15. Emergence from Anaesthesia.

15. Emergence from Anaesthesia.

• The Tulip is best removed in a fully staffed and equipped recovery area, which allows full monitoring and suction.
• The Anaesthetist must check the Patient’s ventilation, and confirm a clear ventilating airway before handing over the Patient to recovery staff.
• The Tulip is to be left in place fully-inflated when leaving theatre and it is recommended that visualized oral suction, external to the Tulip, be performed prior to leaving the operating theatre.

This suction should be carried out gently and with care to reduce the stimulus to the Patient. Such stimulus is common practice, particularly in the recovery area, but carries the hazard of causing the Patient to briefly reveal reflexes of swallowing or coughing, but then when the external, arousing stimulus is discontinued, the Patient descends back into anaesthesia. This may then cause the loss of the airway, which may be unmanageable once the Tulip is removed.

It is important that careful suction is performed under direct vision for Patients undergoing facio-maxillary, oro-dental and E.N.T. surgery. This suction removes any residual secretions or blood that may have been missed by the surgeon, and that may fall back down into the mouth once the Tulip is removed.

Again it is stated that the recommended method of extubation is allowing the Patient to remove the Tulip themselves, or for the recovery staff to remove the Tulip when the Patient responds to verbal commands to open their mouth.

The Tulip should remain fully-inflated upon removal, which will evacuate a majority of the oral secretions present, and prevent the secretions falling back down into the oropharynx, possibly causing laryngospasm if the oropharyngeal and laryngeal reflexes have not returned.

Deflation of the Tulip cuff will remove our ability to perform intermittent positive pressure ventilation to manage the recovering Patient and will destabilize the airway. So the Tulip should never be deflated until the Patient has been neuromuscularly reversed and has established an acceptable, regular, deep, spontaneous inspirational breathing pattern.

Normally in recovery similar devices have to be removed when the Patient is still semi-conscious to prevent the obstruction caused by a biting Patient as they recover. This is not an issue with the Tulip, as the Patient has recovered more fully before they remove the Tulip themselves and are no longer biting the tube. Also the Tulip has no large, hard parts within the Patients mouth, so its removal is easy even between clenched teeth, as the inflatable cuff simply deforms and slips out.

As the Patient removes the Tulip themselves in response to verbal command when recovered and ready, the Recovery attendant no longer has to do this. Also, when the Tulip is removed by the fully recovered Patient, the attendant no longer needs to maintain that Patients airway after removal, as per similar devices. The Tulip also removes most of the internal secretions as it comes out of the mouth when fully inflated, lessening the requirement for attending staff to suction, reducing trauma.

The inflated Tulip should be removed either by the recovering Patient overcoming the gentle resistance of an untied Tulip within the mouth, or by an attending recovery staff member. This state of full cuff inflation allows the Tulip’s cuff to pull out any remaining upper pharyngeal and oral secretions in front of itself as it is pulled out of the Patients mouth upon removal.

The onset of swallowing is a good indication that the Patients reflexes are returning, but removal should be delayed until the Patient responds to verbal commands to open their mouth, or until the Patient removes the Tulip themselves.

The Tulip is inherently designed to be self-retaining, by virtue of the inverted cone-shaped cuff and its location between the soft palate and epiglottis. The usage of soft plastic increases the co-efficient of friction between the mucosa and the Tulip, aiding to its self retention.
Post operatively, the Tulip should be left in place and remain undisturbed so as to remain in the correct position during transfer to the recovery unit acheter viagra ligne france. To aid retention and the correct positioning post-operatively, it is recommended that the Patient remain supine, and that no jaw maneuvers are performed unless there is airway compromise. Any excessive movement of the Tulip may induce trauma by being forced against the mucosa, soft palate or the epiglottic tip. This excessive movement may push the Tulip tip into the epiglottis, which may be pushed inferiorly, in a flap like movement, and occlude the laryngeal inlet causing complete or partial obstruction of the airway. Such movement may stimulate laryngeal reflexes, inducing spasm if the depth of anaesthesia is inadequate. Such movement may be minimized by inflating the Tulip in the described manner initially, and securing it correctly.

Avoid inflating the Tulip and then pushing it down into the mouth, as this will most likely cause epiglottic inversion and consequent airway obstruction. Any re-positioning that may be necessary should be conducted in theatre, under full anaesthesia to suppress oro-laryngeal reflexes, before transfer to the recovery area. If re-introduction is required, the Tulip must be replaced either fully deflated, or partially-inflated (+/-30mls), never fully inflated (+/-60mls).

Lower oropharyngeal and intra-luminal suction may be performed using a fine suction catheter passed through the central breathing tube lumen, but there is always the possibility of inducing laryngeal spasm by contact stimulation of the vocal cords.

In recovery, with the Tulip in position, the oxygen is delivered to the recovering Patient using a “T” piece attached to the Tulip’s connector, which allows the provision of 100% oxygen without the obstruction of either expiration or inspiration. Gaseous exchange should be regularly confirmed by visualizing chest movement and condensation upon the plastic of the “T” piece, as well as full monitoring, which includes saturation monitoring and capnography.

It is important to only remove the Tulip when either the Patient extubates themselves, or when they are responsive to verbal command to open their mouth as such criteria reduce the possibility of extubation before stabilization of the airway by the return of laryngeal reflexes, which may occur secondary to the fluctuation of the conscious level caused by painful stimuli such as wound pain, Patient transfer and stimulii provided by some recovery staff to hasten extubation.

Restlessness and excessive movement may reveal themselves in younger Patients, but this is not an indication for removal of the Tulip, and previously stated criteria should be adhered to. This fluctuation of consciousness is particularly dangerous, as this over-activity may be followed by a further period of unconsciousness, whereby the airway is compromised by the lack of laryngeal reflexes.

It must be remembered that, as with all pieces of equipment, the Tulip may look as though it is correctly placed, but in fact there is a compromise of gaseous exchange secondary to twisting, kinking or cuff rupture. This type of complication is very rare, hence it is important to monitor the Patient very closely, both clinically and by virtue of monitoring equipment.

The position of the Tulip may be rapidly assessed by reference to the tube printing and mid-line marking which will reveal any rotational twisting of the airway, and by assessment of the Patients gaseous exchange that is a reflection of chest wall movement but it is important to determine that this movement is causing effective gaseous exchange and is not of the “see-saw”, reciprocal movement type which is a consequence of airway obstruction.

Evaluation of gaseous exchange is most easily confirmed by placing the palm of the hand in close opposition to the Tulip’s breathing tube lumen and feeling the gas movement upon one’s skin. Should this be insufficient, then the ear may be placed alongside the gas lumen, and the gas movement auscultated.

It is recommended that the Patients respiratory pattern be monitored continually using a capnograph, which will also enable ventilation to be gauged according to end tidal CO2 levels.