LETTER TO EDITOR
Year : 2012 | Volume
: 28 | Issue : 3 | Page : 399--400
Anesthetic management of an unusual complication during laser ablation of congenital subglottic hemangioma
Arul Prakash J Pandian1, Kavita Sharma1, JS Dali1, Anju Bhalotra1, Raktima Anand1, Sathish Aggarwal2,
1 Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India
2 Department of Paediatric Sugery, Maulana Azad Medical College, New Delhi, India
Arul Prakash J Pandian
Room No. 415, Type 2 Quarters, Mirdard Lane, Maulana Azad Medical College, New Delhi - 110 002
|How to cite this article:|
Pandian AJ, Sharma K, Dali J S, Bhalotra A, Anand R, Aggarwal S. Anesthetic management of an unusual complication during laser ablation of congenital subglottic hemangioma.J Anaesthesiol Clin Pharmacol 2012;28:399-400
|How to cite this URL:|
Pandian AJ, Sharma K, Dali J S, Bhalotra A, Anand R, Aggarwal S. Anesthetic management of an unusual complication during laser ablation of congenital subglottic hemangioma. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2020 Jan 26 ];28:399-400
Available from: http://www.joacp.org/text.asp?2012/28/3/399/98363
A 3.8-kg, 4-month-old child presented with progressively increasing respiratory distress for 1 month. The child was delivered by normal vaginal delivery at term and had no respiratory problem at birth. The child was diagnosed to have subglottic hemangioma on bronchoscopy. The upper airway examination was normal, and there was no cutaneous hemangioma or any other associated anomaly. Arterial blood gas examination revealed: pH 7.38, pO 2 30.4, pCO 2 43.3 mm Hg, HCO 3 25, SO 2 56.2, and Hb 8.8 g/dl.
Emergency tracheostomy was done after local anesthetic infiltration, while assisting ventilation using a face mask and a dministering oxygen and sevoflurane. Post-anesthesia recovery was uneventful.
Echocardiography and computerized tomography scan head ruled out any associated cardiac or intracranial abnormality. Oral propranolol 3.5 mg and prednisolone 1 mg per day were started to decrease the size of the hemangioma.
A week later, the child was scheduled for laser ablation of the subglottic hemangioma. Oral prednisolone 1 mg was given in the morning. The patient was premedicated with intramuscular glycopyrrolate 0.04 mg. Anesthesia was induced with sevoflurane 8% in oxygen. Intravenous access was secured, following which fentanyl 8 mcg and atracurium 2 mg were given. Anesthesia was maintained with oxygen, isoflurane 1-1.5%, and atracurium. Using a rigid bronchoscope, a small wet gauze pack was placed distal to the hemangioma, so as to completely occlude the tracheal lumen above the tracheostomy tube. Ventilation was discontinued during the intermittent episodes of laser ablation. When the mass was completely ablated, the lungs could not be ventilated. Rigid bronchoscopy revealed the subglottic pack obstructing the tracheal lumen at the level of carina, which was removed. Adequate ventilation could be resumed immediately. The child remained hemodynamically stable, and no episode of oxygen desaturation occurred during the procedure, which lasted for 130 min. Postoperatively, the child was given supplemental oxygen, paracetamol suppository for analgesia, and dexamethasone 0.24 mg for reducing edema and nausea.
Congenital subglottic hemangioma is a rare but potentially life-threatening condition which may compromise the airway. Laser ablation is one of the modalities of treatment.  Ignition of the endotracheal and tracheostomy tubes during surgery has been reported. 
Self-adhesive, non-reflective aluminum tape may be used to protect endotracheal tubes,  but it increases the outer diameter of the tube, compelling the use of smaller inner diameter tubes. Laser-resistant tracheostomy tubes are not available. We used a wet gauze pack which prevented the leak of anesthetic gases into the subglottic area and prevented aspiration of blood, fumes, and debris from the surgical site.
The pack can migrate distally and cause airway obstruction, as it happened in our case. The migration of pack may be prevented by tying a thread to the pack and taping it on the cheek.
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|2||Wang HM, Lee KW, Tsai CJ, Lu IC, Kuo WR. Tracheostomy tube ignition during microlaryngeal surgery using diode laser: A case report. Kaohsiung J Med Sci 2006;22:199-202.|
|3||Walker P, Temperley A, Thelfo S, Hazelgrove A. Avoidance of laser ignition of endotracheal tubes by wrapping in aluminium foil tape. Anaesth Intensive Care 2004;32:108-12.|