Iatrogenic CVCI

Started by jafo1964, February 20, 2008, 05:05:06 PM

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jafo1964

65 year old male had Ca oesophagus middle 3rd. Underwent a thoracotomy - Oesophageal dissection - mobilization of stomach through the mediastinum and anastomosis in the neck.
Airway was Cormack class 2a and intra-op was uneventful
received 24 hours of post-op ventilation and on day 2 was sequentially stepped down and put on T piece SBT. He had copious lung secretions and was on appropriate nebulized and IV therapy
I am on call and we are waiting for ABG results before we extubate him. He has a bout of severe cough and totally obstructs his ETT with all features of upper airway obstruction. Suction catheter will not pass.
Since I was waiting to extubate anyway, I removed the ETT. I choose not extubate over GEB for fear of pushing the mucus plug into the bronchus and the attendant problems.
Post extubation, patient is unable to breath. IPPV attempted with Ambu bag but no air moving into lungs
Emergent re-intubation planned - laryngoscopy - no sturcture can be identified - just edema everywhere and everything looks like a bunch of grapes.
2 Blind attempts at intubating with GEB got us only into the esophagus
Still cannot ventilate at all and meanwhile patient dropping saturation very fast into low 50's

CVCI scenario - ? induced by me
Had a few helping hands around. 2 persons continue to attempt mask ventilation. I opened the cricothyroid membrane (Emergent surgical airway)  with a 11 blade. Antr jugular vein bleed managed with compression with pad.
smallest ETT available at hand is 6.5 mm.
Difficult to get it into trachea. Used a large straight artery forceps to hold the opeing wide while someone passed the ETT. Ambu ventilation commenced with 100% O2. Sats and consciousness improved
Got urgent ENT consult and got a regular tracheostomy done and cricothyrotomy wound sutured closed

Patient is doing absolutely fine. Thankfully we managed to avoid complications of hypoxia
1 week after the incident arranged for a videa-laryngoscopic examination. Severe edema still persists. ENT people stopped at the epiglottis edema itself and did not want to proceed further

Can the gastric acid from the stomach in the neck be responsible for this edema

By the way this is only the 2nd cricothyrotomy i have attempted in my entire career. In the first instance i failed to save the patient

THE LESSONS I learnt
1. Even if there is ETT obstruction extubate over GEB
2. Cricothyrotomy can be life saving
3. In real life rapidly deteriorating situation, cricothyrotomy is difficult to perform. Theory makes it sound simple. So please attend regular airway workshops to hone up your skills

COULD things have been done more safely ?

yogenbhatt1

My Complements for a presence of mind at the correct time. It is not easy to take a decision like that at the spur of moment, though it is mentioned in all books and studies.

yogenbhatt1

Back in action after a while.
Regards to all, I really missed you all.
A case where I was not suscessful like our friend dr. JAFO.
It was a case of organophospharous poisoning. A young fit lady, 15 days after a normal delivery. She was on venti with trachyostomy. Showed very slow but steady improvement. On 12th day I was called by ICCU team, as they were not satisfied with ventilation. I went there and realised that it is probably trachy problem. She was on SIMV with only 4 BPM as support. I removed the trachy tube and wanted to change, if needed. It looked good to me. I put it back, and to my amazement it would not go in.
I tried and tried, over a GEB too, but no help. Pt became bad. I was alone on a Sunday evening, and now getting frantic. I tried putting a standard endotracheal small size tube, and started ventillating. Same difficulty I got which I was getting before I started. Bag was too tight. Now I saw signs of mediastinal gas collection. I knew, some where the trachy has given way, may be by me, or the previous ppl who attemted. I eventually lost the patient. And still feel bad about it.
What you all think must have happened?
I present my cases, with full knowledge that there will be nasty comments. But lets not be afraid to face them, if me, our others can learn from it.
Regards.
Dr. Bhatt