|LETTER TO EDITOR
|Year : 2012 | Volume
| Issue : 1 | Page : 109-110
Intraoperative desaturation during thyroidectomy. Can endotracheal tube migration still be a cause?
Rohith Krishna, Madagondapalli Srinivasan Nataraj
Department of Anaesthesiology, Kasturba Medical College, Manipal, India
|Date of Web Publication||14-Nov-2012|
Assistant Professor, Department of Anaesthesiology, Kasturba Medical College, Manipal - 576 104
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishna R, Nataraj MS. Intraoperative desaturation during thyroidectomy. Can endotracheal tube migration still be a cause?. Anesth Essays Res 2012;6:109-10
|How to cite this URL:|
Krishna R, Nataraj MS. Intraoperative desaturation during thyroidectomy. Can endotracheal tube migration still be a cause?. Anesth Essays Res [serial online] 2012 [cited 2020 Jun 2];6:109-10. Available from: http://www.aeronline.org/text.asp?2012/6/1/109/103394
Intraoperative displacement of endotracheal tube (ET) can result in serious complications such as accidental extubation or endobronchial intubation.  Early recognition and repositioning of the ET are important. Most of the existing case reports mention ET displacement during change in patient position or during laparoscopic surgeries  or during echocardiography probe placement.  We report a case of endobronchial migration of ET following mobilization of a large multinodular goiter.
A 45-year-old lady with a body mass index of 30 kg/m 2 was diagnosed to have multinodular goiter was posted for subtotal thyroidectomy. General physical and systemic examination including airway were normal. Thyroid function tests were normal. Indirect laryngoscopy was a normal study with bilateral mobile vocal cords. Radiologic examination of neck revealed a significant tracheal shift of 1.5 cm to the left side [Figure 1].
|Figure 1: Radiograph of neck and chest showing gross deviation of trachea to the left by 2 cm|
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A written informed consent was obtained for surgery and anesthesia. After adequate nil per oral status patient was scheduled for surgery. A 16 gauge intravenous (IV) line was secured. Preinduction monitors included electrocardiogram, pulse-oximetry, and noninvasive blood pressure. After adequate preoxygenation, anesthesia was induced with I.V propofol 150 mg and fentanyl 125 μg. After loss of verbal contact, ability to mask ventilate was confirmed. Muscle paralysis was obtained with IV vecuronium 7 mg and airway was secured with 7.0 mm cuffed oral endotracheal tube. Bilateral air entry confirmed by auscultation over the chest and tube was fixed at 20 cm at the incisor level. Maintenance of anesthesia was with oxygen and nitrous oxide (40:60) with 1-1.5% isoflurane. Postinduction end tidal carbon-di-oxide (EtCO 2 ) monitor was used. Patient was positioned for thyroid surgery with extension of the neck and a pillow under the shoulder. The tube position was reconfirmed and surgery proceeded.
Initial intraoperative period was uneventful. Once the thyroid gland was mobilized and removed there was a sudden increase in airway pressure from 22 cm H 2 O to 38 cm H 2 O. Oxygen saturation (SpO 2 ) dropped to 85% and EtCO 2 showed a slight fall to 30 mmHg from 38 mmHg. On auscultation, it was noticed that there was absent air entry on the left side of the chest. A possible diagnosis of endobronchial tube migration was made. The ET was withdrawn by 2 cm and bilateral air entry was reconfirmed. The tube was refixed at 18 cm. With this change, the peak airway pressures returned to normal and oxygen saturation improved to 100%. Rest of the surgery and extubation was uneventful.
Positioning for a thyroid surgery involves extension of the head and neck with a pillow under the shoulder to facilitate good surgical exposure. This position involves the theoretical risk of migration of ET outwards that can sometimes even result in accidental extubation.
In our case, there was a tracheal deviation of about 1.5 to 2 cm from the midline due to the enlarged thyroid gland [Figure 1]. On excision of the thyroid gland, the tracheal deviation was corrected that was evident in the postoperative neck radiograph. This centralization of trachea would have resulted in the tube tip to migrate endobronchial.
The sudden increase in airway pressure and drop in oxygen saturation after removal of the gland along with absent breath sounds on the left side of the chest can be explained by endobronchial migration of the tube that would have probably been secured just above the carina after intubation.
Anesthesiologists have to be aware of this possible cause for endo tracheal tube migration especially in surgeries on the thyroid gland.
| References|| |
|1.||Nishikawa K, Nagashima C, Shimodate Y, Lgarashi M, Maniki A. Migration of the endotracheal tube during laparoscopy-assiated abdominal surgery in young and elderly patients. Can J Anaesth 2004;51:1053-4. |
|2.||Neema PK, Manikandan S, Rathod RC. Endotracheal tube migration following transoesophageal echocardiography probe placement in a child. Eur J Anaesthesiol 2006;23:1060-1. |