Anesthesia: Essays and Researches  Login  | Users Online: 2644 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Home | About us | Editorial board | Ahead of print | Search | Current Issue | Archives | Submit article | Instructions | Copyright form | Subscribe | Advertise | Contacts


 
Table of Contents  
LETTER TO EDITOR
Year : 2013  |  Volume : 7  |  Issue : 1  |  Page : 140-141  

A "cannot ventilate, cannot intubate" situation in a patient posted for emergency surgery for acute intestinal obstruction


Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication26-Jun-2013

Correspondence Address:
Bikramjit Das
Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0259-1162.114026

Rights and Permissions

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 2019 Nov 23];7:140-1. Available from: http://www.aeronline.org/text.asp?2013/7/1/140/114026

Sir,

" 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. [1] 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. [2] The initial surgical airway includes standard open surgical cricothyrotomy, cricothyrotomy, and cannula-over-needle cricothyrotomy with or without jet ventilation with 100% oxygen. [3]

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. [4],[5]

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 Top

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.  Back to cited text no. 1
    
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.  Back to cited text no. 2
    
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.  Back to cited text no. 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.  Back to cited text no. 4
    
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.  Back to cited text no. 5
    




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References

 Article Access Statistics
    Viewed1222    
    Printed22    
    Emailed2    
    PDF Downloaded83    
    Comments [Add]    

Recommend this journal