Chapter 15

Swine Flu in Pregnancy

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

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Anaemia-or-Hydrocele

A 34-year-old, primiparous woman at 37 weeks’ gestation, well-built weighing 84 kg was brought to the outpatient department for consultation. She complained of cough, cold and fever for the past 4 days. No history of any comorbidity in the past. Pregnancy had been normal so far.

Clinical examination showed PR-130 beats/min, BP-90/60, tachypnoea with a RR of 30 breaths/min. Auscultation revealed bilateral crepitations. She began feeling giddy and suddenly became unconscious even while being examined. Immediately she was turned to the left lateral position and vitals were reassessed. Pulse was feeble and BP was 80/50.

An IV line was started and fluids were administered, but she was drowsy and not responding to commands. Due to persistent low level of consciousness, she was shifted to the ICU and intubated in controlled environment for ventilatory support and further management. A Dopamine infusion was started. CTG showed foetal bradycardia. These were unexpected turn of events. The family was counselled and she was immediately taken up for an emergency LSCS.

Since the patient was already intubated, Fentanyl 70 microgram and Succinylcholine 100 mg were administered for surgical relaxation. Anaesthesia was maintained with Oxygen / Nitrous Oxide, and 0.2

% Isoflurane as her level of consciousness could not be assessed.

The baby had to be intubated by the paediatrician as the Apgar score was only 4 and was shifted to the NICU. At the end of surgery, she continued to be unconscious, without any respiratory effort. Pulse rate=120 beats/min, and saturation was 95% with 100% oxygen. BP was 100/60 with Dopamine support. She was shifted to the ICU with the endotracheal tube in-situ for elective ventilation.

A post-operative x-ray revealed extensive bilateral infiltrates and haziness in all areas corresponding to ARDS. Cultures of the endotracheal tube, blood and urine were sent along with all the basic investigations. Infections like malaria, dengue, leptospirosis and swine flu were investigated for. Broad spectrum antibiotics were started.

She was mechanically ventilated as there was no improvement in her condition. She required pressor support with noradrenaline and Dopamine. Eventually she tested positive for swine flu. Her ARDS worsened. Urine output began to drop, Urea-147, Creatinine-8.9. She developed multi organ failure. In spite of all resuscitative efforts, she suffered a cardiac arrest on the 7th day and could not be revived. Her baby was doing well and got discharged.

Discussion

Administering anaesthesia for an unconscious, already decompensated patient is difficult. The outcome of surgery or the prognosis of such a patient cannot be predicted. But we should try our best to maintain haemodynamics and cardiorespiratory status and strive not to worsen the condition. Anaesthesia in presence of fever and infection is challenging especially if it has not been diagnosed yet, even more so in a pregnant patient with altered physiology. Attention has to be paid to perfusion of every organ system, as we may not be aware of what complication to expect.

Also, since the source of the infection is not identified, we should take all safety measures to protect ourselves. Double gloves, aprons and eye protection should be used. Blood and blood products should be handled carefully. The theatre should be fumigated post-surgery before allowing any other procedure.

While managing a critically ill pregnant patient where chances of survival may be grim, it is all the more important to explain the situation to relatives. It may be very difficult for the relatives to accept, and they may be in state of denial. However, counselling them every few hours with update of the patient status is necessary. Time may be a constraining factor, still efforts must be taken.

When there is a critically ill obstetric patient the following should be quickly reviewed:

1. Conditions related to pregnancy – eclampsia, severe pre-eclampsia, haemorrhage, amniotic fluid embolus, acute fatty liver, peri partum cardiomyopathy, aspiration syndromes, and infections

2. Medical diseases that may be aggravated due to pregnancy – congenital heart diseases, rheumatic and non-rheumatic valvular diseases, pulmonary hypertension, anaemia, renal failure etc.

3. Conditions that are not related to pregnancy – sepsis, trauma, asthma, diabetes, autoimmune diseases

In a critically ill pregnant patient, it is important to understand that mother is the priority. Delivery of the baby in the decompensating mother must be done alongside resuscitation as pregnancy worsens her condition. Some of the illnesses may take a very rapid course with no response to treatment.

Perimortem caesarean section is an important topic that is being discussed in recent obstetric anaesthesia meetings.

References

  1. Trikha A, Singh PM. The critically ill obstetric patient – Recent concepts Indian J Anaesth. 2010;54(5):421–7.
  2. Shanker N, Aneja S, Jayalalitha MV, et al. Perioperative management of a parturient for caesarean section with confirmed H1N1 influenza. J Obst Anaesth Crit Care 2013; 3(2).

There is no failure…. It is an experience… to enhance future performance.

 

Chapter 16

Table modified to accommodate a Neck Lipoma

 

neck

Case 1

An 80-year-old man presented with a huge mass in the nape of the neck. He had been having the lesion for over 30 years, slowly increasing in size. There was an ischemic ulcer at the tip which had started bleeding, and that brought him to the hospital. The mass was measuring 10 inches x 12 inches. It was diagnosed as a lipoma with ischemic ulcer due to the stretch of the skin. The mass was as big as his head. Considering the size of the swelling, it was planned to take him up under general anaesthesia. He had no other known comorbidities and not on any drugs. He was maintaining himself in lateral position only.

Challenges in this patient were:

  1. Geriatric patient with restricted neck movement and associated complications.
  2. Positioning the patient was a major concern: he was unable to lie flat, and neck extension was not possible.
  3. Airway problems particularly Intubation
  4. Risk of malignancy, due to age and bleeding

The plan was to modify the operating table to enable positioning of the head and neck, so that intubation was possible. The head end of the table was removed and replaced with a horse shoe attachment that is used in neuro surgery. The patient was made to lie in such a way that the swelling passed through the centre of the horse shoe and he could lie supine. Difficult airway trolley was made available.

