Book 6, Case 5-Down's, sublingual/submandibular abscess Flashcards
Concern’s for this patient: Down’s, obesity, drooling, sat 91%
My initial concern is safely securing the airway in this uncooperative, obese
patient at risk for aspiration, failed intubation/ventilation, and inadequate oxygenation. Her
history of obesity, Down syndrome, and drooling with difficult swallowing, all raise the risk
of failed intubation and/or ventilation. Her recent food ingestion places her at risk for
aspiration. Both her compromised respiratory function (91 % Sp02) and her obesity
(decreased FRC) place her at increased risk of rapid desaturation and inadequate oxygenation
during induction. And, finally, I am concerned about the high incidence of cardiac defects
associated with Down syndrome, including atrioventricular/ventricular septal defects,
tetralogy of Fallot, and patent ductus arteriosus.
How will you evaluate this pts airway? (Down’s obesity, drooling, sat 91%)
I will start with a thorough anesthetic history, including a review of previous
anesthetic records, to identify airway management issues or successful intubation techniques.
I would also wish to note any significant weight change, consider the characteristic
abnormalities of Down syndrome patients that can complicate airway management (short
neck, large tongue, subglottic stenosis, mandibular hypoplasia, palatal abnormalities, and the
risk of atlanto-occipital dislocation), and determine the severity and onset of her current
respiratory distress. My exam would focus on her weight distribution, pulmonary function,
nostril size and patency, dentition, presence and degree of trismus (often present secondary to
compression of nerves by the abscess), palate structure, tongue size, Mallampati score,
cervical range of motion, mandibular protrusion, and thyromental distance. Finally, lateral
radio graphs or a CT of the head and neck, may be helpful in determining the extent of the
abscess, identifying/grading any mass-induced airway obstruction, and identifying atlanto-
occipital dislocation.
Given the patient’s respiratory compromise and a history of Down syndrome, would
you require a CXR, cervical spine radiographs, or a neck CT before proceeding with
surgery? Would you sedate this uncooperative patient to facilitate these studies?
Chest films, cervical spine radiographs, or a neck CT would be helpful in
assessing the extent and location of the abscess, identifying and grading any mass-induced
airway obstruction, and identifying atlanto-occipital dislocation. However, I would not delay
surgery or sedate this patient with a potentially difficult airway to obtain these additional
studies. The risk of losing an already compromised airway secondary to surgical delay or
over-sedation could prove disastrous and, given my already elevated concerns about her
airway, would be unlikely to significantly alter my anesthetic plan. Therefore, I would make
preparations for the management of a difficult airway, develop alternative plans should failed
intubation and/or ventilation occur, and proceed with surgery.
Are you concerned about her Sa02 of 91 % on room air? How will it affect your
anesthetic management?
I am concerned, because this suggests significant respiratory compromise,
which could lead to rapid desaturation, hypoxemia, and an inability to extubate the patient
postoperatively. Her pulmonary distress may reflect significant obstruction with atelectasis,
aspiration pneumonitis, or infectious pneumonia, any of which could complicate her
anesthetic course. Given the possibility that her respiratory distress may be due to significant
airway obstruction, and recognizing that she may be dependent on intact muscle tone to
maintain airway patency, I would avoid apnea, sedation, and muscle paralysis until the
airway is secured. Additionally, I would anticipate a difficult airway and expect rapid
desaturation should apnea occur. So, prior to providing any sedation or inducing the patient,
I would have difficult airway equipment in the room and ensure that a surgeon was present
and prepared to perform an emergent surgical airway procedure should it become necessary.
Would you delay surgery to allow for gastric emptying, since she had soup just one
hour ago?
Given her fever, her respiratory distress, and the risk of further airway
compromise, I would not delay this emergent case for gastric emptying. However, I would
take steps to minimize the risk of aspiration, such as administering metoclopramide and
bicitra, applying cricoid pressure during induction, suctioning the stomach with an orogastric
tube, and allowing the patient to regain airway reflexes prior to extubation (awake
extubation). While an awake intubation may reduce the risk of aspiration, it is unlikely that
this uncooperative patient with Down syndrome would tolerate the procedure.
The ER failed to place an IV after multiple attempts due to inadequate patient
cooperation. The mother asks if you can sedate her daughter before making any
further attempts at placement. What would you tell her?
Given this patient’s potentially difficult airway, significant respiratory
distress, and potential for increased sensitivity to sedative medications (if she is
hypercapnic ), I would explain to her mother that, while I am concerned about her daughter’s
distress and comfort, I would prefer to avoid administering sedatives, if at all possible, due to
the risk of making her daughter so sleepy that she stopped breathing. I would further explain
that, while sedation may ultimately prove necessary, I would first like to try applying skin
cream (EMLA) to a couple of sites so that I can painlessly start an IV.
The patient will not allow you to attempt an IV despite your reassurances that she will
not feel any pain. What will you do?
If the patient were uncooperative and IV access could not be obtained without
sedation, I would take the patient to the operating room, have difficult airway equipment in
the room, and ensure a surgeon capable of obtaining an emergent surgical airway was
present. When this was accomplished, I would administer a small dose of IM ketamine (3
mg/kg) with the goal of maintaining spontaneous ventilation while an IV is established.
Is there any other lab work you would order prior to proceeding with this case?
In this emergent case, I would not delay treatment for additional lab work.
However, ifthere were time, and the patient was cooperative, I would order a urine Hcg to
identify pregnancy, a chest X-ray to aid in assessing her acute pulmonary distress, and
cervical spine radiographs or a head/neck CT to identify and evaluate atlanto-occipital
dislocation.
