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Difficult Airway Case Presentation

Difficult Airway Case Presentation. Dr. Deepak Kumar Dr. Ashish Chakravarty. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. History . 37 year old male from Bihar Presenting complaints: Inability to open mouth x 3 years History of present illness:

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Difficult Airway Case Presentation

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  1. Difficult Airway Case Presentation Dr. Deepak Kumar Dr. AshishChakravarty www.anaesthesia.co.in anaesthesia.co.in@gmail.com

  2. History • 37 year old male from Bihar • Presenting complaints: • Inability to open mouth x 3 years • History of present illness: • 8 years back got hit on the right side of the face • Pain more on right side of face • Aggravated by movement and chewing • Took Rx from local practitioner following which incomplete relief of pain • Subsequently took homeopathic Rx for 1 month • Slight improvement in pain which used to aggravate on wide mouth opening and chewing hard food items

  3. ….contd • Stopped taking any Rx thereafter • Mouth opening progressively decreased • For last 3 years, able to have semisolid food only with spoon • Consulted AIIMS 3 years back- advised Sx • Declined Sx for financial reasons and apprehension • Consulted MADC 1 yr back • Decided to undergo Sx

  4. ….contd • No H/O • Prolonged earache, ear discharge • Joint pains / stiffness • Discharge from joint • Toothache • Radiation exposure • Fever with rashes • Drug abuse

  5. Past history No H/O HTN, DM, chest pain, DOE, syncope, seizures, bronchial asthma, Pulm.TB, jaundice Treatment History Exact nature of Rx after trauma not known Currently not on any Rx No H/O Surgery or Blood transfusion Family History Not significant

  6. Personal History • On semisolid and liquid diet due to difficulty in mouth opening • Bowel, bladder and sleep habits normal • No H/O snoring or nightmares • No H/O smoking or alcohol intake • H/O paan chewing; stopped 3 years back • Socioeconomic History • Labourer , poor socioeconomic status

  7. General examination • Moderately built and nourished • Ht : 165 cms • Wt : 57 Kg • BMI : 20.96 • Decubitus: sitting comfortably • No pallor, icterus, cyanosis, clubbing, edema, LNE • JVP not raised • Afebrile • PR : 78/min, regular, good volume, normal character, all peripheral pulses palpable, no RF delay, condition of vessels normal • BP : 116/78 mmHg, sitting position, right upper limb • RR : 14/min, thoraco-abdominal • Hair, skin , nails : normal • Skull and spine : normal • No joint deformity / decreased mobility • No ear discharge • No neck swelling • I.V access adequate

  8. Local examination • Inspection : • No swelling / redness / discharge • Palpation : • No increase in temperature / tenderness / swelling • 1 finger insinuation not possible

  9. Airway examination • Incisor length : 9 mm • No buck teeth • Prognathism not possible • TMJ : 1F not possible • MO : < 1F, hence MP not possible • TMD > 3F • Submandibular compliance : soft, unindurated, no mass palpable, space compliant • Neck movement : extension, flexion, right and left movement adequate • Length of neck : normal • Neck circumference : 40.5 cm • Nasal cavity : • No polyps • DNS +, deviation to left • Cold spatula test : R > L

  10. Systemic examination • CVS • Respiratory system NAD • Per abdomen • CNS

  11. Investigations • Hb : 12 g% • TLC : 8300 / mm3 • DLC : P61L35E4 • ESR : 20 mm/ 1st hr • RBS : 118 mg% • B.urea : 34 mg% • S.creat : 1.1 mg% • S.Elec : Na+ 139 mEq/L, K+ 3.8 mEq/L • S.protein : 6.8 g%, S. Alb 4.4 g% • CXR : NAD • EKG : NAD • BT: 1’ 15” • CT: 4’ 30”

  12. Preop advice • Explained the problem of difficult airway, the choices for securing the airway, the best option and obtained consent for fiberoptic intubation and surgery • NPO x 8 hrs • T. Alprazolam 0.25 mg HS and 6.00 a.m morning of Sx

  13. Management in Anaesthesia • Patient taken into confidence & Shifted to OT • Preinduction monitors: ECG, NIBP, SpO2 • IV 18G LULV – RL thru fluid warmer • IV Midazolam 1.5mg, Glycopyrrolate 0.2mg • Oxymetazoline nasal drops • Nebulized with 4% lignocaine 10 ml • 2% lignocaine viscous gargle 15 ml x 3 • 2% lignocaine jelly Rt nostril - sniff – digital dilatation • Fiberscope through Rt nostril • Spray-as-you-go technique • Placement of fiberscope into the trachea • # 7.0 mm I.D ILMA ETT rail-roaded into the trachea • Fixed at 26 cm with adhesive tapes after confirmation of its position by fiberscope, 5 point auscultation, ETCO2

