Journal of Anaesthesiology Clinical Pharmacology

LETTER TO EDITOR
Year
: 2015  |  Volume : 31  |  Issue : 3  |  Page : 429--430

What to do when your surgeon cuts off the patients' oxygen supply?


Uma Hariharan1, Anita Kulkarni2, Amit Kumar Mittal2,  
1 Department of Anaesthesia and Oncosurgical Intensive Care, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, New Delhi, India
2 Department of Anesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, New Delhi, India

Correspondence Address:
PGDHM Uma Hariharan
BH-41, East Shalimar Bagh, New Delhi - 110 088
India




How to cite this article:
Hariharan U, Kulkarni A, Mittal AK. What to do when your surgeon cuts off the patients' oxygen supply?.J Anaesthesiol Clin Pharmacol 2015;31:429-430


How to cite this URL:
Hariharan U, Kulkarni A, Mittal AK. What to do when your surgeon cuts off the patients' oxygen supply?. J Anaesthesiol Clin Pharmacol [serial online] 2015 [cited 2020 Oct 28 ];31:429-430
Available from: https://www.joacp.org/text.asp?2015/31/3/429/161747


Full Text

Sir,

A 38-year-old, American Society of Anesthesiologists (ASA) grade 1 male patient was posted for elective composite resection, radical neck dissection and plastic reconstruction for invasive carcinoma of the right buccal mucosa (gingivo-buccal sulcus). On preoperative evaluation, he had no mouth opening, trismus and normal neck movements. As per standard ASA guidelines, awake fiber-optic intubation (FOB) was planned after upper airway anesthesia (superior laryngeal nerve block, trans-tracheal block and lignocaine nebulization). After nasal preparation and mild intravenous sedation, a normal 7 mm cuffed endotracheal tube (ETT) was inserted through the right nostril (more patent), guided by the FOB and the ETT was passed into trachea under vision. Standard general anesthesia with muscle relaxant was given after confirming bilateral air entry and capnography. During the surgery, radical wide local excision of the malignant lesion and the adjacent area was done, followed by partial resection of the involved right mandible using micro-motor instrument (motorized bone cutter). At this point, suddenly there was an alarm of circuit leak, drop in airway pressure and inability to attain adequate tidal volume by the ventilator. Immediately, 100% oxygen was given. ETT cuff was checked and found to be deflated. Manual ventilation was attempted, which caused bubbling at the surgical site. The surgeons were asked to stop their procedure and clear the area of collected blood. A transverse cut of the oral part of the ETT, around 10 cm above the cuff area was noted along with midway cutting of the pilot line (cuff inflation line) [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

Immediate preparations were done to change this partially transected tube. A lubricated gum elastic bougie was inserted through the existing nasal tube after approximating its partial cut ends. Under all sterile conditions, direct laryngoscope was used to move away the tongue and the surgeons asked to manually lift the overlying tissue and suction the field. The transected tube was removed over the bougie, and a fresh cuffed 7 mm ETT was successfully railroaded over the bougie into the trachea and cuff inflated. After confirming correct tube placement, the ETT was connected to the ventilator and the nasal tube fixed again. During this entire episode, the patient maintained his vitals and saturation within normal limits. The rest of the perioperative period was uneventful. After plastic reconstruction of the defect created by the primary radical surgery, neuromuscular blockade was reversed, but the trachea was not extubated. The ETT was retained for 24 h and oxygen was given via T-piece in the postoperative intensive care unit. The trachea was extubated later over a tube exchanger device.

This case highlights the fact that eternal vigilance is the key to identify and manage such catastrophic events. Emergency airway management in such cases of the difficult airway (D.A) can be quite challenging. Adequate preparedness, quick recognition and a ready D.A cart [1] are important for prompt action in such cases of loss of airway. Our case is unique in that the tube was partially transected by the leading sharp edge of the bone-cutting instrument. Three-quarters of the circumference of the tube were cut transversely, with transient manual ventilation possible with the cut ends approximated. The pilot line was also cut completely along with the ETT, resulting in cuff deflation. Gum elastic bougie [2] is a readily available device for use in D.A scenarios. This was already a case of D.A where awake-FOB was done (as per ASA guidelines) to secure the airway initially. [3] Extubation was also done cautiously over a tube exchanger device. [4] This case also sends a message to our surgeons to be utmost careful about the ETT, especially in head and neck surgeries, where anesthesiologists have to share the airway with them.

References

1Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. 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 2013;118:251-70.
2Dogra S, Falconer R, Latto IP. Successful difficult intubation. Tracheal tube placement over a gum-elastic bougie. Anaesthesia 1990;45:774-6.
3Stackhouse RA. Fiberoptic airway management. Anesthesiol Clin North America 2002;20:933-51.
4Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially difficult extubation: A case report. AANA J 2002;70:275-8.