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LETTER TO EDITOR
Year : 2013  |  Volume : 29  |  Issue : 4  |  Page : 558-560

Airway management plan in patients with difficult airways having regional anesthesia


Department of Anaesthetics, Royal Glamorgan Hospital, Cwm Taf Local Health Board, Llantrisant, United Kingdom

Date of Web Publication1-Oct-2013

Correspondence Address:
Neeraj Saxena
Department of Anaesthetics, Royal Glamorgan Hospital, Cwm Taf Local Health Board, Llantrisant CF72 8XR, Mid-Glamorgan, Wales
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.119106

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How to cite this article:
Saxena N. Airway management plan in patients with difficult airways having regional anesthesia. J Anaesthesiol Clin Pharmacol 2013;29:558-60

How to cite this URL:
Saxena N. Airway management plan in patients with difficult airways having regional anesthesia. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2019 Apr 20];29:558-60. Available from: http://www.joacp.org/text.asp?2013/29/4/558/119106

Sir,

Regional anesthesia (RA) is recommended in patients with potentially "difficult airways" who present for surgery. [1] While advantageous in its own right, in areas such as obstetrics, [2],[3] regional techniques help avoid airway difficulty. However, although a successful RA may help avoid the need to directly manage a difficult airway, it does not always prevent it. In such RA techniques, there may be situations, for example, hemorrhage, high/total spinal block, anaphylaxis, failure of regional block, or surgical mishaps necessitating conversion of the RA to a general anesthetic (GA). Although uncommon, such conversions maybe required urgently and may trap an unprepared anesthetist off-guard. Two cases are presented here that highlight the importance of having a definitive airway management plan in patients even if there is a high chance of successful RA.

A 26-year-old primigravida presented at 38-week gestation for an urgent cesarean section delivery due to fetal bradycardia. She had no significant medical or obstetric history and had never received an anesthetic prior to this. On examination of her airway, she had prominent, loose incisors, a prominent over-bite, a high-arched palate, and a Mallampati Class IV visibility of oro-pharyngeal structures. Balancing the risks of the urgency of the surgery with those of a potentially difficult airway, a spinal anesthetic was offered to the patient who consented for the procedure. After a standard spinal anesthetic using hyperbaric bupivacaine (2.2 ml, 0.5%) and fentanyl (20 μg), surgery was started and a live male baby with Apgar scores of 9 and 10 (1 min and 5 min) was delivered. During uterine closure, the obstetrician noticed that the patient's left ureter had been injured during dissection. The on-call urologist was called in and preparations were made for diagnostic dye instillation and ureteric repair. More than an hour had passed since the spinal anesthetic and the patient started complaining of discomfort. The block height (to cold) had receded to about T7-8 dermatomal level. As the procedure would have taken more time, following a discussion with the surgeons and the patient, a GA was planned. Molar sodium citrate was administered. Preoxygenation for 5 min was followed by a rapid sequence induction using thiopental 250 mg and succinylcholine 100 mg with cricoid pressure. Laryngoscopic attempts failed to reveal any glottic structures (Cormack Lehane grade 4 view). Oxygenation was maintained using a face mask and gentle mask ventilation, while senior help was called for. The senior anesthesiologist attempted laryngoscopy with standard Macintosh and Mc Coy blades without any success. Blind bougie-assisted intubation was not attempted. Patient's spontaneous respiration returned, and, considering the futility of any further attempts at laryngoscopy, a size 3 ProSeal TM LMA was inserted. Anesthesia was continued with isoflurane and morphine was given for analgesia. A gastric tube was inserted via the drain tube, and 300 mL of clear fluid was removed from the stomach. The procedure lasted for another hour, and, at the end of surgery, as the patient regained consciousness, she spat the LMA out. On postoperative questioning, she had no recall of airway manipulation and, on examination, the motor block had completely recovered.

An 82-year-old man presented with a hip fracture and was anesthetized for a hemiarthroplasty. His background problems included controlled hypertension and mild ischemic heart disease. He was also undergoing regular tracheal dilatations for tracheal stenosis (CT scan showing the diameter of the narrowest part to be just under 7 mm) and was awaiting definitive treatment for that, but previous notes were not available at hand. External airway assessment was unremarkable except that the patient was edentulous. Spinal anesthetic was performed uneventfully. The surgery was technically difficult, and, 2 h into the surgery, there was a surgical complication and the implanted prosthesis broke. More senior orthopedic help had to be called in. This extended the duration of the surgery and the spinal anesthetic starting wearing off with early recovery of sensations in the operative area. The patient was informed about the need for a GA and the anticipated difficulty in view of the narrowed trachea. Inhalational induction, following intravenous fentanyl, was performed using stepwise increment of sevoflurane. Mask ventilation was confirmed to be easy. The plan was to maintain spontaneous ventilation at all stages to avoid any dynamic loss of tracheal tone complicating the tracheal stenosis. A classic LMA was inserted, but resulted in an inadequate seal and partial airway obstruction. When all attempts at LMA positioning failed, it was decided to intubate the trachea under vision with an appropriate-sized endotracheal tube. The vocal cords were sprayed with 4% lignocaine under direct laryngoscopic view while still anesthetized with sevoflurane. Fiberoptic bronchoscope was used to visualize the tracheal narrowing, bypass it and then railroad a size 5 endotracheal tube over the scope beyond the narrowing. Once trachea was intubated, cisatracurium was given, and mechanical ventilation was commenced. Surgery lasted for another 45 min, following which, the trachea was extubated in a deep anesthetic plane after return of adequate spontaneous respiration. The postoperative course was uneventful.

A spinal anesthetic, if not contraindicated, is our routine anesthetic for surgeries in these two cases. Techniques of prolonging regional blocks such as combined spinal and epidural (CSE) (over single shot spinal ) or other catheter techniques have been advocated in cases where the duration of procedure is uncertain. Both these cases could have been managed with an epidural alone or a CSE, thus allowing continued management of the complications. A successful spinal component of a CSE, however, does not guarantee a successful epidural as well. [4] It may be argued that considering a fetal emergency as a spinal anesthetic was the correct choice in the first case as it would have saved the additional time taken to place an epidural catheter of a CSE. In the second case, a CSE would have offered more assurance. Therefore, it is prudent to consider catheter techniques in all complicated cases where a general anesthesia is best avoided. Both the cases were successfully managed due to the presence of a backup airway management plan.

These cases reiterate the notion that, although a regional anesthetic technique helps avoid a difficult airway situation, it does not 'manage' the problem, and so an airway management plan should always be discussed with the patient and planned in advance.

 
  References Top

1.American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269-77.1.  Back to cited text no. 1
    
2.Khor LJ, Jeskins G, Cooper GM, Paterson-Brown S. National obstetric anaesthetic practice in the UK 1997/1998. Anaesthesia 2000;55:1168-72.2.  Back to cited text no. 2
    
3.Ngan Kee WD. Confidential enquiries into maternal deaths: 50 years of closing the loop. Br J Anaesth 2005;94:413-6.3.  Back to cited text no. 3
    
4.Cook TM. Combined spinal-epidural techniques. Anaesthesia 2000;55:42-64.  Back to cited text no. 4
    




 

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