Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway

Anaesthetic management of a parturient with predicted difficult airway presenting for caesarean section (CS) is not a straightforward decision: general anaesthesia should be avoided because intubation can be impossible and a "cannot intubate, cannot ventilate" scenario might ensue, on the other hand regional techniques can be unsuccessful or, though rarely, have complications that require emergency intubation. The case is presented of a primigravida admitted to hospital at 37 weeks' gestation with hypertension, intrauterine growth retardation and oligohydramnios. After a few days' observation, it was decided to proceed with an elective CS. The preoperative airway examination revealed a poor mouth opening with an interdental distance of 20 mm and a Mallampati class IV. The patient was classified as a case of difficult intubation and the following anaesthetic options were considered: epidural anaesthesia, spinal anaesthesia and awake fibreoptic intubation followed by general anaesthesia. The pros and the cons of these techniques were explained to the patient and it was suggested that awake fibreoptic intubation was the safest option. The patient gave her consent, so an uneventful nasal awake fibreoptic intubation was carried out under local anaesthesia. This case report offers the opportunity to underline the risk to perform a central blockade in a parturient with predicted difficult intubation, arguing that the safest course of action is an awake fibrescopic intubation, besides some controversial points to safely perform awake fibreoptic intubation in obstetric patients are discussed.     

Fibre-optic intubation teaching in sedated patients with anticipated difficult intubation

BACKGROUND AND OBJECTIVES: The objective of the study was to assess the safety of training fibre-optic intubation performed under propofol light general anaesthesia in patients with an anticipated difficult intubation. METHODS: Patients with ear, nose and throat cancer having at least two criteria for anticipated difficult intubation and scheduled for fibre-optic intubation were included prospectively. In 26 patients, intubation was performed by an anaesthesia resident (under senior supervision), whereas in 20 patients, it was performed by a senior anaesthesiologist. All patients received propofol light general anaesthesia adjusted to maintain both loss of consciousness and spontaneous ventilation. RESULTS: Of the 46 patients, 45 had successful fibre-optic intubation, and one needed a rescue procedure because of hypoxaemia. Residents failed to intubate four patients, who were easily intubated by the senior. Episodic hypoxaemia (SPO2 < 90%) occurred in three patients in each group. No statistically significant difference was found between junior and senior neither on the duration of the procedure (9.3 +/- 4.9 vs. 7.5 +/- 4.0 min) nor on the propofol consumption (197 +/- 130 vs. 193 +/- 103 mg) or the ETCO2 at the end of the procedure (36 +/- 6 vs. 38 +/- 6 mmHg), respectively. CONCLUSION: Teaching fibre-optic tracheal intubation in patients with anticipated difficult intubation and sedated with propofol did not increase morbidity significantly compared with an experienced anaesthesiologist. Fibre-optic intubation under propofol light general anaesthesia could be safely performed by a resident as long as a senior anaesthesiologist is permanently present, spontaneous ventilation is maintained and a rescue oxygenation technique is immediately available.     

Limits of laryngeal mask airway in patients after cervical or oral radiotherapy

Purpose

To test the efficacy of the LMA in patients with previous oral or cervical radiotherapy, without upper airway obstruction.

Methods

In nine patients after oral or cervical radiotherapy, efficiency of ventilation was assessed after induction of general anaesthesia and LMA insertion. Fibreoptic examination through the tube was performed to check the position of LMA

Results

In patients who had had oral radiotherapy, all five had limited mouth opening and in two, LMA insertion was difficult but permitted good ventilation. In the four patients who had had cervical radiotherapy, LMA insertion was easy but, in two, the lungs were difficult to ventilate and, in two, the lungs could not be ventilated and orotracheal intubation was required.

Conclusion

In patients with limitation of mouth opening after oral radiotherapy, LMA may represent an alternative to tracheal intubation. In patient with cervical sclerosis after radiotherapy; the use of LMA should be avoided.     

