It’s fascinating to me that every practice seems to have a different protocol to achieve similar results. For this column, we present better ways to intubate and scrub patients. Each doctor or technician probably has a different intubation protocol. I recently read a description of how we should probably all intubate. It was written by Sheilah Robertson, a board-certified anesthesiologist at the University of Florida College of Veterinary Medicine.1 Here’s the idea: Most people test the cuff of a large endotracheal tube by inflating it with a syringe (aka “dry syringe,” “air syringe” or “cuffer puffer”), waiting a few seconds, and deflating it. Then, some people lube the tip and the cuff of the tube with lubricating jelly (again, this specifically applies to large tubes). It seems that most do so on a deflated, folded cuff, which actually greatly decreases the benefits. Dr. Robertson suggests adding lube to an inflated cuff. Think about it. It wouldn’t take any longer than doing both steps separately, but it would lubricate the cuff much more effectively—on 100 percent of its surface—instead of a few random spots. I have only witnessed one technician do that (surely there are more out there!) But Wait, There’s More! An unexpected benefit of this little trick has been discovered in human medicine.2 It greatly decreases the risk of aspiration pneumonia in humans. And there are reasons to suspect it will have the same result in pets. Figure 1: A well-lubricated endotracheal tube does not allow the dye to leak. Dr. Robertson actually tested the concept in vitro. She poured water in two test tubes, placed two endotracheal tubes (one dry, one lubricated) and inflated them with the same amount of air. Then she added dye on top of the inflated cuff.Guess what? The dry cuff didn’t act as a barrier, so dye mixed with the water below. But the cuff that was lubricated while inflated acted as a barrier, and kept the dye away from the water below (see figures 1 and 2).Similar results had been noticed in the human study—in vitro: 0 percent leakage of the dye with the lubricated cuffs vs. 100 percent with the dry cuffs. In vivo, in actual human patients under anesthesia, leakage was 83 percent with dry cuffs, but only 11 percent with lubricated cuffs. Figure 2: A poorly lubricated endotracheal tube allows the dye to leak. Based on these incredibly simple but powerful findings, this is Dr. Robertson’s suggested intubation protocol:* Inflate the cuff of the endotracheal tube to check for leaks * Leave it inflated * Roll the cuff in lube—preferably sterile! (In other words, don’t choose the lubricant you use to lube thermometers.) * Deflate the cuff * Intubate the patient * Gently inflate the cuff while ensuring there is no leak by squeezing the breathing bagA Better Way to Scrub Similarly, it is striking to observe the multitude of protocols to scrub surgery patients. Some people pour antiseptic scrub on the patient’s skin, then scrub with dry, unsterile sponges. Others have various types of containers with sponges soaked in all-too-often very diluted scrub soap, which they grab with their bare hands (see Figure 3). Figure 3: The not-so-ideal way to scrub. The same containers and sponges are used to place IV catheters and other small tasks. Few team members use gloves—sterile or not.Some alternate antiseptic and sterile saline (or water); some alternate antiseptic and alcohol; some scrub with soap, then spray solution.Below is a scrubbing technique that is simple and cheap, yet by the book. Many surgical and general practices use the following protocol. Your patients would clearly benefit from using the same technique.With your surgical patients, it would be ideal to only use sterile supplies. A stainless steel dog bowl could be used. Your favorite supplier probably carries large stainless steel bowls that cost a buck or two. Figure 4: The right way to scrub. Fill the bowl with 20 or 30 sponges, double wrap the whole kit in drape material, and autoclave it. An added benefit of this set up is that both the drapes and the bowl are reusable. Alternatively, you can use pouches, but that costs more because they should be single use. When it is time to scrub your patient, unwrap the bowl and pour scrub soap over the sponges. Using bare hands is not considered appropriate for scrubbing a patient.Rather, use sterile surgical gloves to grab the sponges and remain sterile at all times. In fact, the gloves will also protect your skin from the harsh chemicals (see Figure 4). Alternating antiseptic scrub soap and alcohol is fine, and the last application should be an antiseptic solution, typically from a spray bottle. Why is this all a big deal? Because iatrogenic infection in a patient is never a fun experience for anybody involved: the patient, the client or the practitioner. It’s Important And with the growing threat of MRSA and other emerging resistant pathogens, appropriate surgical technique becomes more important than ever.If you think about it, implementing either suggested protocol (intubation or scrubbing) only costs a few pennies, yet both are simple, effective and straight-forward. As a fellow surgeon told me once: “Try it twice.” Dr. Phil Zeltzman is a mobile, board-certified surgeon near Allentown, Pa. His website is www.DrPhilZeltzman.com. He is the co-author of “Walk a Hound, Lose a Pound (www.walkahound.com).” REFERENCES 1. S. Robertson. "More benefits of lubricating ETT cuffs." Vet. Med. Feb. 2010, p. 48. 2. MC Blunt et al. "Gel lubrication of the tracheal cuff reduces pulmonary aspiration." Anesthesiology 2001, Vol 95, N 2, p. 377-381.11/1/2011 5:42 PM
