Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
blood flow from the port of CVC is a must before using it for vasoactive drugs even if the mark at skin is unchanged. Importantly, a transparent dressing should be preferred allowing a quick check for any fluid leakage or ooze. Lastly, daily case notes should include a record of CVC mark at skin and check chest X‑ray is must to locate the inner part of CVC.
Letters
References 1. McGee DC, Goud MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123‑33. 2. Kapoor MC, Kumar S, Gourishanker R. Fluid infusion into the pericardium resulting from accidental displacement of a subclavian venous cannula. Ann Card Anaesth 2011;14:41‑4. 3. Czepizak CA, O’Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest 1995;107:1662‑4.
Tanmoy Ghatak, Arvind K. Baronia Department of Critical Care Medicine, SGPGIMS, Lucknow, Rai Bareilly Road, Lucknow. Uttar Pradesh, India
Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.114023
Quick Response Code
Corresponding author: Dr. Tanmoy Ghatak, Department of Critical Care Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India. E‑mail: [email protected]
Intubating laryngeal mask airway—A lifesaver during accidental intraoperative extubation in a case of difficult airway Sir, The unanticipated difficult airway, a common clinical problem encountered by all anesthesiologists, is probably the most important cause of major anesthesia‑related morbidity.[1] The American Society of Anesthesiologists published a difficult airway management algorithm more than a decade ago. Lately, devices such as intubating laryngeal mask airway (ILMA) and combi tube have also been included. Recently, we encountered a case of accidental extubation intraoperatively where ILMA proved to be a lifesaver. A 45‑year‑old adult male, ASA grade 1, chronic smoker, and tobacco chewer, was taken up for esophagoscopy for impacted piece of fish bone. His airway examination revealed mouth opening of hardly two fingers, Mallampati grading III with normal thyromental, sternomental distances and neck movements. All his preoperative investigations were within normal limits. He was taken up on operating table, all monitors were attached, an intravenous access was secured, and was nebulized with 4% xylocaine for fiberoptic intubation. Awake fiberoptic intubation (AFOI) was performed using “spray as u go” technique. After successful intubation, patient was given propofol and was paralyzed; anesthesia was maintained with O2, N2O, and sevoflurane. Surgery was started but the piece of bone was impacted in the upper end of esophagus and surgeons were having a difficult time trying to remove it. There was also inadvertent trauma
to the oral cavity associated with bleeding. Around 20 minutes after beginning of surgery, the surgeons accidently dislocated the endotracheal tube. The surgery was immediately stopped and mask ventilation started after oral suctioning. But now, fiberoptic intubation was impossible. Direct laryngoscopy now revealed a Cormack and Lehane grade IV view. Meanwhile, the patient developed severe bronchospasm and his SpO2 started falling to 85%. Immediately, injection deriphyllin and hydrocortisone were administered intravenously along with two puffs of salbutamol. Intubation using gum elastic bougie failed. Intubation was tried using ILMA which was successful only on third attempt. His bronchospasm finally resolved after aminophylline infusion. Surgery was again started and finished successfully after 20 minutes. Managing a difficult airway is a challenge even to an experienced anesthesiologist. Intraoperative accidental extubation in such cases, associated with severe bronchospasm, can be catastrophic. Though fiberoptic intubation is a boon for cases with anticipated difficult airway, it has a very high incidence of failure if there are secretions or blood in the oral cavity. In our case, though fiberoptic intubation was successful in the first attempt, it was not possible to reintubate the patient using the same technique with blood and edema in the oropharynx. The ILMA was designed to facilitate both extraglottic ventilation and tracheal intubation. There are several 139
Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
studies reporting that the ILMA is a remarkable device for failed or difficult intubation with no serious complications.[2] Joo et al. account ILMA as a useful device in the management of patients with difficult airways and as a valuable alternative to AFOI when AFOI is contraindicated or in the patient with the unanticipated difficult airway.[3] It has proved to be effective when used by experienced anesthesiologists in both in‑hospital and out‑of‑hospital settings[4] and is responsible for decreasing morbidity and mortality in many cases of difficult airway, as it proved to be a lifesaver in our case.
Letters
REFERENCES 1. 2. 3. 4.
Cheney FW, Weiskopf RB. The American Society of Anesthesiologists Closed Claims Project: What have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology 1999;91:552‑6. Moller F,Andres AH, Langenstein H. Intubating laryngeal mask airway (ILMA) seems to be an ideal device for blind intubation in case of immobile spine. Br J Anaesth 2000;85:493‑5. Joo HS, Kapoor S, Rose DK, Naik VN. The intubating laryngeal mask airway after induction of general anesthesia versus awake fiberoptic intubation in patients with difficult airways. Anesth Analg 2001;92:1342‑6. Timmermann A, Russo SG, Rosenblatt WH, Eich C, Barwing J, Roessler, M. et al. Intubating laryngeal mask airway for difficult out‑of‑hospital airway management: A prospective evaluation. Br J Anaesth 2007;99:286‑91.
