I recently had a case of a man who had a history of anaphylaxis to a muscle relaxant (?which) without skin testing to confirm. He was having a thyroidectomy. I intubated him using lidocaine spray and deep propofol anesthesia. It all went smoothly.
As I extubated, I check his cords at the request of the surgeon. Symmetrical, midline, moving with repiration.
After he woke up, he had a hoarse voice. The surgeon was adamant it was not his fault as he had visualized the recurrent laryngeal nerve well (he said), and went on to blame my clumsy relaxant-free intubation in front of the patient!
I do relaxant-free intubations commonly (almost routinely) on children and often on adults especially for short cases. And especially, especially with a vague history of anaphylaxis to muscle relaxants. What is the incidence of cord injury when intubating poorly paralysed cords?
I should say that I get them evry deep on propofol and sevo, spray cords generously with LA, and wait 30-45 secodns for the spray to work before I intubate. Rarely can I see a difference in cord position between this type of intubation and a muscle relaxand one.
Incidentally, the patients voice got better after three days.
Quote from: Therese Huntly on December 08, 2004, 10:17:33 AM
Incidentally, the patients voice got better after three days.
The fact that his voice returned to normal confirms it was not a surgical error, and that the intubation was the probably cause.
I too intubate children without relaxant, and the trick seems to be to be slick. You get one shot at it, and if you get it in, it is smooth sailing. If you miss first go, the cords respond, spasm and the next passage of the tube will be tighter and potentially more traumatic.
Jason P
It is well-known that intubating through poorly relaxed cords has a high incidence of cord damage.
>:D