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Morbidity & Mortatlity

Morbidity & Mortatlity. Nicole Weiss, MD August 24, 2011. 64 y/o male with a h/o of a-fib, presenting for a hybrid mini-maze. Height: Weight: Airway Exam: Malampatti : III Thyromental distance: II Mouth opening: II Thick Neck, Full Extension.

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Morbidity & Mortatlity

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  1. Morbidity & Mortatlity Nicole Weiss, MD August 24, 2011

  2. 64 y/o male with a h/o of a-fib, presenting for a hybrid mini-maze • Height: • Weight: • Airway Exam: • Malampatti: III • Thyromental distance: II • Mouth opening: II • Thick Neck, Full Extension

  3. ***The Airway***On the up side, we could ventilate • Attempt #1: Direct Laryngoscopy • Grade III/IV view; in light of DLT, handed over to staff • Attempt #2: Direct Laryngoscopy • 37 Fr DLT placed in esophagus • Attempt #3: Glidescope • Grade I view • Unable to pass DLT secondary to small mouth opening, difficult angle • Attempted to use eschmann with glidescope, but too flimsy to make curve • Placed a single lumen ETT • Attempt #4: Cook Catheter • Placed but unable to slide DLT over • Single lumen ETT placed again • Attempt #5: Smaller Cook Catheter • Still unable to pass DLT • Single lumen ETT placed again

  4. Case Aborted • Decision made to cancel the case • Considered bronchial blocker, univent tube • Safest option to simply stop • Plan: • Extubate in a controlled setting & reschedule the case • Pt taken to PACU intubated • Pt admitted overnight for observation and discharged home the following morning

  5. Unfortunately…this was not the end of the story • Patient continued to have persistent neck pain • Reassured • Two days later, still complaining of neck pain with an “expanding mass”, difficulty swallowing • Presented to VA Urgent Care • CT done…

  6. Parapharyngeal, paratonsillarabscess(5.5x2.6cm)

  7. Still not the end: • Admitted to the ICU • Placed on IV antibiotics • ENT took back to the OR for a neck exploration • Found 2cm laceration of the right pillar tract that communicated and had fistulized to the right neck • Right submandibular, parapharyngeal abscess • I&D grew out Strep • IV antibiotics continued in house • Feeding tube placed for patient to be NPO for one week

  8. The morbidity of intubation • Intubation far most common cause of laryngeal trauma • 10% of patients have demonstrable laryngeal pathology one day after short term intubation for surgery • Longer term intubation results in laryngotracheal injuries in 90% of patients with long term sequelae in 11% Flint: Cummings Otolaryngology: Head and Neck Surgery, 5th edition

  9. Was there a better option? • Glidescope or fiberoptic earlier? • Univent tube? • Good for challenging airways • Do not need to be exchanged after the case • Single lumen tube placed first with a cook catheter exchange • May have been successful if done prior to anyway airway trauma

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