What is your plan for intubation?
And don’t forget to inform the parents and patient of ___
However, considering her level of cooperation preoperatively, I think it unlikely that she
would tolerate either of these procedures while awake. Therefore, I would get emergency
airway equipment in the room, have a surgeon available to obtain an emergency airway, prep
and drape the patient for possible tracheostomy, have someone apply cricoid pressure with a
sterile glove, administer a sedative dose of ketamine, place the patient in slight trendelenburg
position, suction the mouth, perform a slow controlled inhalational induction, maintain
spontaneous respirations, and perform a careful fiberoptic intubation. While this approach
carries increased risk of aspiration, it would: 1) avoid inducing apnea, which could quickly
lead to hypoxia; 2) avoid excessive neck flexion, which could lead to atlanto-occipital
dislocation; and 3) allow for immediate surgical intervention, if required.
Parents and patient need to know that a trach very well could happen!
During fiberoptic intubation, you are unable to advance the ETT more than one
centimeter beyond the vocal cords. What do you think? What will you do?
This subglottic obstruction may be secondary to compression from the
abscess or from the subglottic stenosis often associated with Down syndrome. In either case,
I would first attempt to pass a smaller endotracheal tube and, if this failed, I would suggest
that the surgeon infiltrate the skin with local anesthetic and perform a tracheostomy. During
the procedure, I would be prepared to treat aspiration, laryngospasm, bronchospasm, or apnea
should they occur.
After successful tracheostomy, you give a dose of Vecuronium and begin positive
pressure ventilation. Her blood pressure falls to 74/30 mmHg. What do you think
might be the cause of this acute hypotension?
What would you do?
Is sepsis the likely cause of this hypotensive episode?
Given the timing, this hypotension is most likely secondary to depth of
anesthesia or decreased venous return resulting from increased intrathoracic pressure with
positive pressure ventilation. Other potential causes would include histamine-induced
vasodilation, sepsis, anaphylaxis, surgical bleeding, tension pneumothorax, cardiac failure, or
arrhythmia.
I would:I would inform the surgeon, place the patient in trendelenburg position, hand
ventilate, decrease my inhalational agent, give a fluid bolus, check my EKG, inspect the
surgical field, auscultate the chest, inspect the skin for signs of allergic reaction, and treat
with vasopressors as necessary.
Given her fever and the fact that she has a known infection that has been
developing over several days, it is possible that sepsis played some role in her acute
hypotension. However, considering the timing and acute nature of the episode, it is more
likely that hypovolemia in conjunction with decreased venous return from positive pressure
ventilation and/or anesthetic-induced cardiovascular depression is the primary etiology.
As the case progresses, the saturation suddenly falls to 80%. What would you do?
You hear bilateral wheezing and notice decreased lung compliance with hand
ventilation. What do you think is going on?
I would hand ventilate with 100% oxygen, auscultate the chest, listen for air
leaking around the tracheostomy site, check the tidal volume and airway pressures, check the
capnography and Sp02 waveforms, check the EKG, and ensure adequate perfusion.
Depending on what I found, I would add air to the tracheostomy cuff, administer
bronchodilators, adjust the ventilator settings, deepen the anesthetic, or increase blood
pressure.
The most likely cause of diffuse wheezing and hypoxia is bronchospasm,
which could be due to light anesthesia, blood or purulent material in the tracheobronchial
tree, reactive airway disease, or aspiration. However, these physical findings could also be
the result of pulmonary embolism, CHF, or anaphylaxis.
If I believed this to be bronchospasm, I would hand ventilate with 100% oxygen, deepen my
anesthetic, and administer bronchodilators. If the bronchospasm were severe with worsening
hypoxemia, I would consider a small dose (5-10 mcg) ofIV epinephrine.
Is it possible for this patient to aspirate with a tracheostomy in place? What are the
symptoms of aspiration? When do they present?
It is possible to aspirate with either an endotracheal tube or tracheostomy tube
in place. Aspiration produces a chemical pneumonitis characterized initially by hypoxemia,
bronchospasm, and atelectasis. The earliest physiologic change following aspiration is
intrapulmonary shunting, resulting in hypoxia.
Other changes may include pulmonary
edema, pulmonary hypertension, and hypercapnia. It should also be recognized that,
although a patient may look well in the immediate period following aspiration, without
rhonchi or wheezes on auscultation, respiratory distress may still yet develop. It may take as
long as 6 to 12 hours before the syndrome manifests itself. Therefore, if aspiration were
suspected, I would observe the patient closely for 24 to 48 hours.
If you believed the patient had aspirated, what would you do?
I would immediately place the patient in the trendelenburg position, add air to
the tracheostomy cuff, and suction the trachea and oropharynx. Post-operative management
would include keeping the patient intubated, following arterial blood gases, and obtaining
serial chest x-rays. Regulation of the inspired oxygen concentration, tidal volume, and
PEEP, may be necessary to optimize ventilation and oxygenation. Bronchoscopy, pulmonary
lavage, and broad-spectrum antibiotics are only indicated in patients who have aspirated solid
material resulting in significant airway compromise.
After aspiration, are you administering steroids or abx?
I would not give steroids at this time since they have not been shown to help
in the immediate post-aspiration period and are not currently recommended. Likewise, the
routine use of prophylactic antibiotics is not recommended because antibiotic treatment may
alter the normal flora and promote colonization of resistant organisms. However, antibiotics
should be administered to patients with secondary bacterial pulmonary infection
demonstrated by positive Gram stain and cultures.