Evaluation of the Augustine Guide™ for difficult tracheal intubation

Successful tracheal intubation with Augustine Guide ? (Augustine Medical, Inc., Eden Prairie, MN) in patients with normal airways has recently been described. There are no studies describing Augustine Guide (AG) use in patients with difficult airways. Accordingly, we studied AG intubation in a population of patients with expected difficult airways due to cervical spine pathology, limited mouth opening, obesity, facial trauma or deformity due to previous operation or radiation and in patients with unexpectedly difficult airways. A total of 44 patients were studied. The AG was used as a primary intubating tool in patients with known difficult airways (n = 36) and as a secondary intubating tool in patients with unexpected inability to intubate using conventional direct laryngoscopy (n = 8). Airway difficulty was predicted by history and physical examination. Intubations were performed under general anaesthesia in 40 of the 44 patients studied. In four patients with predictably difficult airways, topical anaesthesia and sedation were used. Backup methods to achieve intubation were available. Thirty-two of the 36 with known or suspected difficult airways were classified as Mallampati Class III or IV. In the remaining eight patients the preoperative examination suggested an easy airway; however, after induction of general anaesthesia, their laryngeal inlet could not be seen using direct laryngoscopy. Using the AG, all were intubated successfully (36/44 at the first attempt, in 8/44 repositioning of the AG to allow successful laryngeal entry of the stylet was necessary). There were no failures or complications secondary to AG use. This study shows that the AG is a useful device for oral tracheal intubation in patients with known or unexpectedly difficult airways.     

Elective oral tracheal intubation in cervical spine-injured adults

There is controversy regarding the optimal mode of elective tracheal intubation in the patient with an unstable cervical spine following trauma. A ten-year review of 150 patients with traumatic cervical spine injuries with well-preserved neurological function, presenting for operative stabilization, was conducted to compare neurological outcome with the mode of tracheal intubation. Preoperative neurological deficits were identified in 49 patients (33%); most were single-level radiculopathies. Intubation occurred after induction of general anaesthesia in 83 patients (55%) and in 67 patients (45%) the tracheas were intubated with the patient awake. One hundred and six patients (71%) underwent oral tracheal intubation and 44 underwent nasal tracheal intubation. Ten intubations were deemed to be difficult requiring more than one attempt to effect intubation. Cervical spine immobilization during intubation was documented in 86 patients (57%). Weighted traction or manual in-line traction were the two manoeuvres most commonly employed to maintain spinal alignment during intubation. After surgery, two patients had new neurological deficits. There were no differences in neurological outcome whether intubation was performed while the patient was awake or under general anaesthesia, or comparing oral tracheal intubation with all other techniques (P = 0.5, Fisher exact test). Also, in-line traction did not affect neurological outcome. Oral tracheal intubation with in-line stabilization, either performed after induction of general anaesthesia or with the patient awake, remains an excellent option for elective airway management in patients with cervical spine injuries.     

The airway: problems and predictions in 18,500 patients

The purpose of this study was to describe methods, risk factors, and outcomes of airway management in all patients (obstetrics excluded) attended by anaesthetists over 27 months. Preoperatively, anaesthetists recorded patient factors and assessed four airway characteristics. Methods of tracheal intubation and ease of direct laryngoscopy following general anaesthesia (easy, awkward, difficult) were noted. Factors predictive of poor outcome and the value of the preoperative airway examination were determined. For 18,205 patients following a direct laryngoscopy, (GA), tracheal intubation was difficult (> 2 laryngoscopies) in 1.8% and awkward (≤2 laryngoscopies) in 2.5%. This approach was a failure in 0.3%, and surgery was postponed in 0.05%. However, an alternative approach to direct laryngoscopy, (GA) was the first choice in 353 patients. Risk factors for difficult tracheal intubation included male sex, age 40–59 yr and obesity (P≤0.01). For direct laryngoscopy, (GA), airway characteristics predictive of difficult tracheal intubation were decreased mouth opening (relative risk 10.3), shortened thyromental distance (9.7), poor visualization of the hypopharynx (4.5), and limited neck extension (3.2), any two (7.6) and more than two (9.4) (P< 0.01). For 1,856 patients (10.0%) where at least one airway characteristic was abnormal, a direct laryngoscopy, (GA) resulted in 8.3% awkward and 6.0% difficult tracheal intubations. For patients with no abnormal airway characteristics, tracheal intubation was easy in 96.3%. Where tracheal intubation was difficult, 34.3% of patients had one or more abnormal airway characteristics preoperatively. Patients with difficult tracheal intubation had an increased rate of desaturation (< 90%), hypertension (> 200 mmHg) and dental damage on induction of anaesthesia. It is concluded that difficult tracheal intubations occurred infrequently but were associated with increased morbidity. Patient factors and four physical airway characteristics were useful predictors but limited in identifying all problems.     