  14. Induction • Inj. Fentanyl 120 µg + Ranitidine 50 mg + Metoclopromide 10 mg IV • Inj. Propofol 120 mg bolus + infusion @ 6mg/kg/hr started • N2O 66% in O2 started • Inj. Vecuronium 6 mg IV + 1 mg IV/ ½ hr • Inj. Diclofenac 75 mg IM • 30º head up position • Tarsorrhaphy sutures to cover eyes • Throat pack could not be placed

  15. Maintenance • Deliberate hypotension with Inj NTG started @ 1µg/kg/min & titrated to keep the MAP between 65-70 mmHg • Aliquots of Inj.Metoprolol 1mg i.v if compensatory tachycardia • 1½ hr into the procedure after achieving release of ankylosis on the Rt side the surgeons turned the head to proceed on with the surgery on the left side without informing the anesthetists • As a routine, position of the ETT was checked and found to be 20 cm at the nostril • Surgeons were asked to stop the surgery immediately

  16. …contd • ETT cuff deflated and pushed inside to negotiate it into the trachea • However the compliance of bag suddenly changed to suggest its entry into esophagus; confirmed by loss of capnograph • SpO2 100% • Extubated immediately, throat suction revealed minimal bleeding • Bag & mask ventilation possible

  17. …contd • Surgeons asked if orotracheal tube acceptable – “ yes” • D/L (Macintosh blade) : Cormack – Lehanne grade 3 • McCoy blade not available • Intubation tried with flexometallic tube over stylet – failed thrice • Intubated successfully with ILMA # 4 / 7.5mm I.D. Secured with adhesive tapes • Inj.Hydrocortisone 200mg i.v

  18. …contd • During the whole drill SpO2 remained between 98-100% • Rest of the intra-op period uneventful • At the end of the surgery D/L: Cormack- Lehanne grade 3, bleeding minimal • Reversed with neostigmine 3.0 mg + glycopyrrolate 0.6 mg i.v • Reversal adequate - throat suctioned – cuff deflated & lumen of ETT occluded & pt asked if difficulty in breathing • “no difficulty” – extubated

  19. Post-operative period • Vitals stable • CVS, respiratory system – NAD • Conscious, well oriented • No PONV • Analgesia adequate • SpO2 98-100% • No intraop awareness • Pt had an uneventful recovery and was discharged on the 6th postop day

  20. Discussion • What went wrong ?...How could this have been prevented ?? • What were the other options available with us in this scenario ? • Given different scenarios what would you do ??!

  21. Prevention • Properly securing the ETT: we recommend suturing the ETT to the ala of the nose in addition to securing with adhesive tapes • Surgeons must be instructed to inform the anesthetist prior to moving the head • Anesthetist must support the tube while moving the head • Difficult airway cart with all recommended equipments MUST BE PRESENT in difficult airway scenario

  22. Difficult Airway Cart - ASA 1993 • Rigid laryngoscope blades of various size & design* • ETT of assorted sizes • ETT guides: • semi-rigid stylets, • elastic gum-bougie with or without hollow core for changing* tubes and providing jet ventilation, • light wands, • Magill’s forceps • Supra-glottic devices: LMA / Combitube* • TTJV assembly* • Equipments for cricothyrotomy* / tracheostomy • Fiberscope • Retrograde intubation equipment* • Exhaled CO2 detector

  23. Scenarios • Suppose mask ventilation was not possible ? • Suppose the tube came out right at the beginning of surgery before mouth opening was achieved ? • Suppose both problems of difficult mask ventilation and mouth opening co-existed ? • Suppose the patient with TMJ ankylosis came for a different surgery and the problem was realized after the relaxant was administered to the patient ?

  24. Difficult Airway Algorithm Recognized Unrecognized Un-co-operative Co-operative GA +/- Paralysis Mask ventilation Awake- intubation ( Fiberoptic Blind Retro-grade ) Easy Difficult Emergency pathway Difficult intubation LMA / Combitube TTJV Intubating options Fail Succeed Fail Definitive airway Sx under mask Mask Regional Sx Airway Yes Confirm No No No Confirm Reverse

  25. Above vocal cords Nasal Fiberoptic Light-wand facilitated Blind nasal Oral Different blades Gum elastic bougie facilitated ILMA Fiberoptic Light-wand facilitated ( “Trachlite” ) Blind oral Below vocal cords Cricothyrotomy Tracheostomy Retrograde intubation Intubation choices

  26. Trans-tracheal Jet Ventilation • 14 G / 16 G cannula through cricothyroid membrane • High pressure oxygen source • Low compliance circuit • Suggested assemblies • 5 mm I.D ETT adapter attached to the oxygen tubing inserted into the fresh gas outlet. To the other end of the oxygen tubing a 3-way i.v connector is attached • 7 mm I.D ETT adapter attached to 2 ml syringe

  27. Cricothyrotomy • Cricothyroid membrane incised with no.11 blade • Incision widened with Kelly clamp • # 4.5 – 5.0 mm I.D ETT may be inserted

  28. Thank You www.anaesthesia.co.in anaesthesia.co.in@gmail.com

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