Complete airway obstruction during awake fibreoptic intubation

Abstract

SummaryEpidural abscess is a well-recognised but rare complication of epidural catheter placement. We have found only five previous reports of epidural abscess from noncatheter-related administration of steroids and/or local anaesthetic. We describe a further case which led to critical illness and emphasise the association between diabetes mellitus and epidural infection.Keywords Anaesthetic techniques, regional; epidural, caudal. Complications; epidural abscess, paraplegia, diabetes. ...................................................................................... Correspondence to: Dr M. G. A. Palazzo Accepted: 21 January 1997 Case historyA 53-year-old man, with noninsulin-dependent diabetes mellitus, was referred for specialist opinion by his general practitioner because of right buttock pain radiating into the posterolateral thigh and calf.Examination revealed straight leg raising limited to 75Њ on the left and 55Њ on the right. Knee reflexes were present and equal but ankle reflexes were absent. The plantar responses were equivocal and power was normal in both legs. A clinical diagnosis was made of lumbosacral nerve root compression due to intervertebral disc pathology and a caudal epidural injection was performed.A mixture of procaine hydrochloride and triamcinolone acetonide (unlicensed for epidural use) was drawn up from new sterile vials, the tops of which had been swabbed with 0.5% chlorhexidine in 70% spirit and allowed to dry. The skin was cleaned with 0.5% chlorhexidine in 70% spirit and allowed to dry. A new sterile 2'' 21G needle was introduced through the sacral hiatus using a no-touch technique (without the use of gloves, gown or mask). A total of 22 ml of 0.5% procaine hydrochloride with 80 mg of triamcinolone acetonide was slowly injected into the epidural space. After an initial administration of 10 ml, continued injection produced bilateral leg pain. However, within minutes of completing the procedure re-examination revealed that straight leg raising was full and painfree at 85Њ. On review 3 weeks later the patient reported significant coccygeal pain which had made sitting difficult. In addition he had experienced 4 days of bilateral leg pain, radiating into the posterior thighs and calves which had necessitated bed rest. Examination revealed pain-free spinal movements and straight leg raising was pain-free at 80Њ. His neurological status was unremarkable except for absent ankle reflexes. A further caudal injection was performed in an identical way to the first, including drug volume and dosage. However, bilateral leg pain was provoked after 5 ml had been injected.The following day he felt feverish and had a headache. He developed rigors and was admitted to hospital 3 days after the second epidural injection. On examination he was afebrile, had a stiff neck but no focal neurological signs. His bladder was distended. Haematological investigation showed a white blood cell count of 24.6 × 10 9 .l ᮊ 1997 Blackwell Science LtdAn L 4/5 and L 5 /S 1 bilateral foraminal and nerve root...

The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study

“…It is also worth mentioning that 5% of the self-reported complications related to partial or complete compromise of airway patency simply with application of topical airway anesthesia. This has been previously described [28][29][30][31][32][33] but is an underappreciated phenomenon that underscores the need for an alternative plan even with the alleged safety margin provided by awake intubation.…”

Conscious sedation for awake fibreoptic intubation: a review of the literature

“…Avoidance of drugs that depress conscious level and ventilatory drive is usually recommended; however, application of topical anesthesia has been reported to precipitate complete airway obstruction. 63,65 Theoretically, remifentanil should not affect a patient's level of consciousness or airway patency and may be of benefit in patients where extreme anxiety or distress with resultant tachypnea and tachycardia may compound the problem. Nevertheless, hypoventilation associated with its use can compromise the airway, especially in this clinical setting, and low doses of remifentanil would be used only with extreme caution in these circumstances.…”

“…While no one would argue that this recommendation applies to any agent that acts by modulating the GABA A receptor, there is little evidence that sedation with an agent that depresses ventilation but not level of consciousness (remifentanil) or vice versa (dexmedetomidine) is more dangerous than conducting AFOI with LA alone. Topical anesthesia in patients with critical airway obstruction can be difficult to achieve, 62 and though a rarity, inadequate anesthesia of the larynx or even the application of topical anesthesia itself can precipitate total airway obstruction [63][64][65] Although there has been a recent description of the use of dexmedetomidine with no use of LA at all, 57 there is generally more evidence supporting the safe use of remifentanil in this fashion, at least in the context of patients without critical airway obstruction.…”

Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway

“…Complete airway obstruction after topical LA on and before instrumentation of the upper airway has also been reported by Shaw et al 10 in a patient with a goiter and abnormal pharyngeal/laryngeal anatomy causing functional obstruction, and by White et al 11 in a patient who had inhaled cocaine. Airway obstruction during manipulation of a fibreoptic bronchoscope in patients with other head and neck pathologies has also been reported.…”