Volume 3 - Issue 7
Dr. Vasanthi Vidyasagaran*
Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India
A 58-year-old man presented to the emergency department with stridor. He was a known case of CA thyroid for which a total thyroidectomy was done six years ago, followed by 5 cycles of I131. The patient was hemodynamically stable: PR=108/min, BP =140/80, but his saturation with oxygen mask was only 89%.
Chest x-ray revealed a critical obstruction of the trachea. He needed an emergency tracheostomy to secure airway. The patient was in severe respiratory distress that had to be relieved without any delay. In order to give him some form of anaesthesia, and to secure an airway, prior to tracheostomy, a trial FOB was attempted, but even a paediatric scope would not pass through. We had to maintain spontaneous ventilation as paralysing him to secure airway may lead to disaster, but at the same time, he needed to go on a cardio pulmonary bypass, even to attempt a tracheostomy.
With monitors for SpO2, ECG and invasive pressure (right radial) attached, spinal for cardiopulmonary bypass using femoral vessels was planned. A subarachnoid injection of 2.5 ml 0.5% Bupivacaine in L3-L4 space was given to achieve a T10 block. This was adequate to access the femoral vessels. The patient was heparinised. Femoral artery and vein were cannulated and cardiopulmonary bypass was initiated.
A reverse Trendelenburg position was maintained to alleviate his respiratory distress. As the surgeons approached the neck, injection Glycopyrrolate 0.2 mg, Fentanyl 50 mcg, Midazolam 1 mg, Propofol 30 mg, and Ketamine 50 mg was administered. Conscious sedation was maintained. Patient was hemodynamically stable throughout. Intermittent blood gas analysis was satisfactory. Aliquots of 10 mg IV Ketamine and 10 mg IV Propofol were repeated as required.
Performing the tracheostomy was extremely difficult due to fibrosis and calcification of the trachea, but eventually it was done successfully. Further complicating the scenario was the heparinised state of the patient. The trachea was flooded with blood, even though suctioning was performed before weaning off bypass. FOB was used to give a thorough wash before heparin reversal and decannulation of vascular channels. Patient was shifted to intensive care unit with an acceptable SpO2 of 94%.
Institution of cardiopulmonary bypass under GA, for surgery involving the carina and bronchus is well documented. However, in this scenario the patient was breathing spontaneously and bypass was initiated under SAB. This was an extreme case of airway obstruction presenting with stridor. (few cases have been reported) Unanticipated subglottic obstruction may land the anaesthesiologist in trouble as intubation will become difficult. It is possible to visualise the glottis using FOB, like in this case, but ETT may not pass through. It should become a regular habit to have a look at the tracheal shadow in every chest x-ray prior to surgery and request a CT if necessary.
A 5-year-old boy weighing 12 kilograms presented with unilateral nasal discharge with slight bleeding from his nostrils. The parents confirmed that the child had inserted a single watch battery. A diagnosis of foreign body right nostril was made and patient was taken up for foreign body removal under GA.
He was induced with Propofol 30 mg and intubated with 20 mg Succinylcholine with a size 4 cuffed oral ETT. A throat pack was placed. For maintenance, a 50% mixture of Oxygen and Nitrous Oxide, and 2% Sevoflurane was used.
Nasal endoscopy was done and a watch battery was removed from the right nostril. Due to oedema and foreign body chemical reaction, the endoscope would not go any further. The left nostril was also quickly checked and it did not reveal any foreign body. Dexamethasone 4 mg was given.
The throat pack was removed and the patient was extubated after thorough oral suctioning. Nasal suctioning was not done as it was a paediatric patient, due to the risk of trauma to the adenoids and bleeding. After extubation, the child was very restless and seemed to have upper airway obstruction, saturation dropped to 93% and there were retractions in the suprasternal and intercostal area.
This was thought to be a case of laryngospasm which did not improve with steroid. Hence it was decided to re-intubate the patient. 100% oxygen was administered and reintubation was attempted with Propofol 20 mg and Succinylcholine 10 mg. On direct laryngoscopy, a battery was seen dropping into the oropharynx from the nasopharynx on the left side. This was deftly removed by the anaesthetist using an artery forceps. Reintubation was done and repeat nasal endoscopy revealed another battery in the left nostril. The parents could not believe that their child had inserted 3 batteries into both his nostrils! Though the nasal discharge was only on the right.
Presence of more than one foreign body should be borne in mind for every case of foreign body extraction. A thorough nasal endoscopy should be performed before attempting extubation. The chemical reaction caused by an inorganic foreign body, especially a battery may give rise to mucosal oedema and inflammation comparable to an organic foreign body. A dose of steroid (Dexamethasone) usually helps to reduce the airway oedema. Xylometazoline nasal drops should be used for effective vasoconstriction and shrinking of the oedematous nasal mucosa.
Throat should be packed in nasal procedures for airway protection. Foreign body may migrate and cause aspiration, which can be quite catastrophic if it causes complete obstruction. The head should be placed in a sniffing position for easy access.
The most common locations for nasal foreign bodies to lodge are just anterior to the middle turbinate or below the inferior turbinate (see illustration below). Unilateral foreign bodies affect the right side about twice as often as the left. This may be due to a preference of right-handed individuals to insert objects into their right nostril, but both nostrils should be thoroughly checked under anaesthesia, since more than one foreign body may be present, as seen in this patient. Parents should be educated that when there is a unilateral blocked or running nose in a child, an ENT surgeon must be immediately consulted.