through a hole into the trachea and holding it in place with stitches or soft tie around the neck (trach tie)
• Indications for a tracheostomy

  • Respiratory failure where long-term ventilation may be required
  • Prolonged weaning from mechanical ventilation
  • Upper airway obstruction
  • Management of respiratory secretions
  • Reducing the risk of aspiration
• Tracheostomy tubes


  • Short and curved
  • Have variations depending on their use
  • Usually have an outer tube that stays in place and an inner tube that can be removed for cleaning or changing
  • Can have inflatable cuffs to hold them in place and seal the airway
• Difficult Airway


  Steps to take in the case of unanticipated difficulty intubating a patient: Plan A - laryngoscopy with tracheal intubation, Plan B - supraglottic airway device, Plan C - face mask ventilation and wake the patient up, Plan D - cricothyroidotomy
• Arterial Line


  A special type of cannula inserted into an artery for accurate real-time blood pressure monitoring and arterial blood sampling
• Medications are never given through an arterial line
• Central Line


  Also called a central venous catheter, a long thin tube with several lumens inserted into a large vein with the tip located in the vena cava
• Locations for inserting a central line

  • Internal jugular vein
  • Subclavian vein
  • Femoral vein
• Central Lines


  • Have separate lumens for giving medications or taking blood samples
  • Last longer and are more reliable than peripheral cannulas
  • Can be used for medications that would be too irritating for a peripheral cannula
• Vas Cath


  A type of central venous catheter inserted on a temporary basis, usually into the internal jugular or femoral vein, with two or three lumens
• PICC Line


  A peripherally inserted central catheter, a long, thin tube inserted into a peripheral vein and fed through the venous system until the tip is in a central vein, with one or two lumens
• Tunnelled Central Venous Catheter


  A type of tunnelled central venous catheter, such as a Hickman line, a long, thin catheter that enters the skin on the chest
• Types of central venous catheters

  • Tunnelled Central Venous Catheter
  • Hickman line
  • Pulmonary Artery Catheter
  • Portacath
• Hickman line


  • Long, thin catheter that enters the skin on the chest, travels through the subcutaneous tissue, then enters into the subclavian or jugular vein with a tip that sits in the superior vena cava
  • Has a cuff (sleeve) near the skin insertion that promotes adhesion of tissue, making the catheter more permanent and providing a barrier to bacterial infection
  • Can stay in longer-term and be used for regular IV treatment such as chemotherapy or haemodialysis
• Pulmonary Artery Catheter


  • Also known as Swan-Ganz catheters
  • Inserted into the internal jugular vein, through the central venous system, right atrium, right ventricle, and into a pulmonary artery
  • Has a balloon on the end that can be inflated to "wedge" the catheter in a branch of the pulmonary artery
  • Pressure distal to the wedged balloon can be measured to give the pulmonary artery wedge pressure, indicating pressures in the left atrium
  • Rarely used, mostly in specialist cardiac centres for close monitoring of cardiac function and response to treatment
• Portacath


  • Has a small chamber (port) under the skin at the top of the chest that is used to access the device
  • Connected to a catheter that travels through the subcutaneous tissue and into the subclavian vein with a tip that sits in the superior vena cava or right atrium
  • Fully internalised under the skin, reducing the chance of infection, lasting the longest of the options for central venous access
  • When nothing is attached to the port, the skin remains intact, and there are no lines outside the body
  • Can be used for regular IV treatment such as chemotherapy
  • Only specially trained staff are able to access a Portacath
• Last updated


  August 2021