Tetraplegia After Coronary Artery Bypass Grafting in a Patient with Undiagnosed Cervical Stenosis

Abstract

References 1. Schlesinger AE, Tucker GF, Young SA. Postintubation granuloma of the anterior subglottic larynx. Int J Pediatr Otorhinolaryngol 1985;10:279 -84. 2. Drosnes DL, Zwillenberg DA. Laryngeal granulomatous polyp after short term intubation of child.Often, the anesthesiologist is confronted with the management of a difficult airway outside the operating room setting. This can be quite a challenge and the knowledge of different techniques can prove to be life-saving. At our institution, a case of unexpected difficult airway was managed successfully using a "through the LMA" fiberoptic intubation. The on-call team was called to emergently intubate a patient on the floor. Initial intubation was attempted by the resident after appropriate medication was administered. No visualization of posterior pharyngeal structures was appreciated even after repositioning the head for a second look and a laryngeal mask airway (LMA) #4 (Laryngeal Mask Company Limited, Mahe, Seychelles) was inserted as per the difficult airway algorithm (1). The fiberoptic airway cart was obtained and a 6.0 cuffed endotracheal tube (ETT) (Mallinckrodt Inc., St. Louis, MO) was prepared and fed over a lubricated pediatric bronchoscope. The patient was induced with 20 mg etomidate and longer-acting muscle relaxant, cis-atracurium 10 mg, was administered. The LMA was removed and a direct laryngoscopy was attempted by the attending anesthesiologist yielding the same result. While the LMA was removed, the two plastic bars on the inside were cut away and then reinserted without difficulties (Fig. 1). Correct position was confirmed with auscultation and confirmation of carbon dioxide. The bronchoscope was then inserted through the LMA and into the trachea of the patient without difficulty. The ETT advanced over the bronchoscope and was left in the trachea while the bronchoscope was withdrawn. The distal end of the ETT was verified to be in the trachea of the patient. A COOK airway exchanger catheter, (Bloomington IN), for ETT with internal diameter larger than 4 mm was passed through the ETT. A second ETT of the same diameter was inserted over the tube exchanger and the first ETT was advanced another 3 cm, the LMA was then deflated and removed while the combination of both ETTs and the COOK tube exchanger were held in place (Fig. 2). Once the LMA was removed, the second ETT tube and the COOK connector were removed as well. The connector to the first ETT was inserted and connected to the manual ventilation bag. Carbon dioxide was confirmed and the position of the ETT was fiberoptically reassessed. The patient remained stable throughout.Difficult airway situations can occur at any time and are particularly challenging in the settings outside the operating room because conditions may be suboptimal and there may be limited access to supporting equipment. The difficult airway algorithm (1) requires the availability of an LMA, which is used to bridge the time until a more secure airway, i.e., endotracheal tube, is inserted. Maintaining the airway with an L...

Paraplegia after Gastrectomy in a Patient with Cervical Disc Herniation: A Case Report and Review of Literature

“…This could be explained by the narrower spinal canal anatomy among Asians [9, 13, 14]. In the present case, the patient had spinal canal stenosis which made him more vulnerable to compressive disturbances [15, 16]. To make things worse, the patient did not mention his previous cervical spondylosis history.…”

Quadriplegia post-coronary artery bypass graft surgery: an unusual case

“…Joint discussions between the anesthetist and the surgical team came up with a hypothesis to explain the bleeding in the spinal cord: the way the shoulder roll is placed to lift up the chest could inadvertently extend the neck, resulting in tearing of a vulnerable or stretched venous plexus on the cords, and also cause further herniation of intervertebral discs. 7,8 Antiplatelet agents or anticoagulation could intensify and prolong any bleeding, worsening the situation. A possible solution for the vulnerable patient with neck stiffness and on antiplatelets is to perform the operation without using a shoulder positioning roll.…”

Neurological deterioration during intubation in cervical spine disorders

“…Intraoperative SCI and neurological deterioration can occur even in the absence of cervical instability. [ 21 22 23 24 25 ]…”