USG-guided jelly injection: An answer to leaking cuff.

Sir,

Endotracheal tube (ETT) cuff leak is a common intraoperative problem encountered that can lead to disastrous complications such as aspiration and failure of oxygenation and ventilation.[1] Temporary interventions include pharyngeal packing, jet ventilation, and continuous air insufflations. Definitive management is the replacement of the tube, which can be cumbersome and undesirable as it involves the contamination of sterile surgical zone.

Here, we describe a new technique of sealing the cuff leak and maintaining the airway intraoperatively. A 50 year old male with pan facial injury was scheduled for plating under general anesthesia. Following orotracheal intubation, ETT was taken out through the submental opening. Midway through the surgery, we found ventilator discrepancy between the delivered and expired tidal volumes. An audible air leak noise during inspiration and the deflated pilot balloon indicated cuff leakage. Reinflating pilot balloon with air improved the ventilation only temporarily. A high-frequency linear transducer was kept transversely below the cricoid cartilage and the ETT cuff was visualized by intermittent pushing air. A 20-G needle was advanced in plane to the probe to puncture the cuff at the time of its inflation. A mixture of 2% lignocaine jelly and distilled water (ratio 1:2) was injected directly inside the cuff. A cap was applied over the needle to prevent spillage of the sealing mixture [Figure 1]. A knot on the inflating tube also served the same purpose. An adequate seal was obtained and the surgery was restarted with uneventful intraoperative period. At the end of surgery, the cuff was deflated with ease and the patient's trachea was extubated.

Figure 1

Ultrasound-guided lignocaine jelly instillation

A similar case was reported by Bajwa et al.[2] where a mixture of lignocaine jelly and distilled water (1:1) was injected in the ruptured cuff intraoperatively by the surgeon himself. They reported difficulty in cuff deflation at the end of surgery; hence, we used a more dilute mixture.

Inflation of the ETT cuff with a lignocaine jelly–saline mixture successfully eliminated the leak, while maintaining sterility and allowing completion of the procedure without reintubation. Hence, ultrasound-guided injection of lignocaine jelly–saline mixture inside the cuff can be a useful measure during intraoperative cuff rupture.

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Conflicts of interest

There are no conflicts of interest.