difficult airway CASE management

Transcription

1 difficult airway CASE management DEPT. OF ANAESTHESIA Dr. SUPRIYA PUSAPATI ANAESTHESIA PG 2 ND YR

2 In a case of Cervical spine fracture and myelopathy

3 CASE PRESENTATION A 60yr male presented with complaints of weakness of both upper and lower limbs since one and a half month following H/O fall from height ( 1 st floor) The pt. was diagnosed a case of cervical myelopathy with # C5 vertebra. He was posted for C3 C4, C5 C6 laminectomy and lateral mass pedicle screw fixation.

4 PRE ANAESTHETIC ASSESSMENT ( ) HISTORY 60yr male, non vyshya, with H/O asthma since 10yrs ( on rotahaler) No H/O diabetes, hypertension, tuberculosis, epilepsy, jaundice. Chronic alcoholic since 20 yrs

5 Following fall from height No H/O loss of consciousness ENT bleed vomitings seizures Past history no H/O surgeries in the past. Family history not significant.

6 General examination Pt. was conscious, coherent and well oriented. O/E: moderately built and nourished pallor no cyanosis no icterus no clubbing no lymphadenopathy no pedal oedema no

7 VITALS TEMP= 98.4*F H.R= 66 beats/min B.P= 130/90 mm Hg Spo2= 98 % on room air R.R= 18/min

8 AIRWAY ASSESSMENT Nose: B/L patent nares Nasal cavity: S shaped DNS Mouth opening adequate (3 fingers) Oral cavity no abscess, growth or tumors Teeth lower 2 premolars missing and 1 loose left upper canine No short neck (contd )

9 TMJ movement: normal Cervical spine movement: restricted flexion, extension 10 degrees Mallampatti grade: grade III Thyromental distance: 6cm Trachea: midline Spine: no kyphoscoliosis

10 SYSTEMIC EXAMINATION BREATH HOLDING TIME: 20 secs RESPIRATORY SYSTEM Inspection: trachea central in position B/L chest movements equal Palpation: adequate chest expansion no asymmetry Percussion: normal resonant note Auscultation: B/L airentry +. vesicular breath sounds + all over chest

11 CARDIOVASCULAR SYSTEM: PULSE: rate 66/min, regular rhythm, adequate volume. B.P: 130/90 mm Hg S1, S2 heard. No murmurs. no pulse deficits, delays.

12 CENTRAL NERVOUS SYSTEM: HIGHER MENTAL FUNCTION: normal. SENSORY: decreased over upper limbs MOTOR: POWER: UPPER LIMB: 3/5 ELBOW AND HAND GRIP bilaterally LOWER LIMB: 2/5 KNEE AND ANKLE bilaterally

13 REFLEXES : DEEP TENDON REFLEXES: UPPER LIMB: BICEPS AND TRICEPS ++ LOWER LIMB: EXAGGERATED SUPERFICIAL REFLEXES: PLANTAR: dorsiflexion of great toe and fanning of other toes. AUTONOMIC NERVOUS SYSTEM: bladder and bowel incontinence +

14 INVESTIGATIONS ROUTINE: Hb%= 13.5 gm% blood urea= 36mg/dl platelets=4.15 lks/mm3 sr. creatinine=0.9mg/dl BT= 2min LFTs CT= 3min TB: 1.78 mg/dl RBS= 94mg/dl DB: 0.41mg/dl blood group= B+ve liver enzymes : WNL

15 SPECIAL: CXR ( AP view) = WNL Xray cervical spine (lateral view) = fracture C5 vertebra 12 lead ECG = normal sinus rhythm MRI cervical spine (T1) ( sagittal plane) = significant cord compression at C4 C5, C5 C6 levels. Cervical myelogram = cervical spinal canal stenosis from C4 to C6 level

16 MRI CERVICAL SPINE

17 INDIVIDUAL INDICES Cervical spine rigidity: reduced ability to align oropharyngeal and laryngeal axes. Mallampatti grade III DIFFICULT INTUBATION

18 GROUP INDEX SCORE BONES 1 EASY MASK VENTILAON

19 DIFFICULT AIRWAY ASA DIFFICULT AIRWAY ALGORITHM RECOGNIZED UNRECOGNIZED LMA PROPER PREPARATION GENERAL ANESTHESIA +/- PARALYSIS MASK VENTILATION EMERGENCY PATHWAY NO COMBITUBE TTJV AWAKE INTUBATION CHOICES SUCCEED FAIL SURGICAL AIRWAY REGIONAL ANESTHESIA CANCEL CASE YES NON -EMERGENCY PATHWAY INTUBATION CHOICES * AWAKEN INTUBATION CHOICES SURGICAL AIRWAY * REGROUP SUCCEED FAIL CONFIRM * Intubation choices include use of different laryngoscope blades, LMA as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. AWAKEN ANESTHESIA WITH MASK VENTILATION SURGICAL AIRWAY EXTUBATE OVER JET STYLET

20 DIFFICULT AIRWAY SOCIETY ALGORITHM FOR UNANTICIPATED DIFFICULT INTUBATION:

21 PLAN OF ANAESTHESIA In view of ANTICIPATED (RECOGNISED) difficult airway CAN ventilate and CAN intubate scenario) patient was opted for ELECTIVE awake FIBEROPTIC intubation over conventional intubation.( plan B) The procedure was explained to the pt.and written consent taken.

