Learning from Experience - Intra Operative, Chapters 25 and 26

A 16-year-old girl was admitted for maxillofacial surgery, she needed a sagittal split of the mandible. Her facial symmetry was altered with a very prominent, forward thrusting mandible and a receding maxilla. Blood investigations were within normal limits. CT revealed an under developed maxilla. She also had a previous surgery, where two wires were seen holding the maxilla to maintain facial structure.

On examination of her airway, she had undergone cleft lip and palate surgery. Mouth opening was adequate. On further examination with a tongue depressor, it was noticed that she had also undergone a pharyngoplasty. There was no movement of uvula on phonation, which is usually the case in post- pharyngoplasty patients. There was almost no communication between the nasopharynx and oropharynx, except for a small orifice.

Patient was adequately premedicated with Pentazocine 30 mg, Promethazine 25 mg, and Glycopyrrolate 0.2 IM. half an hour prior to surgery, Dexamethasone 8mg IV, Ranitidine 50 mg IV and Ondansetron 4 mg IV were given. Mask ventilation and intubation difficulty were anticipated.

In planning for anaesthesia, awake intubation was ruled out because patient was very young and uncooperative. After being wheeled into the operation theatre, monitors were placed. Patient was adequately pre-oxygenated and anaesthesia was induced with Propofol 120 mg and Fentanyl 75 mcg. Suxamethonium 70 mg was given as relaxant.

Nasal RAE 6.5 tube was inserted through the left nostril which as expected did not reach the oropharynx. Patient began coming out of the effect of Suxamethonium. Oral intubation using a regular cuffed 6.5 size endotracheal tube was done quickly to maintain adequate oxygenation. A mixture of Oxygen/Nitrous Oxide 50:50 and Isoflurane was administered to maintain anaesthesia. Now the airway was secured, and ventilation was good, and there enough time to do a nasal intubation without fear of hypoxia.

The bevel of the nasal RAE tube was palpated in the posterior wall of the oropharynx. Once felt, a long- curved artery forceps was introduced into the small opening in the pharyngoplasty and the tube clasped. With gentle pressure, the tube was pulled out into the oral cavity. With good visualization by direct laryngoscopy the oral tube was removed and the nasal tube was guided through the vocal cords in a synchronized manner using Magill's forceps.

Surgery was uneventful. Extubation was performed when patient was fully conscious, maintaining good respiratory pattern, and ensuring complete reversal of muscle relaxation.

Discussion

1. In this case, even though mouth opening was normal we chose Suxamethonium as muscle relaxant of choice because of anticipated difficult mask ventilation due to absent maxilla and protruding mandible
2. Due to previous pharyngoplasty with altered anatomy and adhesions, naso-tracheal intubation will be difficult with increased bleeding. Thus, it is beneficial that the patient recovers from the relaxant effect and reflexes are restored in case there is loss of airway.
3. When the tube does not go past the nasal cavity into the oropharynx, it must not be forced in. Instead a laryngoscopy must be done, a quick oral intubation and ventilation will give us time to manipulate the nasal tube.
4. Any trauma and bleeding caused by nasal intubation will potentially make bag-mask ventilation difficult and the patient can desaturate rapidly. Hence it is important to secure the airway with an oral tube at that moment without removing the nasal tube.
5. As mentioned above, guiding the nasal tube via the pharyngoplasty using long curved artery forceps after manual palpation of bevel of nasal tube is a very useful technique. Few other novel techniques described in literature are based on palpation method. It is useful to learn one technique and master it.
6. Use of Jacques Catheter to guide insertion of nasal endotracheal tube to prevent trauma is also a good useful technique described.

Patients posted for maxillo-facial surgery come with tricky airways and it is mandatory to know the type of procedures done before, how they maintain airway usually and what procedure is currently planned. Careful assessment and planning of intubation and extubation is essential. Intubation might have been simple and straightforward during the first surgery. However, when they come for subsequent procedures it might become difficult due to repositioning of the maxilla and mandible. One has to be prepared for this alteration in airway anatomy. Another point of relevance here is that even when there is adequate mouth opening following TMJ ankylosis release, intubation will still be difficult, and we should be prepared to tackle it appropriately.

