P010: MANAGEMENT OF DIFFICULT INTUBATION IN A PATIENT WITH ANKYLOSING SPONDYLITIS AND CEREBRAL ANEURYSM
Harshvardhan Rajen, MD1; Javier Kaplan, MD2; Michael Decker, MD2; 1HCA Florida Kendall Hospital; 2HCA Florida Aventura Hospital
Introduction: Our patient is a 76 year-old-male with past medical history of ankylosing spondylitis s/p cervical fusion of C6-T1 who presented for elective cerebral aneurysm coiling to be done under general anesthesia. He has a history of difficult airway due to limited range of motion of the head and neck and fusion of the cervical spine. His previous CT brain revealed a left M1 and right internal carotid artery aneurysms. The decision was made to proceed with an awake endotracheal intubation. We present a case with several anesthetic considerations including managing a challenging airway, while at the same time maintaining hemodynamic stability to minimize the risk of aneurysm rupture.
Methods: In the preoperative area, the patient received nebulized 4% lidocaine, as well as midazolam and remifentanil infusion. An infusion of nicardipine was started prior to intubation to blunt the sympathetic response from airway manipulation and for tight control of blood pressure. The patient was successfully intubated with an endotracheal tube and paralyzed for the coiling of the M1 aneurysm, which proceeded without event intraoperatively.
Results: At the end of the case the patient was breathing spontaneously and following commands. Paralysis was reversed appropriately. The patient was extubated in the operating room. Neurological exam immediately post extubation noted no focal neurological deficits. Subsequently, the patient became obtunded, stopped following commands, and new right sided hemiparesis was noted. As a result of these new findings, the decision was made to secure the airway once more due to concern for new onset stroke. Awake reintubation was attempted, which proved unsuccessful and the patient underwent emergency awake tracheostomy. The patient was transferred to the ICU and MRI brain postoperatively revealed new acute completed infarct in the left MCA territory with associated T2/FLAIR hyperintense signal.
Discussion: This case brings up important considerations when creating an anesthetic plan for this type of patient. Firstly, how to secure the airway for someone with a known challenging airway. This must be done while also maintaining tight control of hemodynamics to prevent undue wall tension of the known aneurysm and minimize the risk of rupture. Different methods exist for an awake intubation, whether using regional anesthetic techniques to anesthetize the airway or using intravenous and topical medications to allow the patient to tolerate airway manipulation. Regardless, care must be taken due to the anatomical difficulties of patients with ankylosing spondylitis.
The second is how to approach the end of the case. In the event of a post-procedure stroke, if the patient is kept intubated, there may be a delay in diagnosing the stroke. This is why the decision was made to wake the patient to test neurological function. Optimize the patient for extubation by completely reversing paralytics and ensuring they follow commands without residual anesthetics. Something to consider is whether a prophylactic awake tracheostomy prior to the procedure would be appropriate.However, the same risks of aneurysm rupture are present. Also, given the neck anatomy for this patient, the procedure would have an increased level of difficulty.