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Paediatric Cannot Intubate ,Cannot Ventilate & Cannot Oxygenate – a case report

 

 

Monthly journal reading again. Just got the November edn of Anaesthesia and Intensive care, 2012.

Case report of paediatric Cannot Intubate/Ventilate/Oxygenate. Gives you cold sweat on reading…

TITLE OF REPORT :

Failed intubation and failed oxygenation in a child

A S Santoro, M G Cooper, A Cheng.

Dept of Anaesthesia, Children’s hospital at Westmead, Sydney, New South Wales, Australia

Anaesth Intensive Care 2012 ;40:1056-1058

A summary of the case :

4 yo boy with rare genetic disorder, fibrodysplasia ossificans progressiva, needing reduction of jaw dislocation.

Multiple anatomical factors predicting difficult airway = poor mouth opening, fixed head flexion, marked kyphosis, thickening of nuchal muscles and right sternocleidomastoid

 

Anaesthetic plan = gaseous induction with sevoflurane, LMA standby with pre-prepared flexible bronchoscope.

 

Case progress = induction straightforward and jaw reduction successful. Sudden apnoea. Unable to Bag/mask ventilate. Small dose of propofol given with no improvement in ventilation. LMA inserted and unable to ventilate. Direct laryngoscopy failed. Critical desaturation ensues with bradycardia. Chest compressions commenced and atropine and adrenaline IV doses given. Flexible bronchoscope passed via LMA and tracheal position achieved with passage of tracheal tube over scope. Atracurium given. No improvement in clinical state. No endtidal CO2 trace gained. ENT surgeon summoned from another area. He attempts needle cricothyroidotomy but fails and proceeds to open tracheostomy which succeeds. Patient recovers rapidly.

Postoperative course : tracheostomy formalised and remains in situ. Voice has not been regained.

 

Learning points from this case :

  1. Paediatric CICV/CICO cases are rare and the authors describe their anecdotal claim that in their specialist service , of over 20 years and 275000 anaesthetic cases, this is the first true CICV on record.
  2. Lack of general consensus internationally as to best approach for paediatric CICV. Needle cricothyroidotomy is recommended by some resuscitation guidelines. Open tracheostomy, not cricothyroidotomy ,is recommended by authors as the suggested emergency airway technique in children and they cite their witnessed failure of the needle cric by an ENT surgeon.
  3. Importance of ETCo2 monitoring to confirm tracheal tube position
  4. “Everyone has a plan until you get punched in the face ” – Mike Tyson

 

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