References

1. Hee HI, Conskunfirat ND, Wong SY, Chen C. Airway management in a patient with a cleft palate after pharyngoplasty: a case report. Can J Anaesth. 2003;50(7):721-4.
2. Lee BB. Nasotracheal intubation and previous palatal or pharyngeal surgery. 2005;60(2);204-5.
3. Lee BB. Nasotracheal intubation in a patient with maxillo-facial and basal skull fractures. Anaesthesia 2004;59:299-300.

Every day, every patient, is a learning experience.

Chapter 26

Neck Trauma - Intubation Via an Existing Wound

A 40-year-old man was brought into the emergency room with history of trauma to the neck, laceration from kite thread (Manja) while travelling on a bike. On examination, he was in hemodynamic shock with a severe laceration in front of the neck with bleeding from the right side of the neck. He was gasping for breath, drowsy, with heart rate 160/min and feeble pulse. 100% oxygen was applied via face mask.

Examination of the neck wound, revealed injury to major vessels in the right side of the neck, which was beginning to swell with the haematoma. There was a cut over the trachea below level of hyoid, with a rent size adequate enough to insert a little finger. Patient was just about managing his breathing by holding a gauze over the rent and covering it.

Immediate assessment showed:

1. Precarious airway with a rent in trachea
2. Vascular injury in neck
3. Hemodynamically unstable patient

First line of management was to secure the airway. There was no time to get a fibre optic scope and secure the airway in an unstable patient. A quick and novel idea was suggested at this crucial time by the anaesthetist.

The anaesthetist utilized the pre-existing rent in trachea that could be easily visualized and passed a size 6.5 endotracheal tube through that to secure airway, and held it in position using Allis forceps. General anaesthesia was then given. ENT surgeon performed a surgical tracheostomy and secured a definitive airway. The vascular surgeons were efficient in clamping the injured vessels and repairing the vascular injury.

Patient was hemodynamically resuscitated simultaneously. Three units of packed cells, along with crystalloid solutions were transfused. Analgesia was given with IV Fentanyl and Paracetamol. Vitals were maintained, heart rate at 120/min, and BP at 90/50 mm Hg, on Dopamine support. Saturations were maintained at 96-98% with oxygen. Patient was shifted to ICU and ventilated through the tracheostomy. He was weaned off ventilator at 24 hours post trauma. Patient recovered well and shifted to the ward on day 3. The high light of this case was securing the airway through an existing rent in the trachea which saved the patient.

Discussion

Neck trauma is a challenge to manage. Single penetrating injury to the neck may be fatal due to the fact that neck is a conduit of respiratory, vascular, neural and gastrointestinal structures. Externally innocuous appearing wounds may be actually life threatening due to the anatomical nature.

Airway occlusion and haemorrhage are the immediate risk to life. They must be managed as first priority. Well-conceived multidisciplinary plan would help successful management of such patients. The evaluation of a patient must always commence with advanced trauma life support (ATLS) approach, a primary survey and management of airway, breathing, and circulation (ABC).

Once patients are stabilized, a secondary survey must be done. Associated injury to the neural structures and spine may be present and hence care must be taken to protect and prevent further damage during positioning and surgery.

1. Airway injury: Voice change, haemoptysis, subcutaneous emphysema. Airway noises must raise a suspicion of major airway injury.
2. Vascular injury: Presence of pulse does not exclude vascular injury. Expanding hematoma and shock unresponsive to fluids must be immediately attended to. This is essential to prevent central neurological deficit.
3. Other serious injuries involving head, spine and chest must be suspected and looked into in a patient with neck trauma

Our patient had a zone 2 injury. Hence early airway management was crucial in saving the patient.

References

1. Jeffrey G. Jarvik, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008;64(5):1392-405.
2. Mattox K, et al. Penetrating and blunt neck trauma. Trauma. 4th ed. Appleton and Lange; 1999. 437-450.