Mr Abdul Samath, 61 years gentleman, came to emergency department. He sustained injury over his right shoulder and complained of shoulder & neck pain. X Ray of right shoulder revealed communited fracture of right shaft of Humerus and accompanied C4 osteophyte fracture.
Diabetes mellitus * 10 years on oha
Hypertension * 10 yrs on tablet metoprolol and tab.losartan
Obesity: weight (109 kg) BMI = 32.85
Haemoglobin = 11.2 mg/dl .other labs =wnl.
Ecg = normal sinus rhythm
Echo = normal lvef =62% ,no regional motion wall abnormality
MRI cervical spine = fracture of bridging osteophyte at lower aspect of C4 .
Cardiology opinion and neurosurgeon opinion obtained.
On hard cervical collar.
Neck movements restricted. Mouth opening adequate.
Mallampati grade =3
Short neck
Dentition = normal, no artificial dentures.
The patient was shifted to operating table. As per ASA guidelines, ECG, BLOOD PRESSURE, SPO2,ETCO2 monitors are attached to the patient. 18 gauge i.v cannula placed in left forearm and connected to crystalloids.
Patient positioned in RAMP position to align oropharyngolaryngo axis. Anaesthesia machines and circuits were checked for leak and malfunction- induction baseline vitals were recorded. Antibiotic was given.
Pre oxygenated with 100% oxygen through appropriate tight-fitting mask for 3 minutes to fill up the functional residual capacity. The patient was induced with fentanyl 2 mcg/kg and Propofol 2 mg/kg. Oropharyngeal airway was inserted & bag and mask ventilation initiated. Injection Succinylcholine 2mg/ kg i.v was given. After 45 secs, intubation was attempted using video laryngoscope. MILS was followed. Glottis could not be visualized (Cormack – Lehane grade 4b) Again bag and mask ventilation initiated.
The 2nd attempt was done by senior consultant using video laryngoscope with MILS. only posterior arytenoids were seen (Cormack Lehane grade 4b) Bougie assisted intubation was done using 7.5 cm ID CETT. Etco2 trace was recorded and bilateral air entry was confirmed. Cisatracurium 0.3 mg/kg was given and connected to ventilator. Suddenly, the patient had desaturation and etco2 waveform started to fade and bilateral air entry reduced due to inadvertent slippage of endotracheal tube from position.
The ET tube was removed and bag and mask ventilation was initiated with 100%oxygen. Ventilation was difficult despite oropharyngeal airway. Saturation did not improve, so Laryngeal mask airway was inserted. Saturation gradually improved to 95%.
3rd attempt was made to reintubate using video laryngoscope, but this time, the oropharynx was fully filled with bloody secretions and laryngeal inlet was edematous, could not visualize the structures clearly. Meanwhile again patient started to desaturate and had bradycardia- so intubation was withheld. Inj. Hydrocortisone 200 mg iv stat was given. After thorough oropharyngeal suctioning, laryngeal mask airway was re -inserted & ventilated. This time the saturation picked up to 93% & couldn’t take it further anymore. So, surgery was deferred. Patient was ventilated for another 20mins until he regained spontaneous respiratory effort. Later he was reversed with inj. Myopyrolate slow iv. After he regained consciousness, responded to oral commands & had regular adequate spontaneous breathing effort, patient was extubated and connected to non-invasive ventilation in view of obesity, cervical spine injury & short neck.
Then, the patient was shifted to ICU with NIV support and observed there for a day. The patient’s condition, need for fob intubation on a later date was well explained to patient’s attender in detail. Patient was put on nasal prongs after a couple of hours & was saturating well. Patient was observed in ICU & then sent to ward the next day. After 2 days, patient was posted for procedure. Airway block & Awake FOB intubation was well explained to patient.
On the scheduled day, patient was premedicated with inj. pantoprazole 40 mg, inj. themiset 75 mg & injection glycopyrrolate 0.2 mg iv, then shifted to operation room & monitors were connected. Under mild sedation using inj. Midazolam 0.5 mg and inj. fentanyl 30 mcg, cervical collar was removed and airway block was given . Patient was adequately preoxygenated with nasal mask for 5 mins before attempting FOB intubation. Using fibre optic bronchoscope patient was successfully intubated. After visualizing carina & checking etco2 waveform, patient was induced with injection fentanyl 2mcg/ kg, injection propofol 2mg/ kg & injection Cisatracurium 0.3 mg/ kg.
Under ultrasound guidance, right Interscalene block with 0.375 % ropivacaine 18 ml was given.
Patient was positioned in beach chair position for surgery. Intraoperative was uneventful. Patient was safely extubated and shifted to ICU. Postoperatively he was treated with injection paracetamol, inj clexane 0.6 mg s/c for dvt prophylaxis and i.v antibiotics. The next day, patient was shifted to ward.
Patients with cervical spine injury where there is very minimal or nil cervical extension, Fibreoptic bronchoscope offers a great help in intubation. Awake intubation not only requires knowledge & skill but also a calm and composed patient. Explaining the procedure in detail helps in getting the confidence from the patient & making them feel safe.
Dr. Hemalatha Iyanar Consultant Anaesthesiologist Kauvery Hospital, Chennai.
Dr. B. Varalakshmy DNB registrar Dept of Anesthesiology
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