P059: SEVOFLURANE AND NITROUS OXIDE INHALATIONAL INDUCTION IN A FEMALE PATIENT WITH LUPUS NEPHRITIS, INADEQUATE FASTING TIME, AND NO INTRAVENOUS ACCESS
Allison Pocsik; Patricia Uher, MD; Gisele Wakim, MD
University of Miami Jackson Health System
Introduction: Rapid sequence induction and intubation (RSII) is the standard of care for emergency airway management, minimizing the time between loss of airway protection and intubation. RSII involves the use of an intravenous anesthetic agent immediately followed by a neuromuscular drug and preoxygenation. When intravenous access can’t be obtained prior to induction, the risk of aspiration of gastric contents increases, which can cause life-threatening pneumonitis or pneumonia. Alternative inductive methods include inhalational sevoflurane, intramuscular ketamine, and induction via an intraosseous route. The literature regarding these techniques describes their use in obstetrics; little was found about use in other settings or populations. We describe a successful case of inhalational induction in a 17-year-old (BMI 22.86) with a history of lupus nephritis with inadequate nil per os (NPO) status and without intravenous access.
Methods/Results: The patient arrived at the ER with a left lower extremity necrotizing soft tissue infection and was at increased risk for progression due to immunosuppressive therapy for lupus nephritis. She was booked for an emergent incision and drainage of the left lower extremity and arrived at the preoperative area with no intravenous access and inadequate NPO time with a recent snack. Peripheral intravenous access failed repeatedly due to lupus vasculitis and patient uncooperativeness. To mitigate the risk of limb loss, the decision was made to proceed immediately to the operating room. Once there, the patient was pre-oxygenated, and inhalational induction with maximal concentration of nitrous oxide was initiated. The patient remained agitated and was not responding to the nitrous oxide, so sevoflurane was added. Due to anxiety, the mask was initially held at a distance until the sevoflurane took effect, at which time she was masked. Modified RSII was employed with maintenance of spontaneous ventilation and minimal assisted breaths with pressures maintained below 20 cm H2O. Thereafter, a right internal jugular central venous catheter was placed under ultrasound-guidance, and 140 mg propofol, 80 mg rocuronium, and 50 mcg fentanyl were administered. A 7.0 mm cuffed endotracheal tube was then secured with direct laryngoscopy (Mallampati II, grade 1 view). No gastric contents were observed during direct laryngoscopy. Subsequently, an orogastric tube was placed with suctioning of gastric fluids. Anesthesia was maintained throughout the procedure with sevoflurane and nitrous oxide. After the extremity was debrided, the patient was transferred to the ICU and was successfully extubated on postoperative day 2.
Discussion: No previous cases have described inhalational modified RSII with nitrous oxide and sevoflurane in a pediatric patient with difficult intravenous access. Due to the inadequate NPO status of the emergent patient, extra care must be taken to mitigate the risk of aspiration. Here, a delay in surgical debridement could lead to poor patient outcomes including sepsis and limb loss. Sevoflurane modified RSII has been proposed as a possible alternative to propofol RSII and can still be executed promptly to avoid desaturation. This case demonstrates the potential for inhalational induction with nitrous oxide and sevoflurane in patients without intravenous access and inadequate NPO status requiring emergent surgery.