AIRWAY OBSTRUCTION IN AN UNPLANNED EXTUBATION · PDF filewith intubation, inadvertent...

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Transcript of AIRWAY OBSTRUCTION IN AN UNPLANNED EXTUBATION · PDF filewith intubation, inadvertent...

  • CONCLUSION Proper planning and

    preparations are essential

    elements in the management

    of extubation of a patient with

    difficult airway.

    A difficult airway management

    committee should be organized

    in each tertiary hospital in

    Nigeria to formulate protocols

    and manage patients with

    anticipated airway difficulty as

    found in developed worlds.

    Safety has no border hence at

    every stage of management of

    a patient with difficult airway

    optimum manpower and

    equipment must be available to

    prevent catastrophic outcome

    DISCUSSION Airway obstruction is a potentially life threatening

    complication following cleft palate repair

    Tracheal intubation alone does not define an endpoint in

    airway management.

    Poor preparation extending to the process of extubation was

    the cause of death in this patient.

    In this report there was no rescue plan made by the resident if

    failure to maintain the airway following extubation occurred .

    This may be because essential equipment was unavailable or

    the anaesthetist did not have the requisite skills or training to

    use rescue equipment provided.

    Management of the obstructed airway is a significant clinical

    challenge as reported by the National Confidential Enquiry into

    Peri-Operative Deaths published in 1998 [2].

    Complex problems managed by trainees lacking the

    appropriate airway skills, should be discouraged.

    A more senior anaesthetist especially paediatric anaesthetist

    or other clinicians performing airway management should be

    present also during extubation to manage crisis.

    ABSTRACT Introduction: Cleft palate occurs in 1 in 2000 live births [1].. The majority of anaesthetic morbidity related to

    these procedures relate to the airway: either difficulty

    with intubation, inadvertent extubation or postoperative

    airway obstruction. An experienced anaesthetist is

    required to provide the optimm management needed by

    these patients at any level of care.

    Objective: To show that management of difficult airway goes beyond the intubation period, it is a continuum

    including maintenance of intubation as well as adequate

    planning of extubation

    Summary: We present a sixteen month old female child, with isolated cleft palate for repair. She had a history of

    recurrent upper respiratory tract infections and failure to

    thrive. Surgery had been cancelled on two previous

    occasions because of difficulty in intubating the trachea.

    Successful intubation of the trachea occurred on the third

    occasion. Surgery was uneventful. The patient

    subsequently developed airway obstruction after

    extubation. Attempts at re-intubating the trachea and

    mask ventilation failed and the child developed

    cardiopulmonary arrest and could not be resuscitated.

    PRE-ANAESTHESIA MANAGEMENT The patient was pre-oxygenated with 100% oxygen for 5minutes

    Laryngoscopy was carried out under deep inhalational anaesthesia using


    The Comarck and Lehine was grade 3, successful tracheal intubation occurred

    after the third attempt with Optimal external laryngeal manipulation (OELM) and

    shoulder support. This was confirmed by capnography

    Uneventful intraoperative period and surgery lasted one and half hours with

    mininal blood loss

    During the procedure the importance of a controlled planned extubation was

    discussed with the resident.

    However while attending to another patient, the resident reversed and

    extubated the patent awake

    Immediately post-extubation, the child had airway obstruction which could not

    be relieved.

    All attempts to re-intubate and manually ventilate to maintain adequate

    oxygenation was ineffective

    This resulted in deterioration of the childs condition and a cardiac arrest from



    Scheduled for repair of cleft palate at one year

    She was found to have an upper respiratory tract infection

    necessitating treatment

    There had been two previous history of difficult intubaton


    Was informed in the management of airway on the third


    The patient was categorized according to the American

    Society of Anesthesiologists Physical status Class II.

    The laboratory results were within normal limits except for

    sinus tachycardia on the electrocardiogram.

    Contingency plans for airway management were made


    REFERENCES R. C. Law and C. de Klerk. Anaesthesia For Cleft Lip And Palate Surgery, Update in Anesthesia: Volume 14 (2002), 27-30

    Gray AJG, Hoile RW, Ingram GS, Sherry KS. The Report of the NaAonal ConfidenAal Enquiry into PerioperaAve Deaths 1996 1997. London:

    NCEPOD, 1998.

    CASE PRESENTATION S A, a sixteen month old 6Kg female child with cleft

    palate for repair presented at the age of four


    There was history of failure to thrive, poor sucking

    of breast and recurrent chest infections

    Examination revealed a clinically ill-looking infant,

    small for age

    There was a cleft of the secondary palate, the

    gingiva were normal.

    The cardiovascular and central nervous systems

    were normal.

    The respiratory system showed tachypnoea,

    40cycles/minute, no dyspnoea with transmitted

    sounds on both lung fields


    ANTICIPATED DIFFICULT INTUBATION Oyedepo Olanrewaju Olubukola MD1, Adeyemi Moshood Folorunsho MD2

    Department of Anaesthesia1, Department of Surgery2, University of Ilorin Teaching Hospital, Ilorin. Kwara

    State. Nigeria.

    Keywords: Airway obstruction, unplanned extubation, child, cleft palate, difficult intubation