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Challenging Airway Secondary to Purpura Fulminans With Face and Neck Bullae in a Premature Infant: A Case Report

Ekeoduru, Rhashedah A. MD; Greives, Matthew R. MD; Nesrsta, Eric A. MD

doi: 10.1213/XAA.0000000000000426
Case Reports: Case Report

A former 25-week-old neonate presented at 34 weeks postconceptual age with necrotizing fasciitis and purpura fulminans because of Group B Streptococcus infection. He was septic and coagulopathic when he was intubated, and the endotracheal tube was secured with adhesives. When he subsequently developed large purpuric, bullous lesions on the face and neck, he presented to the operating room for excision and debridement of his facial lesions. No change was made in how the endotracheal tube was secured. Midprocedure, an unintentional extubation occurred. We describe how we subsequently secured the airway and make recommendations on how to avoid this problem in the future and for rescue preparation before the procedure.

From the Departments of Pediatric Anesthesiology and Pediatric Plastic Surgery, Children’s Memorial Hermann Hospital, McGovern Medical School, Houston, Texas.

Accepted for publication August 11, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Rhashedah A. Ekeoduru, MD, Departments of Pediatric Anesthesiology and Pediatric Plastic Surgery, University of Texas Health Science Center at Houston, Children’s Memorial Hermann Hospital, 6431 Fannin St, 5.020, Houston, TX 77030. Address e-mail to

Group B Streptococcus (GBS) is commonly transmitted to neonates during vaginal delivery. It can cause serious infections such as sepsis and meningitis. Occasionally it causes soft-tissue infection and necrosis with an age predominance of 5 weeks postgestation and a predisposition for male patients (75%). The pathogenesis is most likely lymphatic spread from an otitis media or mucous membrane colonization, causing bacteremia and seeding of the soft tissues.1 Risk factors include hospitalization, recent antibiotic use, and prematurity.2 Usually it rapidly resolves with antibiotic therapy. Rarely purpura fulminans occurs. It is characterized by the sudden onset of progressive cutaneous hemorrhage, skin necrosis, vascular thrombosis, and disseminated intravascular coagulation and is frequently fatal.3 We report a case of a 25-week-old neonate with purpura fulminans who presented for debridement of facial lesions at 34 weeks postconceptual age. The hemorrhagic purpuric bullae of the skin of the face and neck created circumstances that resulted in an unintentional extubation midprocedure, distorted the airway for subsequent intubation attempts, and made securing the endotracheal tube (ETT) a challenge.

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Written consent from the family was obtained to use the photo and case information for professional purposes.

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A former 25-week premature neonate presented to our tertiary care center with GBS sepsis. He was on a dopamine infusion for cardiovascular support and required multiple transfusions of platelets, fresh-frozen plasma, and packed red blood cells for coagulopathy and bleeding. He was intubated with a 3.0 uncuffed ETT that was secured with tape and DuoDERM (ConvaTec; Greensboro, NC) in the neonatal intensive care unit (NICU; Figure). The coagulopathy worsened, and the patient developed large purpuric and bullous lesions on the face, neck, penis, feet, and hands. Concerns for possible necrotizing fasciitis prompted transfer to our facility for tertiary surgical and anesthesia care.



The patient was treated with vancomycin, ceftazidime, and clindamycin. Although there was some clinical improvement, it became necessary to debride large areas of necrotic tissue over the face and neck. Ten days later, the patient was brought to the operating room for excisional debridement of 3% total body surface area wounds to the face and neck. The patient remained intubated with stable ventilatory parameters. Given the significant head and neck lesions, concerns for the security of the ETT during the procedure were discussed with the surgeon before the start of surgery and during the time out before incision. Rescue airway equipment, including a laryngeal mask airway, and a true view laryngoscope were made readily available.

During the procedure, the head of the bed was turned 90° for surgical access. Unfortunately, the patient was accidentally extubated during extensive head manipulation required for the procedure. We were able to easily bag mask ventilate the patient then attempt reintubation. Intubation was complicated by significant edema of the face and neck, edematous vocal cords, and the need to maintain sterility of the surgical field mid-procedure. Sterility could not be completely maintained as the patient began to desaturate quickly. There was not adequate time to don sterile gloves or attempt to drape the airway separately. A grade IIb view was obtained with a Miller 0 blade and cricoid pressure. After reintubation and securing the ETT with a suture, the surgery was completed, and the patient was transferred to the NICU for continued antibiotic therapy with plans for repeat debridement and skin grafting in the future.

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In this case, rather than relying on adhesive tape and DuoDERM adhesive dressing applied in the NICU to secure the ETT, we should have sutured the ETT to the oral cavity at the discretion of the surgeon before starting the surgical procedure. Not only was the adhesiveness compromised by the surgical preparation, but it also may have caused additional tissue injury. Suturing the ETT would likely have reduced both soft-tissue injury and the risk of unintentional dislodgment during head manipulation. There were concerns about the coagulation status of the patient causing significant oozing from the suture site; however, in retrospect, we could have given additional fresh-frozen plasma or platelets as warranted and used clinical observation and a thromboelastogram as guidance.

During the reintubation process, the combination of airway edema from prolonged intubation, inflammation from the GBS infection, and limited mobility of the head and neck because of the lesions resulted in a decreased ability to visualize the vocal cords. In addition, the attempted maintenance of the sterile field while we intubated mid-operation further increased the challenge in this patient. It would be advisable to have a sterile bronchoscope, sterile gloves, and towels for draping set-up near the intraoperative field to avoid contaminating the surgical field during emergency airway procedures. We did not have these readily available and did not have adequate time to prepare them after ETT dislodgment resulted in rapid desaturation.

In summary, this patient would have benefitted from suturing of the ETT before draping to decrease the chance of unintended extubation rather than relying on the pre-existing taping from the NICU. As with any potential difficult neonatal airway, readily available airway equipment, including supraglottic and surgical devices, is beneficial in anticipation of the airway not being secured through standard laryngoscopy.

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Name: Rhashedah A. Ekeoduru, MD.

Contribution: This author helped complete the manuscript.

Name: Matthew R. Greives, MD.

Contribution: This author helped complete the manuscript.

Name: Eric A. Nesrsta, MD.

Contribution: This author helped complete the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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1. Baker CJ. Group B streptococcal cellulitis-adenitis in infants. Am J Dis Child. 1982;136:631633.
2. Mittal MK, Shah SS, Friedlaender EY. Group B streptococcal cellulitis in infancy. Pediatr Emerg Care. 2007;23:324325.
3. Zenciroglu A, Karagol BS, Ipek MS, Okumus N, Yarali N, Aydin M. Neonatal purpura fulminans secondary to group B streptococcal infection. Pediatr Hematol Oncol. 2010;27:620625.
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