Dr S. Shakir Hasan
Manchester (UK)
Difficult intubation can be a real challenge for any anesthesiologist. It is particularly hazardous and much more difficult to manage in an emergency situation.
We present a case of a 72 years old male patient who was brought to ER with stridor and increasing shortness of breath. He was unstable hemodynamically on presentation, so was managed with adrenaline/salbutamol nebs, I/V fluids and intermittent boluses of vasopressors in the ER. ENT referral was also sought who tried a quick nasal scope, but couldn’t come to any conclusion. During neck examination they could feel a mass in the upper part of the neck and made a provisional diagnosis of a pharyngeal abscess. Portable chest x-ray was unremarkable and there was no time to do a CT neck to confirm the diagnosis due to the patient’s worsening condition. It was decided to rush the patient to OR for an awake fibre-optic intubation in the presence of ENT team in case if there was a need to do an emergency tracheostomy. The OR was prepared accordingly and the patient’s upper airway was sprayed and nebulized with lignocaine. A very small dose of remifentanil infusion was started for better tolerance of the procedure. Patient remained in an extremely critical condition with a systolic blood pressure 60-70 mmHg, despite of I/V fluids and metaraminol infusion. He also required intermittent boluses of 25 mics of adrenaline. There was no time for central venous access.
The plan was modified under the circumstances and it was decided to use a glidescope first to assess the airway. Patient tolerated it very well. Fortunately he was intubated easily. Patient was then stabilized by getting the central venous access and received the noradrenaline and adrenaline infusions. He was then transferred to ICU. His CT neck was done later, which was inconclusive. Chest x-ray in ICU did show bilateral infiltrates, probably it was the cause of his dyspnea and septic shock, but the cause of his stridor remained unclear. In due course, he died of multi-organ failure.
In this case a difficult airway was anticipated due to dyspnea plus stridor, but a rapidly worsening condition due to septic shock (bilateral pneumonia) led us to prepare for even the ultimate management – the surgical airway, as the margin of error was very slim.