Neha Baduni, Manoj K. Sanwal, Aruna Jain Department of Anesthesiology and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.114025
Quick Response Code
Correspondence author: Dr. Neha Baduni, Department of Anesthesiology and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E‑mail: [email protected]
A “cannot ventilate, cannot intubate” situation in a patient posted for emergency surgery for acute intestinal obstruction Sir, “Cannot ventilate, cannot intubate” (CVCI) situation is a nightmare for all clinicians who manage airways with an incidence of 0.01‑2 in 10 000 cases.[1] Despite marked improvement in airway management in the last decade, the continued existence of CVCI can possibly be attributed to lack of specificity and low predictive value of current techniques for predicting difficult airway.[2] The initial surgical airway includes standard open surgical cricothyrotomy, cricothyrotomy, and cannula‑over‑needle cricothyrotomy with or without jet ventilation with 100% oxygen.[3] A 55‑kg, 37‑year‑old man, a diagnosed case of acute intestinal obstruction, was scheduled for exploratory laparotomy. The patient was conscious, well oriented, and without any medical comorbidity. Airway examination revealed mouth opening of 4 cm, thyromental distance of 7 cm, full range of neck movements, and Mallampati grade was III. After premedication with inj. fentanyl (100 µg), inj. midazolam (2 mg), inj. ondansetron (4 mg), inj. hydrocortisone (100 mg), and inj. glycopyrrolate (0.2 mg), patient was preoxygenated with 100% oxygen. Induction 140
was with inj. thiopentone (250 mg) and paralysis with inj. succinylcholine (75 mg). Laryngoscopy attempt was taken with MacIntosh size 3 blade. First intubation attempt with size 8.0 tube was failed and according to laryngoscopist, it was Cormack and Lehane grade IIIb. Second attempt was taken inserting a malleable stylet inside the endotracheal tube, but the tube could not be passed below the epiglottis. At that time (7:30 pm), patient started desaturating and SpO2 reached 68%. Then, an Laryngeal Mask Airway (LMA) size 4 was placed but ventilation was still not achieved. The patient became progressively hypoxemic. The Laryngeal Mask Airway (LMA) was removed and needle cricothyrotomy was done with a 14 G needle attached to a saline‑filled syringe. Proper placement was confirmed by aspiration of air bubble. Then, the needle was attached to a 3‑ml syringe barrel to a 7.0 tracheal tube adapter to circuit. This enabled connection of the anesthesia circuit and the patient was manually ventilated. When spontaneous respiration was returned, needle cricothyrotomy unit was removed and patient was delivered 100% oxygen through bag and mask. Patient’s saturation finally reached 99% and settled. He regained consciousness, vocalized, and followed commands.
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
blood flow from the port of CVC is a must before using it for vasoactive drugs even if the mark at skin is unchanged. Importantly, a transparent dressing should be preferred allowing a quick check for any fluid leakage or ooze. Lastly, daily case notes should include a record of CVC mark at skin and check chest X‑ray is must to locate the inner part of CVC.
Letters
References 1. McGee DC, Goud MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123‑33. 2. Kapoor MC, Kumar S, Gourishanker R. Fluid infusion into the pericardium resulting from accidental displacement of a subclavian venous cannula. Ann Card Anaesth 2011;14:41‑4. 3. Czepizak CA, O’Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest 1995;107:1662‑4.
Tanmoy Ghatak, Arvind K. Baronia Department of Critical Care Medicine, SGPGIMS, Lucknow, Rai Bareilly Road, Lucknow. Uttar Pradesh, India
Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.114023
Quick Response Code
Corresponding author: Dr. Tanmoy Ghatak, Department of Critical Care Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India. E‑mail: [email protected]
Intubating laryngeal mask airway—A lifesaver during accidental intraoperative extubation in a case of difficult airway Sir, The unanticipated difficult airway, a common clinical problem encountered by all anesthesiologists, is probably the most important cause of major anesthesia‑related morbidity.[1] The American Society of Anesthesiologists published a difficult airway management algorithm more than a decade ago. Lately, devices such as intubating laryngeal mask airway (ILMA) and combi tube have also been included. Recently, we encountered a case of accidental extubation intraoperatively where ILMA proved to be a lifesaver. A 45‑year‑old adult male, ASA grade 1, chronic smoker, and tobacco chewer, was taken up for esophagoscopy for impacted piece of fish bone. His airway examination revealed mouth opening of hardly two fingers, Mallampati grading III with normal thyromental, sternomental distances and neck movements. All his preoperative investigations were within normal limits. He was taken up on operating table, all monitors were attached, an intravenous access was secured, and was nebulized with 4% xylocaine for fiberoptic intubation. Awake fiberoptic intubation (AFOI) was performed using “spray as u go” technique. After successful intubation, patient was given propofol and was paralyzed; anesthesia was maintained with O2, N2O, and sevoflurane. Surgery was started but the piece of bone was impacted in the upper end of esophagus and surgeons were having a difficult time trying to remove it. There was also inadvertent trauma
