P039: AIRWAY MANAGEMENT IN AN OBESE PATIENT WITH A TYPE II DENS FRACTURE
Jessica Reyes, MD; Catalina Carvajal, DO; Sofia Fischer, MD; Kendall Regional Medical Center
Introduction/Background: 83 yo male with a past medical history of hypertension, hyperlipidemia, coronary artery disease s/p PCI and moderate aortic stenosis presented following a ground-level mechanical fall and was found to have a type II odontoid process fracture. Patient was scheduled neurosurgery to undergo an anterior neck exploration and odontoid process fixation with a screw. On exam, the patient was obese, c-collar in place, and edentulous. The decision was made to use a glidescope for intubation and an 8.0 mm NIM tube for the procedure. Two large-bore peripheral IVs were placed as well as an arterial line for hemodynamic monitoring.
Methods: In the operating room, monitors were connected and a controlled induction of general anesthesia was performed. A size S4 glidescope blade was inserted and vocal cords were promptly visualized. The trachea was intubated with an 8.0 NIM tube with direct visualization of the cords upon the blue strip of the NIM tube for neuromonitoring. Anesthesia was maintained with remifentanil and propofol; and upon completion of the neuromonitoring, the drips were stopped and inhalation anesthesia was initiated. The patient remained hemodynamically stable throughout the procedure and ventilation was adequate. The plan was to extubate and transfer to the intensive care unit for monitoring overnight.
Results: Following the emergence of anesthesia, the patient met extubation criteria and the NIM endotracheal tube was removed. Shortly thereafter, the patient began to develop sounds of upper airway obstruction and apparent difficulty ventilating. Oxygen saturation began to decline. An attempt was made to manually ventilate the patient, however, only small increases in oxygen saturation were noted. The request for help from additional anesthesia providers was made as well as the decision to re-intubate the patient. The patient was promptly intubated with a glidescope while maintaining cervical spine midline and c-collar in place. The view of the airway on re-intubation demonstrated airway edema. After establishing tracheal intubation, oxygenation increased and the patient was then transferred to the ICU.
Discussion/Conclusion: Surgery involving the neck could always pose the risk of airway edema and subsequent risk of failed extubation. Other risk factors associated with airway edema include airway or major neck surgery, prolonged prone or steep Trendelenburg positioning, multiple intubation attempts, or large volumes of IV fluids. Steps can be taken prior to extubation if airway edema is anticipated such as administration of intravenous corticosteroids and performing a cuff leak test while the patient is spontaneously ventilating. An odontoid process type II fracture is among the most unstable of the dens fractures of all and the fixation of such fracture in an obese, elderly patient makes the procedure technically difficult. While the surgical procedure did not involve tissues of the airway, it is important to anticipate the possibility of airway edema due to the proximity of the C2 vertebrae to the airway and the surgical approach taken.