Securing Airways for Mandibular Malformation Patient

Abstract

In 2011 National Audit Project in United Kingdom reported approximately 40% of all difficulties in airway management cases were associated with head, neck pathologies.1 Out of all anticipated difficult intubations only 25% turn out to be difficult. Likewise, difficult mask ventilation occurs only in 22% out of all expected. When difficult intubation is anticipated only 25% are, likewise when difficult mask ventilation is anticipated, it occurred in 22%.2 There are Difficult Airway Society’s guidelines that can be followed. Ethical approval from relatives was received verbally. A case report of 83 y.o. patient, female, 50 kg, 160 cm. Hospitalized on 27/01/2019 in the hospital of Traumatology and Orthopaedics in Riga, Latvia due to household trauma (24/01). Physical examination: GCS 13 (E4V4M5), no mandibular bone on the right side affecting the speech, Mallampati I, El Ganzouri index high risk. Patient confused, uncompliant and no full medical history can be gathered from relatives. In anamnesis unspecified carcinoma in os mandibula (2016, 2018), gallbladder, small intestine operations. Initial diagnosis: secondary right upper limb fracture with dislocation at proximal os humerus level. With consent from relatives a planned osteosynthesis is performed (30/01). Prior surgery plexus brachialis block was used for perioperative analgesia, Diazepam 2mg i/v was given. The first choice was to intubate with video laryngoscope, difficult airway trolley nearby with possibility to use supraglottic airway device or other techniques. Before induction: HR 110x min, BP 105/55 mmHg, SpO2 100%. Patient received 2% sevoflurane in 100% oxygen 6L/min initially for a minute and inspired concentration was increased to 6% until loss of consciousness, then reduced back to 2%, using tight face mask with oropharyngeal tube Nr.3. As a result, during spontaneous ventilation S.Phentanyli 0.1mg was given and intubation succeeded with GlideScope on second attempt, ET 6.5 (picture Nr.1). Fresh gas flow reduced to 2.5 L/min (1.9L/min air, 0.6L/min oxygen) with Sevoflurane 1%. During surgery additional S.Phentanyl 0.05mg was used. To maintain MAP 60-65mmHg used S.Noradrenaline 0.04-0.12 mg infusion. Prior extubating 100% oxygen for four minutes, with spontaneous ventilation patient was extubated. In five minutes, patient started to desaturate, therefore additional oxygen in non-rebreather mask was used with 6L/min oxygen, transferred for observation to ICU. In conclusion, proper preoperative assessment can reduce the risk of unanticipated difficult airways as in this case and allows for timely preparation of necessary equipment. [Formula presented] Picture Nr.1 Patient pre and post intubation, personal archive Financial support, conflicts of interest: none. References [1] Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106:617-631. [2] Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015;70(3):272–81