UBP 6.5 (Short Form): ENT – Submandibular Abscess Flashcards
Down Syndrome/Airway Management/Atlanto-Occipital Dislocation/Preoperative Respiratory Distress/Full Stomach/Difficult Intravenous Access/Subglottic Stenosis/Bronchospasm/ Pulmonary Aspiration/Ventilator Management
What are your initial concerns with this patient?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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% SpO2) 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 the patient’s airway?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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 radiographs 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, woud 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?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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 SaO2 of 91% on room air?
How will it affect your anesthetic management?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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 woud 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 seadtion 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?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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 unlikley 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?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
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?
(An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient has Down syndrome and is uncooperative. Her mother cares for her at home and states that she has noticed significant drooling and difficulty swallowing over the last 2 days. She also states that her daughter ate part of a bowl of soup one hour ago. The patient will not cooperate for a CT scan. There is no other significant medical or anesthetic history. Vital Signs: BP = 140/90 mmHg, P = 77, RR = 25, T = 103.5 F, SaO2 = 91% on room air.)
In this emergent case, i would not delay treatment for additional lab work.
However, if there were time, and the patient was cooperative, I would order a urine HCG to identify pregnancy, a chest xray to aid in assessing her acute pulmonary distress, and cervical spine radiographs or a head/neck CT to identify and evaluate atlanto-occipital dislocation.
