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Fiberoptic Scope as a Rescue Device in an Anesthetized Patient in the Prone Position

Section Editor(s): Saidman, LawrenceKramer, David C. MD; Lo, Joyce C. BS; Gilad, Ronit MD; Jenkins, Arthur III MD

doi: 10.1213/01.ane.0000269690.05759.eb
Letters to the Editor: Letters & Announcements
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Division of Neuroanesthesiology; Mount Sinai Medical Center; dkrame01@mac.com; dkrame01@msnyuhealth.org (Kramer)

Medical Student; Mount Sinai School of Medicine (Lo)

Resident; Department of Neurosurgery; Mount Sinai Medical Center (Gilad)

Department of Neurosurgery; Mount Sinai Medical Center; New York, NY (Jenkins)

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To the Editor:

Inadvertent intraoperative loss of airway control in a patient in the prone position is life-threatening. Several authors have described re-establishing control of the airway in these patients with the LMA (1–3). There is a limited literature describing management of this condition solely with fiberoptic intubation (4,5).

A 65-year-old male with a 45-degree kyphosis of the cervico-thoracic junction and 80-degree kyphosis of T1–T5 underwent a staged procedure for cervical spinal fusion. The trachea was initially atraumatically intubated with a GlideScope and standard cuffed endotracheal tube for stage one of the procedure. On postoperative Day 2, the patient self-extubated and required emergent nasal reintubation with a blue-line endotracheal tube.

On Day 6, the patient returned to the operating room for the second stage of the procedure. His head dislodged from cranial fixation during elevation with the Mayfield frame, causing migration of the endotracheal tube superior to the epiglottic aperture. Multiple attempts at blindly advancing the endotracheal tube were unsuccessful, and the tube was manually maintained at the epiglottic opening. Although the patient's arterial saturation remained greater than 98% during this entire episode and his end-tidal CO2 was maintained <38 mm Hg, there was a significant leak. Since our patient had dental instability secondary to an ENT procedure during the first stage of this operation, securing the airway with an LMA may have produced complete dislodgement of the dental plate from the maxilla. A second anesthesiologist was called and the trachea was successfully reintubated while the patient was prone using a fiberscope. The patient subsequently underwent completion of cervical fusion.

Several options exist for securing the airway of the patient whose trachea has been inadvertently extubated while prone, including: blind reinsertion, insertion of supraglottic device or a combitube, fiberoptic reintubation, or emergently covering the surgical site and turning the patient supine to secure the airway. The anatomy of the Jackson Table with the Mayfield apparatus proved particularly amenable to the prone emergency fiberoptic approach, as there is open access to the face and neck.

As part of the anesthetic care plan for spinal surgery patients, the anesthesiologist should develop an algorithm to facilitate securing the airway in the event of inadvertent extubation. Reintubation of the trachea in a patient in the prone position, using a fiberscope should be one such option.

David C. Kramer, MD

Division of Neuroanesthesiology

Mount Sinai Medical Center

dkrame01@mac.com

dkrame01@msnyuhealth.org

Joyce C. Lo, BS

Medical Student

Mount Sinai School of Medicine

Ronit Gilad, MD

Resident

Department of Neurosurgery

Mount Sinai Medical Center

Arthur Jenkins III, MD

Department of Neurosurgery

Mount Sinai Medical Center

New York, NY

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REFERENCES

1. Valero R, Serrano S, Adalia R, Tercero J, Blasi A, Sanchez-Etayo G, Martinez G, Caral L, Ibanez G. Anesthetic management of a patient in prone position with a drill bit penetrating the spinal canal at C1-C2, using a laryngeal mask. Anesth Analg 2004;98:1447–50
2. Dingeman RS, Goumnerova LC, Goobie SM. The use of a laryngeal mask airway for emergency management in a prone child. Anesth Analg 2005;100:670–1
3. Brimacombe J, Keller C. An unusual case of airway rescue in the prone patient with Proseal laryngeal mask airway [letter]. Can J of Anesth 2005;52:884
4. Rampersaud YR, Moro ER, Neary MA, White K, Lewis SJ, Massicotte EM, Fehlings MG. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine 2006;31:1503–10
5. Neal MR, Groves J, Gell IR. Awake fiberoptic intubation in the semi-prone position following facial trauma. Anaesthesia 1996;51:1053–4
© 2007 International Anesthesia Research Society