Dental anaesthesia for a child with complete amelia

A four year-old boy born without limbs (amelia) presented for dental restorations under general anaesthesia as an outpatient. Following intramuscular atropine administration anaesthesia was induced using halothane, oxygen and nitrous oxide inhaled by mask. Next, intravenous access was secured by external jugular vein catheterization. Because of his small mouth, hypognathic mandible, arched palate and anterior-superiorly located larynx, oral intubation under deep anaesthesia during spontaneous ventilation was difficult. The epiglottis was noted to be inverted on subsequent laryngoscopic inspection after intubation but was reduced mechanically to anatomic position. Despite being unable to accurately monitor the blood pressure the intraoperative period was uneventful. Postoperatively the patient was extubated and was able to return home the same day.     

Fastrach — a new intubating laryngeal mask airway: successful use in patients with difficult airways

Purpose

The Laryngeal Mask Airway — Fastrach? (Fastrach) is a new modified laryngeal mask with the capability for guided tracheal intubation while maintaining ventilation. We report the use of this device in patients with proven difficult airways, following induction of general anaesthesia.

Clinical features

After induction of general anaesthesia, having failed tracheal intubation with conventional laryngoscopy, the first patient’s trachea was intubated via the Fastrach with fibreoptic guidance. In the second and third patients, who had documented histories of difficult tracheal intubation, tracheal intubation was performed electively with the Fastrach following induction of inhalational anaesthesia with spontaneous respiration.

Conclusion

The Fastrach is an option in the management of the airway following failed tracheal intubation or for elective tracheal intubation in patients with anatomically difficult airways.     

Lightwand intubation: II — Clinical trial of a new lightwand for tracheal intubation in patients with difficult airways

Lightwands have been used to assist in the tracheal intubation of patients with difficult airways for many years. A new lightwand (Trachlight?) with a brighter light source and a flexible stylet permits both oral and nasal intubation under ambient light. This study reports the effectiveness of the Trachlight? in tracheal intubation in patients with difficult airways. Two groups of patients were studied: Group 1 — patients with a documented history of difficult intubation or anticipated difficult airways; Group 2 — anaesthetized patients with an unanticipated failed laryngoscopic intubation. In Group I, the tracheas were intubated using the Trachlight? with patients either awake or under general anaesthesia. In Group 2, tracheas were intubated under general anaesthesia using the Trachlight?. The time-to-intubation, number of attempts, failures, and complications during intubation for all patients were recorded. Two hundred and sixty-five patients were studied with 206 patients in Group 1, and 59 in Group 2. In most patients, the tracheas were intubated orally (183 versus 23 nasal) during general anaesthesia (202 versus 4 awake) in Group 1. Intubation was successful in all but two of the patients with a mean (± SD) time-to-intubation of 25.7 ± 20.1 sec (range 4 to 120 sec). The tracheas of these two patients were intubated successfully using a fibreoptic bronchoscope. Orotracheal intubation was successful in all patients in Group 2 using the Trachlight? with a mean (± SD) time-to-intubation of 19.7 ± 13.5 sec. Apart from minor mucosal bleeding (mostly from nasal intubation), no serious complications were observed in any of the study patients. With proper preparation, this study has demonstrated that Trachlight? is an effective and safe device to intubate the tracheas of elective surgical patients with a history of difficult airway in experienced hands.     

Ilio-inguinal Ilio-hypogastic nerve block with a single puncture: an alterantive for anesthesia in emergency inguinal surgery

The authors describe the anaesthetic procedure for a strangulated hernia repair needing resection and anastomosis of the small bowel in an adult patient. This procedure was performed with an ilio-inguinal/ilio-hypogastric nerve block according to a paediatrical simplified technique with a single puncture. For this patient who had relative contraindications for central blocks, this regional technique allowed to avoid general anaesthesia with its gastric aspiration and predictible difficult intubation risks. This block associated with a very light sedation was sufficient for all the surgical procedure, and postoperative analgesia was efficient over 3 hours. This simplified nerve block, better than the conventional approach for the clinical practice, represents a recommended alternative for hernia repair in emergency for high risk patients who could have a general anaesthesia or a central block.     