22 AWAKE INTUBATION ADVANTAGES Natural airway preserved. Better musle tone ( tongue, epiglottis, larynx post pharangeal muscles ) Larynx moves to anterior position with muscle relaxation Conventional intubation more difficult

23 PRE OPERATIVE PREPARATION Known c/o asthma 1 week before surgery Tab. Deriphyllin BD Tab. Salbutamol BD Tab. Azithromycin 500 mg OD Budecort nebulisation 6 th hrly Incentive spirometry exercises

24 On the day of surgery ( ) Nebulisation with duolin and budecort was done ½ hr prior to shift. Inj. Hydrocort 100 mg I.V administered Inj. Deriphyllin 225mg I.V administered Inj. Monocef 1gm I.V administered

25 Pt. was shifted to the O.T on trolley enmass with adequate neck stabilisation using cervical 9am Pt. was kept in supine position (without causing neck movements) on trolley and connected to monitor. Vitals recorded were: ECG (lead II), H.R, SpO2, NIBP, R.R 18 G I.V cannula secured on rt. Forearm and crystalloid was run. THE PROCEDURE WAS EXPLAINED TO THE PATIENT.

26 STEPS OF PROCEDURE premedication Anaesthetising oropharynx Preoxygenation Anaesthetising larynx and trachea Awake Fiberoptic intubation Induction and muscle relaxation DURING ENTIRE PROCEDURE NECK WAS STABILISED

27 PREMEDICATION Inj. Glycopyrrolate 0.2mg I.V Inj. Midazolam 1mg I.V Inj. Ondensetron 4mg I.V Inj. Fentanyl 100 microgram I.V GIVEN 15 min BEFORE PROCEDURE

28 ANAESTHETISING OROPHARYNX 4% xilocaine nebulisation of upper airway was done 10 min prior. For nebulisation and sprays

29 PREOXYGENATION Pre oxygenation was done with 100% 8litres/min for 5min encouraging pt. for large vital capacity breaths.

30 ANAESTHETISING LARYNX AND TRACHEA For nerve blocks LIGNOCAINE TOXIC DOSE = 4mg/kg

31 SUPERIOR LARYNGEAL BLOCK after stabilising the larynx, 3ml of 2% xilocaine was injected bilaterally at the greater cornua of hyoid bone, piercing the thyrohyoid membrane.

32 TRANSTRACHEAL BLOCKwith the larynx stabilised, 3ml of 2% xilocaine was injected rapidly through the cricothyroid membrane after aspirating air. Cough thus occurred, spread the anaesthetic over the tracheal mucosa.

33 BLOCKING GAG REFLEX Glossopharyngeal nerve and internal laryngeal nerve were blocked with cotton pledgets soaked in 4% xilocaine placed over posterior 1/3 rd of tongue and tonsillar fossa for 3min.

34 Flexible fiberoptic bronchoscope

35 Jaw thrust manouver Bite block Confirming adequate light source Insertion of scope

36 ksmineni.mp4

37 video clip 37

38 ETT position was confirmed by CAPNOGRAPHY B/L airentry was checked by air blast and chest auscultation. ETT cuff was then inflated and tube secured, connected to bains coaxial circuit.

39 INDUCTION AND MUSCLE RELAXATION Inj. Thiopentone 300 mg slow I.V Inj. Vecuronium 6 mg I.V given Patient was supported on IPPV. Position was changed from supine to prone with head resting on CERVICAL FRAME.

40 After adequate protection of ETT, neck, pressure points, and ensuring free movement of abdomen, surgery was begun. MAINTAINENCE Inhalational: N2O : 5:3 L/min halothane@ MAC Intravenous: inj. Vecuronium 1mg ½ hrly I.V Hypotensive agent: Inj. 100microgm/kg/min titrated with B.P

41 Once surgical closure was done, relaxant was seized, halothane and N2O cut off and pt. was turned supine with cervical collar insitu, ensuring no neck movements. In view of cervical spine laminectomy and anticipating the following problems: cervical spinal cord oedema neck mobility difficult airway Pt. was planned on elective mechanical ventilation post operatively.

42 POST OPERATIVELY Pt. was assisted on SIMV mode with I.V fentanyl 0.5 microgm/kg/hr overnight. POD 1: 6am sedation was stopped. Muscle power and reflexes improved.

43 7am : pt. was weaned to CPAP mode and maintained. 9am : t piece o2 6l/min am: ABG (on T piece) ph: 7.45 PCO2: 36 mmhg PaO2:65 mmhg HCO3:24.6 BEB: 0.3 SpO2: 100%

44 EXTUBATION( ) After fulfilling extubation criteria inj. Hydrocortisone 100mg I.V adequate ETT and oral suctioning done. duolin and budecort nebulisation given. PT. WAS EXTUBATED IN SUPINE AND HEAD IN NEUTRAL POSITION.

45 POST EXTUBATION Vitals were stable. Pt. was maintained on O2 inhalation via 6l/min Incentive spirometry exercises were resumed.

46 Pt. was shifted to ward. Antibiotics and bronchodilators were continued. Sensory and motor improved. Bladder incontinence decreased. Pt. was discharged on

47 THANK YOU

48 ANTICIPATED PROBLEMS inability to negotiate ETT Risk of airway bleeding and aspiration Laryngospasm Laryngeal oedema