A Case of Unanticipated difficult Intubation in a patient posted for C5-C6 Posterior Fixation
Dr. Jayashree Sen1, Dr. Parvoti S.2, Dr. Bitan Sen3, Dr. Sheetal Madavi4
1Prof. Dept. of Anaesthesia DMIMS, Wardha, Maharashtra, India.
2Junior Resident, Dept. of Anaesthesia DMIMS, Wardha, Maharashtra, India.
3DNBSS Senior Resident, Bombay Hospital Institute of Medical Science, Dept. of Critical Care Medicine Mumbai, Maharashtra, India.
4Asstt. Prof. Dept. of Anaesthesia DMIMS, Wardha, Maharashtra, India.
*Corresponding Author E-mail:
ABSTRACT:
Management of a “difficult airway” poses one of the most relevant and challenging tasks for anesthesiologists. Unanticipation with difficult airway and endotracheal intubation during the conduction of general anesthesia may result in complications and fatality. We report the case of a 14 yr old boy for planned C5-C6 spine fixation under general anaesthesia. Unanticipated difficult oral intubation after three failed attempts, managed by a stylleted cuffed endotracheal tube, head up tilt of the operation table, shoulder support, cricoid pressure and rotation of the endotracheal tube anticlockwise at the glottic opening.
KEYWORDS: Intubation technified, mental preparedness, Unanticipated difficult airway.
INTRODUCTION:
As defined by the American Society of Anesthesiologists, a difficult intubation is a tracheal intubation which requires more than three attempts, in the presence or absence of pathology in trachea. Failed or difficult endotracheal intubation is a significant cause of morbidity and mortality during anesthesia.1 Predictors of difficult airway include high body mass index, older age, Mallampati grade III or IV, thyromental distance of less than 6cm and severely limited jaw protrusion. However, even those predictors may fail at anticipating difficult laryngoscopy and endotracheal intubation at times. An unanticipated difficult airway can pose a real challenge for an experienced airway enthusiast even, to be able to use a wide variety of tools and techniques to avoid catastrophic outcomes, including cerebral anoxia and death.2 We report a case of an unexpected difficult airway found during laryngoscopy and endotracheal oral intubation.
Presentation of case:
A 14 yr old boy hailing from Wardha Maharashtra presented with chief complaints of difficulty in walking and weight bearing for last 3 months. Patient had a past history of progressive deterioration in hand grip and weakness in both upper and lower limbs since 1 year following which he was hospitalised and evaluated. Hyperextension of Cervical (C) spine was noticed. Fixation and stabilisation of C1-C2 was done 10 months ago due to posterior displacement of C2 causing spinal cord compression. But there was deterioration of symptoms for the past few weeks. He was then diagnosed with grade I spondylolisthesis of C5 over C6 with hypoplastic right vertebral artery. So C5-C6 spine fixation was planned.
All routine laboratory investigations like complete blood count, coagulation profile, liver and kidney profile tests were done. On preanaesthetic evaluation Mallampati grade of II,3 adequate mouth opening and normal TMJ (temporo mandibular joint) mobility was noticed. Informed and written consent was obtained from the patient and his parents. NBM of 6 hours was confirmed. Patient was shifted to the OT table and routine monitors as electrocardiogram, noninvasive blood pressure, pulse oximetry, capnography were attached and baseline parameters noted. A 22G intravenous access was secured. After 4 min of breathing of 100% oxygen via facemask, general anesthesia was induced with intravenous glycopyrrolate 0.004mg kg-1, midazolam 0.04mg kg-1, inj. fentanyl 30μg kg-1 and propofol 100 mg. Because to accomplish ventilation via a facemask was easy, rocuronium 0.6mg kg-1 IV was injected and ventilated for 90s putting an appropriate sized oropharyngeal airway (size 3 guedel's airway).
Proper mask ventilation was confirmed by capnography, to facilitate laryngoscopy and endotracheal intubation. However, following administration of muscle relaxant, chest expansion was found to be not adequate and the patient started desaturating even with intermittent positive pressure ventilation. Laryngoscopy was attempted immediately with #3 McCoy blade but the epiglottis could not be visualised corresponding to a Cormack– Lehane grade III airway.4 Several attempts at endotracheal intubation, using flexible gum-elastic bougie (tracheal tube introducer), differently sized tubes with stylet, using the techniques such as BURP (Backwards, Upwards and Right Pressure), application of cricoid pressure so that the vocal cords could be visualised on laryngoscopy were unsuccessful.5
Intubation was the attempted blindly with #4 McCoy blade and a stylleted cuffed endotracheal tube of ID #6 through mouth while giving cricoid pressure, a support (bolster) between the shoulder blades, raising the OT table up to the naval level of the concerned anaesthesiologist and rotating the endotracheal tube (ETT) anticlockwise at the glottic opening, finally the ETT could beplaced and secured correctly. A confirmation of the proper placement of ET tube was done by the continuous sine waveform capnogram and by the presence of six consistent capnograph traces without any decline in the detected carbon dioxide (CO2) levels which is the gold standard. On the operation table pre-operative (Pre-op) SpO2 was 99% on oxygen with routine monitoring. Ryle’s tube was then inserted.
DISCUSSION:
The vital goal in any situation is to maintain oxygenation and ventilation. Management of difficult airway is always a challenge to anesthesiologists. To consider the control of airway, options of equipments are varied which depend on the operator's skill and experience. When anticipated, patient's safety can be ensured by buying time for preparation. In unanticipated rare occasions if a sudden ‘cannot intubate’ situation arises that may lead to a catastrophe and can make the airway enthusiast paniked. Nolan found that, in comparison with sniffing position, manual inline stabilization decreased laryngoscopic view in 45% of patients, an epiglotis only (grade III) view in 22% of patients and using a gum-elastic bougie the rate of successful intubation within 45 seconds was greatly increased.6 Our case report presented with such a situation. What we did for maintaining the airway and adequate ventilation was discussed in details in our manuscript.
In this case, following induction, ability to ventilate was checked and assured, hence possibility of cannot ventilate situation was not anticipated and so muscle relaxant rocuronium administered.
The ideal procedure to avoid such a disastrous situation what we faced, would have been to take an attempt to estimate any potential problem in visualizing airway by direct laryngoscopy using the Cormack-Lehane classification, after induction of anaesthesia, facemask ventilation and muscle relaxation. To take adecision about awakening the patient and postponing the case can depend upon the prevailing circumstances. Calling for expert help early, continuous high flow nasal oxygenation, nostril preparation for nasal intubation, prevention of oxygen desaturation, availability of fibreoptic bronchoscope, supraglottic techniques in the hypo pharynx, front of neck access equipment to perform a needle cricothyroidotomy and proper documentation are the prime concerns before the proceeding for tracheal intubation. Adequate operation theatre as well as mental preparedness to handle such surprises is the hallmark of success.7
CONCLUSION:
Failure to act in time with right move in sudden unanticipated difficult airway can be devastating with far-lasting consequences. Implementation of the guidelines for unanticipated difficult intubation may not enable appropriate evaluation, recommendations and amendment. Clinicians' own skill level and experience and assessment of each patient on individual merit is the corner stone to avoid complications and fatality.
REFERENCE:
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Received on 28.08.2020 Modified on 15.10.2020
Accepted on 23.11.2020 © RJPT All right reserved
Research J. Pharm. and Tech. 2021; 14(7):3896-3898.
DOI: 10.52711/0974-360X.2021.00676