Ankylosing spondylitis: lateral approach to spinal anaesthesia for lower limb surgery

We describe three patients with long-standing ankyolsing spondylitis (AS) who underwent lower limb joint surgery under spinal anaesthesia. At preoperative assessment, it was considered that intubation of the trachea was likely to be difficult or impossible and previous general anaesthesia was associated with increased morbidity. Midline approach spinal anaesthesia failed but the lateral approach was successful. Spinal anaesthesia was induced using a 24 gauge Sprotte (Pajunk) needle with 3.5 ml heavy bupivacaine 0.5% at the L_3–4 interspace with the patients in the sitting position. This resulted in adequate sensory blockade for the surgical procedure. None of the patients required airway interventions but equipment and aids to secure airway were available.     

Surgery of temporomandibular joint under local anaesthesia

Temporomandibular joint ankylosis is a debilitating disorder arising from an inability to open the mouth. This leads to poor nutrition, poor dental hygiene, and stunted growth. Anaesthesia, especially general anaesthesia, is very difficult to administer. There is a lack of direct visualization of the vocal cords, tongue fall following relaxation, and an already narrowed passage due to a small mandible, which makes even the blind nasal intubation difficult. There are various techniques described in literature to overcome these challenges, failing which, one needs to do tracheostomy. All the risks of difficult intubation and general anaesthesia can be avoided if the surgery is done under local anaesthesia. A simple but effective method of successful local anaesthesia is described, which allows successful temporomandibular joint reconstruction.     

Awake heart valve surgery in a patient with severe pulmonary disease

Cardiac operations may be performed in a conscious, spontaneously breathing patient, but it is difficult to justify an awake technique in patients undergoing coronary artery procedures with low operative risk. We describe an elderly patient with severe chronic obstructive pulmonary disease in whom general anesthesia was contraindicated. A valve procedure was performed under thoracic epidural anesthesia alone, thus avoiding intubation and mechanical ventilation. The patient had an uneventful postoperative course and excellent recovery.     

Awake intubation using the LMA‐CTrach™ in patients with difficult airways*

We studied 21 patients with known difficult airways who underwent awake tracheal intubation using the LMA CTrach^?. Patients were given midazolam, atropine, a continuous infusion of remifentanil and topical lidocaine applied to the oropharyx. We limited the number of insertion attempts to three and the time to adjust the view to 5 min. In case of failure, we performed awake fibreoptic tracheal intubation. We found insertion of the device was successful and well tolerated in all patients. Vocal cords could be seen immediately in nine patients and following corrective manoeuvres in 10 patients. Tracheal intubation was successful in 20 patients: 19 cases under direct vision and in one blindly. In one patient with undiagnosed lingual tonsil hyperplasia, tracheal intubation was impossible using the device. No patient had an unpleasant recall of the procedure. We conclude that the LMA CTrach is easy to use, well tolerated and suitable for awake orotracheal intubation in patients with known difficult airways.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Impact financier et médicolégal des traumatismes dentaires

IntroductionDental injuries are among the most common complications of general anesthesia. Yet few studies have assessed the costs and factors that involve the responsibility of the anesthetist.Study designA retrospective study was conducted at the university hospital of Reims on 46 cases of dental injuries directly related to anaesthesia.ResultsTen patients made a claim for compensation. Two of them have received compensation following a medical expertise, which revealed for the first patient a possible alternative to general anaesthesia, and the second, hardware failure of intubation. The Administrative Court was entered once in 9 years. The global insurance-cost amounts to 4476 euros for all patients. The review of all cases of anaesthesia shows clearly that the dental claims are associated with a significant under clinical evaluation of dental status and criteria for difficult intubation during the anaesthesia. The information to the patient on this risk is not obvious from reading the anaesthesia records. No mouth guard was used.ConclusionThis work proves that the statements of caution are the most common and a minority of dental trauma lead to a claim. Claims are due to the high cost of dental care repair. The proportion of patients receiving benefits is extremely low. Medical expertise is an essential part of the evaluation of medical responsibilities. No compensation was paid without expertise. The lack of physical examination and information are contrary to our professional obligations and may involve our responsibility. The lack of patient information is not generated for compensation to the extent that the consequences of failure are easily dental weighed against the benefits of the entire medical-surgical procedure that the patient has agreed.     