to the oral cavity associated with bleeding. Around 20 minutes after beginning of surgery, the surgeons accidently dislocated the endotracheal tube. The surgery was immediately stopped and mask ventilation started after oral suctioning. But now, fiberoptic intubation was impossible. Direct laryngoscopy now revealed a Cormack and Lehane grade IV view. Meanwhile, the patient developed severe bronchospasm and his SpO2 started falling to 85%. Immediately, injection deriphyllin and hydrocortisone were administered intravenously along with two puffs of salbutamol. Intubation using gum elastic bougie failed. Intubation was tried using ILMA which was successful only on third attempt. His bronchospasm finally resolved after aminophylline infusion. Surgery was again started and finished successfully after 20 minutes. Managing a difficult airway is a challenge even to an experienced anesthesiologist. Intraoperative accidental extubation in such cases, associated with severe bronchospasm, can be catastrophic. Though fiberoptic intubation is a boon for cases with anticipated difficult airway, it has a very high incidence of failure if there are secretions or blood in the oral cavity. In our case, though fiberoptic intubation was successful in the first attempt, it was not possible to reintubate the patient using the same technique with blood and edema in the oropharynx. The ILMA was designed to facilitate both extraglottic ventilation and tracheal intubation. There are several 139
Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
studies reporting that the ILMA is a remarkable device for failed or difficult intubation with no serious complications.[2] Joo et al. account ILMA as a useful device in the management of patients with difficult airways and as a valuable alternative to AFOI when AFOI is contraindicated or in the patient with the unanticipated difficult airway.[3] It has proved to be effective when used by experienced anesthesiologists in both in‑hospital and out‑of‑hospital settings[4] and is responsible for decreasing morbidity and mortality in many cases of difficult airway, as it proved to be a lifesaver in our case.
Letters
REFERENCES 1. 2. 3. 4.
Cheney FW, Weiskopf RB. The American Society of Anesthesiologists Closed Claims Project: What have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology 1999;91:552‑6. Moller F,Andres AH, Langenstein H. Intubating laryngeal mask airway (ILMA) seems to be an ideal device for blind intubation in case of immobile spine. Br J Anaesth 2000;85:493‑5. Joo HS, Kapoor S, Rose DK, Naik VN. The intubating laryngeal mask airway after induction of general anesthesia versus awake fiberoptic intubation in patients with difficult airways. Anesth Analg 2001;92:1342‑6. Timmermann A, Russo SG, Rosenblatt WH, Eich C, Barwing J, Roessler, M. et al. Intubating laryngeal mask airway for difficult out‑of‑hospital airway management: A prospective evaluation. Br J Anaesth 2007;99:286‑91.
Neha Baduni, Manoj K. Sanwal, Aruna Jain Department of Anesthesiology and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.114025
Quick Response Code
Correspondence author: Dr. Neha Baduni, Department of Anesthesiology and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E‑mail: [email protected]
A “cannot ventilate, cannot intubate” situation in a patient posted for emergency surgery for acute intestinal obstruction Sir, “Cannot ventilate, cannot intubate” (CVCI) situation is a nightmare for all clinicians who manage airways with an incidence of 0.01‑2 in 10 000 cases.[1] Despite marked improvement in airway management in the last decade, the continued existence of CVCI can possibly be attributed to lack of specificity and low predictive value of current techniques for predicting difficult airway.[2] The initial surgical airway includes standard open surgical cricothyrotomy, cricothyrotomy, and cannula‑over‑needle cricothyrotomy with or without jet ventilation with 100% oxygen.[3] A 55‑kg, 37‑year‑old man, a diagnosed case of acute intestinal obstruction, was scheduled for exploratory laparotomy. The patient was conscious, well oriented, and without any medical comorbidity. Airway examination revealed mouth opening of 4 cm, thyromental distance of 7 cm, full range of neck movements, and Mallampati grade was III. After premedication with inj. fentanyl (100 µg), inj. midazolam (2 mg), inj. ondansetron (4 mg), inj. hydrocortisone (100 mg), and inj. glycopyrrolate (0.2 mg), patient was preoxygenated with 100% oxygen. Induction 140
was with inj. thiopentone (250 mg) and paralysis with inj. succinylcholine (75 mg). Laryngoscopy attempt was taken with MacIntosh size 3 blade. First intubation attempt with size 8.0 tube was failed and according to laryngoscopist, it was Cormack and Lehane grade IIIb. Second attempt was taken inserting a malleable stylet inside the endotracheal tube, but the tube could not be passed below the epiglottis. At that time (7:30 pm), patient started desaturating and SpO2 reached 68%. Then, an Laryngeal Mask Airway (LMA) size 4 was placed but ventilation was still not achieved. The patient became progressively hypoxemic. The Laryngeal Mask Airway (LMA) was removed and needle cricothyrotomy was done with a 14 G needle attached to a saline‑filled syringe. Proper placement was confirmed by aspiration of air bubble. Then, the needle was attached to a 3‑ml syringe barrel to a 7.0 tracheal tube adapter to circuit. This enabled connection of the anesthesia circuit and the patient was manually ventilated. When spontaneous respiration was returned, needle cricothyrotomy unit was removed and patient was delivered 100% oxygen through bag and mask. Patient’s saturation finally reached 99% and settled. He regained consciousness, vocalized, and followed commands.
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
