|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 140-141
A "cannot ventilate, cannot intubate" situation in a patient posted for emergency surgery for acute intestinal obstruction
Bikramjit Das, Farah Nasreen, Shahla Haleem, Qazi Ehsan Ali
Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||26-Jun-2013|
Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das B, Nasreen F, Haleem S, Ali QE. A "cannot ventilate, cannot intubate" situation in a patient posted for emergency surgery for acute intestinal obstruction. Anesth Essays Res 2013;7:140-1
|How to cite this URL:|
Das B, Nasreen F, Haleem S, Ali QE. A "cannot ventilate, cannot intubate" situation in a patient posted for emergency surgery for acute intestinal obstruction. Anesth Essays Res [serial online] 2013 [cited 2020 Jul 7];7:140-1. Available from: http://www.aeronline.org/text.asp?2013/7/1/140/114026
" Cannot ventilate, cannot intubate" (CVCI) situation is a nightmare for all clinicians who manage airways with an incidence of 0.01-2 in 10 000 cases.  Despite marked improvement in airway management in the last decade, the continued existence of CVCI can possibly be attributed to lack of specificity and low predictive value of current techniques for predicting difficult airway.  The initial surgical airway includes standard open surgical cricothyrotomy, cricothyrotomy, and cannula-over-needle cricothyrotomy with or without jet ventilation with 100% oxygen. 
A 55-kg, 37-year-old man, a diagnosed case of acute intestinal obstruction, was scheduled for exploratory laparotomy. The patient was conscious, well oriented, and without any medical comorbidity. Airway examination revealed mouth opening of 4 cm, thyromental distance of 7 cm, full range of neck movements, and Mallampati grade was III.
After premedication with inj. fentanyl (100 μg), inj. midazolam (2 mg), inj. ondansetron (4 mg), inj. hydrocortisone (100 mg), and inj. glycopyrrolate (0.2 mg), patient was preoxygenated with 100% oxygen. Induction was with inj. thiopentone (250 mg) and paralysis with inj. succinylcholine (75 mg). Laryngoscopy attempt was taken with MacIntosh size 3 blade. First intubation attempt with size 8.0 tube was failed and according to laryngoscopist, it was Cormack and Lehane grade IIIb. Second attempt was taken inserting a malleable stylet inside the endotracheal tube, but the tube could not be passed below the epiglottis. At that time (7:30 pm), patient started desaturating and SpO 2 reached 68%. Then, an Laryngeal Mask Airway (LMA) size 4 was placed but ventilation was still not achieved. The patient became progressively hypoxemic. The Laryngeal Mask Airway (LMA) was removed and needle cricothyrotomy was done with a 14 G needle attached to a saline-filled syringe. Proper placement was confirmed by aspiration of air bubble. Then, the needle was attached to a 3-ml syringe barrel to a 7.0 tracheal tube adapter to circuit. This enabled connection of the anesthesia circuit and the patient was manually ventilated.
When spontaneous respiration was returned, needle cricothyrotomy unit was removed and patient was delivered 100% oxygen through bag and mask. Patient's saturation finally reached 99% and settled. He regained consciousness, vocalized, and followed commands. Surgery was postponed.
The "cannot ventilate, cannot intubate" emergency situation is responsible for a previously irreducible 1-28% of all deaths associated with anesthesia. Needle cricothyrotomy followed by transtracheal jet ventilation or surgical cricothyrotomy are the recommended final life-saving treatments in the CVCI emergency by both the American Society of Anesthesiologists (ASA) and the Difficult Airway Society. ,
During airway examination of our patient, we found no significant predictor which could be a warning of difficult airway except Mallampati class III. There was also no predictor of difficult bag and mask ventilation. Recent strategies to deal with 'cannot ventilate, cannot intubate' situation include multiple new alternative airway devices like Laryngeal Tube and ProSeal Laryngeal Mask Airway (LMA).
In the "can't intubate, can't ventilate" scenario, cricothyrotomy can be a life-saving procedure. Consideration of the anatomy and good patient positioning will increase the chances of success.
| References|| |
|1.||Heard AM, Green RJ, Eakins P. The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice. Anaesthesia 2008;64:601-8. |
|2.||Khan RM. Management of cannot ventilate, cannot intubate situation. In: Khan RM, Maroof M, editors. Airway Management-Made Easy, 3 rd ed. Hyderabad: Paras Medical Publisher; 2009. p. 202-12. |
|3.||Kofke WA, Horak J, Stiefel M, Pascual J. Viable oxygenation with cannula-over-needle cricothyrotomy for asphyxial airway occlusion. Br J Anaesth 2011;107:642-3. |
|4.||An update report by The American Society of Anesthesiologists Task Force on Management of Difficult Airway. Practice guidelines for management of the difficult airway. Anaesthesiology 2003;98:1269-77. |
|5.||Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59:675-94. |