Fluoroscope-aided retrograde placement of guide wire for tracheal intubation in patients with limited mouth opening

Passing a retrograde catheter/wire into the pharynx througha cricothyroid puncture can facilitate tracheal intubation indifficult situations where either a flexible fibre-optic bronchoscopeor an expert user of such a device is not available. Some mouthopening is essential for the oral and/or nasal retrieval ofthe catheter/wire from the pharynx. Two patients with temporo-mandibularjoint (TMJ) ankylosis and extremely limited mouth opening requiredgap arthroplasty of the TMJ under general anaesthesia. Becausewe did not have a flexible fibre-optic bronchoscope, we performedfluoroscopy-assisted nasal retrieval of the guide wire passedup through a cricothyroid puncture and subsequently accomplishedwire-guided naso-tracheal intubation. In the absence of a flexiblefibre-optic bronchoscope, this technique is a very useful aidto intubation in patients with limited mouth opening.     

Prediction of difficult tracheal intubation in Turkish patients: a multi-center methodological study

BACKGROUND AND OBJECTIVE: Preoperative evaluation is important in the detection of patients at risk for difficult airway management. It is still unclear whether true prediction is possible and which variables should be chosen for evaluation. The aim of this prospective, multi-centre study was to investigate the incidence of difficult intubation, the sensitivity and positive predictive values of clinical screening tests and whether combining two or more of these tests will improve the prediction of difficult intubation in Turkish patients. METHODS: Seven study sites from six regions in Turkey participated in this study. One thousand six hundred and seventy-four ASA physical status I-III patients, scheduled to undergo elective surgery under general anaesthesia, were included. RESULTS: The incidence of difficult intubation was 4.8% and increased with age (P < 0.05). The incidence of difficult intubation was significantly higher in patients who had a Mallampati III or IV score, a decreased average thyromental and sternomental distance, decreased mouth opening, or decreased protrusion of the mandible (P < 0.05). Mouth opening and Mallampati III-IV were found to be the most sensitive criteria when used alone (43% and 35%, respectively). Combination of tests did not improve these results. CONCLUSIONS: There is still no individual test or a combination of tests that predict difficult intubations accurately. Tests with higher specificity despite low positive predictive value are needed.     

A rare cause of difficult intratracheal intubation: Langenbeck's disease]

A case of difficult tracheal intubation due to insufficient mouth opening once anaesthesia had been induced is described. At the pre-anaesthetic visit, the 47-year-old female patient had painless restricted mouth opening (two fingers' breadth), dental malpositions, and slight lateral mandibular deviation. Cervical spine movements were normal. She was ranked 3 on the Mallampati scale. The anaesthetic technique preserved spontaneous breathing (induction with propofol 1.5 mg.kg-1 and alfentanil 15 micrograms.kg-1). Manual ventilation was impossible. An oral cannula could not be inserted. As intubation by the normal route was impossible, the retromolar approach had to be used. Several attempts were required for successful intubation by this route. At the end of surgery, the patient was extubated without any difficulties. Postoperative investigations revealed hypertrophic coronoid processes. In this condition, the mandible is jammed by hitting the maxilla, especially when mandibular lifting manoeuvres are used to facilitate manual ventilation and tracheal intubation. Clinical and paraclinical predictors of difficult tracheal intubation seem to be unreliable in such dynamic abnormalities of mouth opening.     

Acute epiglottitis: current management and review

Forty-seven patients treated for acute epiglottitis by nasotracheal intubation under general anaesthesia following a preset protocol are presented. The results are compared with 61 cases treated by tracheostomy following induction of general anaesthesia and intubation in the same institution. Both groups were followed clinically, and 13 of the children treated by nasotracheal intubation alone had a follow-up endoscopic examination of the larynx. There was no mortality in either group, but the morbidity was significantly higher in the children who had tracheostomy. Details of the management protocol are presented. Only inhalation anaesthetic agents are recommended and it is concluded that children with acute epiglottitis should always have an artificial airway inserted. Nasotracheal intubation seems to be associated with less morbidity than tracheostomy in experienced hands.