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Difficult Intubation in Thoracopagus Twins in MRI Suite

Szmuk, Peter, MD; Ghelber, Oscar, MD; Ezri, Tiberiu, MD

doi: 10.1213/01.ANE.0000173758.73363.1F
Letters to the Editor: Letters & Announcements

Department of Anesthesiology; University of Texas Medical School; Houston, TX; (Szmuk, Ghelber)

Department of Anesthesiology; Edith Wolfson Medical Center, Holon, Sackler School of Medicine; Tel Aviv, Israel; Outcomes Research™ Institute; Louisville, KY (Ezri)

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To the Editor:

The case report by Shank et al. (1) raises some interesting airway management issues. The authors describe a case of thoracopagus conjoined twins requiring anesthesia for magnetic resonance imaging angiography of complex cardiac anatomy. Endotracheal intubation was unsuccessful in both twins because the babies were facing each other. The twins’ heads were turned sideways to provide more room for direct laryngoscopy, but this resulted in distorted laryngeal anatomy. The authors were able to successfully place a No. 1 laryngeal mask airway in each twin but not before laryngospasm occurred. A nondepolarizing muscle relaxant was used mostly because of concerns of further episodes of laryngospasm and lungs of the patients were manually ventilated with 21% oxygen (which yielded saturations of 90% and 80% in twin A and twin B, respectively). The procedure lasted 6 h.

Is it appropriate to use the laryngeal mask airway in cases of difficult intubation, especially for an elective procedure undertaken in the magnetic resonance imaging suite, where patients are far away from the anesthesiologist and any airway intervention can be performed only outside the high magnetic field?

The ASA difficult airway algorithm recommends that a patient scheduled for elective surgery in whom endotracheal intubation failed should preferably be awakened and/or the airway be managed in a different way (i.e., awake fiberoptic intubation or intubation through a laryngeal mask), unless the planned surgery is short and the airway is easily approachable at any moment. This was not the situation in this case, which could have led to catastrophic consequences.

The use of muscle relaxants in cases of failed intubation may not be a good choice, as it might be followed by the inability to ventilate the patient’s lungs. We believe that either intubation through a laryngeal mask airway or awake fiberoptic intubation would be more appropriate and safer under such circumstances.

Peter Szmuk, MD

Oscar Ghelber, MD

Department of Anesthesiology

University of Texas Medical School

Houston, TX

Tiberiu Ezri, MD

Department of Anesthesiology

Edith Wolfson Medical Center, Holon,

Sackler School of Medicine

Tel Aviv, Israel

Outcomes Research™ Institute

Louisville, KY

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1. Shank E, Manohar N, Schmidt U. Anesthetic management for thoracopagus twins with complex cyanotic heart disease in the magnetic resonance imaging suite. Anesth Analg 2005;100:361–4.
© 2005 International Anesthesia Research Society