Sir,

Minitracheostomy kits are commercially available and are used for the tracheal toileting in intensive care units. Commercially available kits are expensive; despite the expense they are not perfect. We have used the indigenously prepared kit several times in place of minitracheotomy kits and found it useful. Following this experience, we have also kept the same kit for carrying out emergency cricothyroidotomy is a potentially life-saving procedure in the "cannot intubate cannot ventilate (CICV)" scenario.\[[@ref1][@ref2][@ref3][@ref4]\] Although, surgical cricothyroidotomy remains the technique recommended in many "CICV" algorithms, the insertion of a tracheostomy as a cannula over a trocar, or using the Seldinger\'s method, may have advantages as they are more familiar to the anesthetist.\[[@ref5]\]

Intra-aortic balloon catheter pump (IABP) is used in cardiac centers to treat intractable low cardiac output syndrome. A typical IABP catheter kit contains intra-aortic balloon catheter, Seldinger needle, guide wires, sheaths with the dilators. Of these, a few optional items are rarely used. They are: The non-reinforced sheath and dilator wire reinforced sheath and dilator \[1 and 2, [Figure 1](#F1){ref-type="fig"}\], and extra set of the guide wire (0.036 inch, 100 cm long). The sheath provided in the IABP kit is nowadays not used by most clinicians, because using it has been shown to be an independent risk factor for the development of vascular complications after use of IABP catheter.\[[@ref6]\] Despite this, the manufacturers continue to include these reinforced sheaths in the IABP kits. During an uncomplicated sheath less insertion of IABP, the reinforced sheath and the non-reinforced sheaths are unused and commonly discarded. The reinforced sheath is kink proof and the tip has a protective atraumatic plastic ring, therefore, provides an atraumatic airway access. We report here an indigenous method to prepare a minitracheotomy/cricothyroidotomy set from aforementioned unused contents of the IABP kit.

![The various parts of the sheath with dilator. 1. Metal reinforced sheath, 2. Dilator, 3. "Black cap" with non-return valve, 4. Extension tube attached to the "connector" proximally, 5. "Connector" obliterated with Emseal](JOACP-29-418-g001){#F1}

The reinforced sheath, which is 9.5 French, is gathered from the IABP kit and the indwelling blue colored dilator is removed. The proximal end of the sheath has a black colored non-return valve \[3 [Figure 1](#F1){ref-type="fig"}\] to prevent spillage of blood when the sheath is indwelling in an artery. The black "cap" on the proximal end of the sheath is flipped open and the one-way valve existing in the inside of the black cap is removed with the help of a forceps. The black cap is snapped shut and the continuity of flow may be checked by visual patency through the black cap into the sheath. The extension tube (located at the proximal end of the sheath) meant to be used for flushing the sheath \[4 [Figure 1](#F1){ref-type="fig"}\] is not required for the cricothyroidotomy kit; therefore, it is disconnected from the connector using a firm tug at the tubing. The open ended connector is "sealed" using a commercially available sealing solution (Emseal)\[5 [Figure 1](#F1){ref-type="fig"}\], alternatively, the extension tube may be left as such. A 6 inch long piece of ¼ inch poly vinyl chloride tubing (which is freely available from cardiopulmonary bypass circuitry) is taken \[1 [Figure 2](#F2){ref-type="fig"}\] and to one end of that, a ¼ inch -- luer lock connector \[2 [Figure 2](#F2){ref-type="fig"}\], which is routinely used by the extracorporeal technology team is connected. To the other end a 5.5 mm endotracheal tube connector is inserted. The indigenous cricothyroidotomy *et al* so includes a Seldinger needle, 0.036 inch 100 cm guide wire, which may all be gathered from an IABP kit itself in an unused state. The guide wire length of 110 cm could at times prove cumbersome; then commercially available guide wire 0.036 inch, measuring 50 cm long could be used instead. The reinforced sheath is marked with a permanent marker at about 2 inches from the tip \[3 [Figure 2](#F2){ref-type="fig"}\]. This marker would help the operator to restrict further insertion of the sheath. The indigenous cricothyroidotomy kit is suitably packaged and sterilized. These kits are kept handy and available in every operation theater.

![The cricothyroid kit ready for use. 1. ¼ inch polyvinyl chloride tube, 2. ¼ inch -- luer lock connector, 3. Mark on the metal reinforced sheath indicating the depth of insertion into trachea](JOACP-29-418-g002){#F2}

Procedure of Insertion {#sec1-1}
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When cricothyroidotomy is required, the patient is placed supine; it is preferable to keep a bolster under the shoulder and a ring under the occiput. The anterior aspect of the neck is prepared by a suitable disinfecting agent and the part is isolated by drapes. If the patient is not already anesthetized, cricothyroid membrane is identified and local anesthetic agent is infiltrated. A stab incision is made with \#11 surgical knife over the cricothyroid membrane and the Seldinger needle is inserted through it. The Seldinger needle is oriented distally; this may prevent proximal migration and exit of the guide wire through the mouth. After confirmation of the needle entry into the trachea by aspiration of air, the guide wire is inserted up to 20 cm into the trachea. After inserting sufficient length of the guide wire, the Seldinger needle is withdrawn while taking care to keep the guide wire indwelling in the trachea. The reinforced sheath with the dilator is inserted into the trachea over the guide wire with a twisting motion to facilitate the gentle atruamatic entry of the assembly into the trachea. It is advanced into the trachea up to the 2 inch mark. The dilator is then removed and the male end of the luer lock is connected to the female end of the reinforced sheath\'s black cap. It could be then used as a route for tracheal toilet. If one is dealing with CICV situation, the universal connector may be connected to any of the device to provide intermittent positive pressure ventilation. If a suitable connector is used, one could use the jet ventilator as well. In *in-vitro* experiments, we have observed that at a peak inspiratory pressure of 30 cm H~2~O, a tidal volume of 250-300 ml may be provided at a frequency of 20/min \[Figures [3](#F3){ref-type="fig"} and [4](#F4){ref-type="fig"}\]. Such tidal and frequency is optimal for most of the Indian patients.

![The *in-vitro* assembly to check the ventilatory efficacy of the minitracheostomy kit](JOACP-29-418-g003){#F3}

![Monitor of the anesthesia workstation showing the returned tidal volume](JOACP-29-418-g004){#F4}

The kit has been used on many occasions at our center, to railroad several minitracheostomy catheters effortlessly in the intensive care unit to carry out tracheal toileting. The average time required to insert minitracheostomy was less than 3 min. Considering this experience it is reasonable to estimate that in CICV situations, one might be able get airway access in less than a couple of minutes because the indigenous cricothyroidotomy set is much sleeker in contrast to minitracheostomy catheter. At the author\'s institution, every operation theatre is provided with one such kit and every anesthesiologist is trained in it\'s use. Seldinger needle and the guide wire from the *et al* so help one to carry out retrograde endotracheal intubation. It is obvious that instead of frantically searching for these devices at emergent CICV situations, it is prudent to make these kits readily available. Cost seems to be a major advantage over the commercially available cricothyroidotomy sets. Providing one commercially available cricothryroidotomy set in each operation theater appears cost ineffective in comparison to the indigenous kit.