Anaesthesia was induced slowly and carefully titrated. Bag mask ventilation was confirmed and then muscle relaxant was administered. Intubation was successful in the first attempt using Macintosh size 4.0 blade. Flexo-metallic endotracheal tube size 8.0 was used and secured well. He was then repositioned into the prone position. Pressure areas were protected. Surgery lasted about 3 hours. He required 3 units of packed cells. Fluids were titrated appropriately. Recovery was uneventful.

Case 2: Position of patient modified to enable intubation.

A 45-year-old man was posted for excision of a huge lipoma on the nape of his neck. The lipoma had been present for over 5 years, but now he developed pressure symptoms and pain. He found it difficult to lie down supine. The mass measured 8 x 10 inches, it restricted his neck extension. Examination revealed an obvious airway difficulty. His neck was flexed from the weight of the lipoma and there was no neck movement. In addition, he had 2 dentures in place of his upper incisors.

Airway management was the challenge as he was to be operated under general anaesthesia. The plan was to perform an awake intubation in the sitting position, from the front of the patient with a video laryngoscopy commonly used by ENT surgeons for direct laryngoscopy.

Patient was prepared with mild sedation using Dexmedetomidine. Upper airway was adequately anaesthetized with Lignocaine 10% spray, glossopharyngeal and superior laryngeal nerve block. In the sitting position, under standard monitoring, oxygen was administered through nasal prongs at 4 litres/min, Direct video laryngoscope was used to visualize the larynx.

With the video laryngoscope, the larynx could be visualised. ENT surgeon held the tongue forward, and it was possible to intubate the trachea successfully. A flexo-metallic 7.5 cuffed endo tracheal tube was used. After ensuring the position of the tube with end tidal capnography trace, anaesthesia was induced with Propofol and atracurium the cuff was then inflated. Surgery was completed in two hours and recovery was uneventful.

(whenever awake intubation is done, the cuff should be inflated only after administering muscle relaxant, or the patient may have a violent cough reflex, and this will lead to very high airway pressures) This was the first and only time, intubation, facing the patient, in the sitting position has been attempted by me.

Fibre optic scope was not available and hence other techniques had to be applied. It was also informed that if intubation was not feasible he would be referred to a higher centre where FOB was available. Blind nasal intubation would have also been difficult as there was no movement in the neck. LMA may not be the right choice as the procedure had to be done in the prone position. We wanted to try something new. Steps of the plan were thought through efficiently and applied in a strategic manner to ensure success at first attempt. Repeated manoeuvres make it very inconvenient for the patient and frustrating for the scopist, resulting in unsuccessful attempts and loss of airway specially if excess sedation is also given. Hence the plan A becomes important! Also, it is important to have a fall-back plan

B. It must be noted that a definitive tracheostomy may be impossible in cases with mass in front or back of the neck.

This was a surgery done before the introduction if all the modern airway gadgets. It may still be relevant in today’s practice in certain centres!

Discussion

Appropriate thought process and certain degree of innovation is required in special cases to make life easy for patient, anaesthetist and surgeon for efficient anaesthetic management of a difficult scenario.

Various case reports of loss of airway and catastrophic situations have been reported due to inappropriate positioning and inadequate planning in that perspective. This case highlights the importance of such preplanning to ensure safety and efficiency.

In addition to positioning, concerns here are the anatomical and pathophysiological changes in airway and neck in an elderly patient.

  1. Stiff neck due to osteoarthritis, leading to limited range of neck movement
  2. Tooth decay, edentulous, loss/atrophy of airway muscles leading to loss of normal airway contour. Bag mask ventilation may be difficult.
  3. Common pulmonary issues in elderly like COPD and obstructive sleep apnoea
  4. Reduced oxygen reserve capacity leading to early desaturation, hence quick control of airway and constant vigilance in prone position in essential.
  5. Achalasia and gastrointestinal reflux disease increase the risk of aspiration. When rapid sequence intubation is applied, drugs to obtund hemodynamic stress response are essential. At the same time, hemodynamic stability must be maintained.
  6. Cognitive changes related to age are associated with increased risk of airway problems in the postoperative period, this must be borne in mind.

Several modified positions have been reported in literature in difficult cases.

  1. Ramped up/head elevated position for morbidly obese patients
  2. Sniffing position is described as classical ‘win with the chin’ position. New jaw elevating device has been described in the west causing guarded forced extension of the mandible to optimize mouth opening
  3. Beach chair/sitting position helps prevention of airway collapse, helpful in obese patient, useful technique for fibre optic intubation

Availability of adequate support staff and equipment with team understanding and cooperation makes the process successful.

The whole team including the patient was extremely receptive in this case.

 

References

  1. Johnson KN, Botros DB, Groban L, et al. Anatomical and pathophysiological changes affecting the airway of the elderly patient: implications for geriatric focused airway management. Clin Interv Aging 2015;10:1925-34.
  2. Frank C, Heyland DK, Chen B, et al. Determining resuscitation preferences of elderly inpatients: a review of the literature. CMAJ 2003;169:795.
  3. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000;92:1229.
  4. Cattano D. Airway management and patient positioning: A clinical perspective. Anesthesiology news guide to airway management 2010.
  5. Takenaka I, Aoyama K, Iwagaki T, et al. Approach combining the airway scope and the bougie for minimizing movement of the cervical spine during endotracheal intubation. Anesthesiology 2009;110(6):1335-40.

 

 

Innovation – keeping in mind the safety of the patient is exciting and rewarding.

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