A challenging case of esophageal stenting in a patient with tracheoesophageal fistula under intravenous sedation: A case report

Rebecca Shalini Lionel, Vijayakumar. D

Department of Anaesthesiology, Kauvery Hospital Radial Road, Chennai, Tamil Nadu

Abstract

This case describes the management of a case of esophageal stenting in a patient with carcinoma buccal mucosa, status post chemo radiation, developing a trachea-esophageal fistula. Sedation in anaesthesia is one of the most challenging skills which demands expertise and precision. With advances in sedation and monitoring, many endoscopic procedures are performed as day care services, under intravenous sedation for a painless and comfortable recovery. [2] Patients resume their routine activities that very evening owing to the tightly titrated anesthetic doses. However, in our patient, the associated difficult airway poses unique challenges in sedation techniques and peri-procedure safety.

Introduction

Procedural sedation involves administering sedative, anxiolytic and analgesic medication to facilitate the safe completion of procedures, that a fully conscious patient cannot tolerate. [1] The biggest challenge in sedation is maintaining a patent airway for oxygenation and at the same time providing an adequate plane for the gastroenterologist to perform a smooth endoscopy.

In our hospital most of the endoscopies are performed as daycare procedures, wherein patients resume their routine activities that very day. Our patient mentioned here is a 60yr old male with a history of carcinoma buccal mucosa status post chemo radiation. This had predisposed him to have a difficult airway. [3]

Case Presentation

A 60 years old male with a BMI of 21 presented to our hospital for an elective esophageal stenting. This gentleman had a history of carcinoma buccal mucosa 2 years ago. He underwent chemotherapy and radiotherapy for the same. In the process of radiation, he developed a tracheo esophageal fistula. A month back he underwent tracheal stenting in the bronchoscopy suite. Apart from the malignancy, patient had no other comorbidities.

Routine preoperative investigations revealed no abnormalities. Airway examination revealed a Mallampati grade 4, with a thyromental distance of 6cm. Neck examination revealed moderate limitation of neck extension due to extensive fibrosis of soft tissue in the head and neck region.

After ensuring adequate NPO status, patient was wheeled into the endoscopy suite. The difficult airway cart was kept ready including a videolaryngoscope and Fibreoptic scope to ensure airway safety. Standard ASA monitors were connected. Baseline vitals recorded. Patient was placed in a left lateral position and connected to 2L oxygen through nasal prongs. A 20G venflon was secured in the right upper limb. Inj. Glycopyrrolate 0.2mg, Inj. Midazolam 1mg and Inj. Ondansetron 4mg were given intravenously as premedication. After 1min Inj. Fentanyl 30mcg, Inj. Ketamine 20mg and titrated doses of propofol were given intravenously.

An intravenous propofol infusion was run as a maintenance sedation and just I minute prior to scope introduction, Inj. Lignocaine IV 60mg was given. Patency of the airway was maintained with a nasal airway. Throughout the procedure patient’s heart rate, oxygen saturation, end-tidal CO2, blood pressure and breathing pattern were monitored. Post procedure patient was shifted with oxygen in propped up position to the recovery room.

Conclusion

Daycare sedation in a patient with a difficult airway can be performed safely with accurate pre procedure assessment, titration of anaesthetic drugs and comprehensive airway preparedness.

The most crucial challenge in this procedure was the fact of it being a NORA (Non-Operating Room Anaesthesia). Hence preparedness was very essential and all emergency drugs and difficult airway cart including airway adjuvants and advanced airway equipment’s were kept in place. Shared airway was the other major consideration which was managed with a constant etco 2 monitor and nasal oxygen through prongs. This case being an anticipated difficult airway, utmost care was taken to keep the patient spontaneously breathing. Unlike other surgeries access to the head end of the patient was also limited due to space constraints in endoscopy suite.

Finally blunting the gag and cough reflex and simultaneously prevention aspiration of secretions was the key to safety. Sedation in anaesthesia is one of the most crucial skills as an anesthetist. The right balance between depth of anaesthesia and airway patency strikes the balance. The technique to avoid apnea is to avoid boluses of IV induction agents. Airway adjuvants also play a key role in assisting airway maintenance. Positioning for endoscopy in left lateral position helps clear upper airway secretions and prevent aspiration. In conclusion ensuring that the patient has a definitive etCO2 trace throughout the procedure helps in early identification of apnea and prompt airway manipulation to ensure a safe smooth procedure.

References

  • Tobias JD, Leder M. Procedural sedation: A review of sedative agents, monitoring, and management of complications. Saudi J Anaesth. 2011 Oct;5(4):395-410.
  • Lin OS. Sedation for routine gastrointestinal endoscopic procedures:a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res. 2017 Oct;15(4):456-466.
  • Jung H. A comprehensive review of difficult airway management strategies for patient safety. Anesth Pain Med (Seoul). 2023 Oct;18(4):331-339.

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