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Letters to Editor
is a better advocated technique. This is very easy, reliable,
and rewarding but should be practiced on normal
patients for easy application in actual difficult cases.[1]
Apurva Mittal, Yogita Dwivedi, Komal Joshi, Arpita Saxena,
Amrita Gupta
Department of Anesthesiology and Critical Care,
SN Medical College, Agra, Uttar Pradesh, India
Address for correspondence:
Dr. Apurva Mittal,
Department of Anesthesiology and Critical Care,
SN Medical College, Agra, Uttar Pradesh, India.
E-mail: apoorvsn@yahoo.com
REFERENCES
1. Potdar M, Patel RD, Dewoolkar LV. Molar intubation for Intra
oral swellings: Our Experience. Ind J Anaes 2008:52;861.
2. Vashist M, Miglani HP. Approach to difficult and compromised
airway in neonatal and paediatric age group patients. Ind J
Anaes 2008;52:273-81.
3. Henderson JJ. The use of Paraglossal straight blade laryngoscopy
in difficult tracheal intubation. Anaesthesia 1997:52;552-60.
4. Yamamoto K, Tsubokawa T, Ohmura S, Itoh H, Kobayashi T.
Left molar approach improves the laryngeal view in patients
with difficult laryngoscopy. Anesthesiology 2000;92:70-4.
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DOI:
10.4103/0019-5049.82657
Dangerous sedation in an obese
patient
Sir,
Obesity is an epidemic in much of the Western world
and is invading the Indian population also. A 50-year-
old man, an engineer, presented for anaesthesia
for Eversion Tunica Vaginalis sac. He was obese
(178 cm tall, weight 125 kg, Body Mass Index – 42),
hypertensive and admitted to smoking five cigarettes
per day and moderate alcohol intake. Blood pressure
was 140/90 mm Hg and ElectroCardioGram showed
sinus tachycardia and Left Ventricular Hypertrophy.
Airway examination revealed normal neck movements,
dentition, mouth opening and a Malampatti score of
3. Neck circumference and thyromental distance were
47 cm (19 inches) and 6 cm respectively. Investigations
including thyroid function tests were within normal
Indian Journal of Anaesthesia | Vol. 55| Issue 3 | May-Jun 2011
limits except for SGOT and SGPT (Serum Glutamic
Oxaloacetic Transaminase and Serum Glutamic
Pyruvic Transaminase) which were elevated to 638 and
619 IU/L respectively (alcohol-induced). He was pre-
medicated with 0.5 mg Alprazolam (half life 12 h) on
the previous night. On the morning of surgery, the ward
nurse reported the patient to be excessively drowsy and
transferred him to the operation room, where he was
found to have obstructed breathing. There was central
cyanosis, pulse was 98/min, bounding, blood pressure
180/98 mm Hg. Auscultation of chest revealed normal
heart sound and bilateral equal air entry. Saturation was
74% in room air. Bag, mask ventilation was carried out
with 100% oxygen using closed circuit system and the
saturation increased to 98%. The patient was propped
up and after 20 min, the patient started responding to
commands. The arterial blood gas analysis revealed
severe respiratory acidosis with a PaCO2 of 104 mmHg.
Direct laryngoscopy did not reveal any intraluminal
airway obstruction. Non-invasive ventilation, BiPAP
mode was initiated in propped up position in the
Post Anaesthesia Care Unit (PACU). Echocardiogram
revealed mild Pulmonary Arterial Hypertension
(PAH), mild Right Ventricular (RV) enlargement and
LVH. Serial Trop – I values were negative. Pulmonary
embolism was ruled out by computed tomography
(CT) pulmonary angiogram. After 48 h in the PACU,
when he could maintain >90% saturation in room air,
he was shifted out. Pulmonary function test revealed
mixed type airway disease and polysomnography
revealed severe Obstructive Sleep Apnoea (OSA) with
Respiratory Disturbance Index > 37/h. Patient was of
ASA -III as far as OSA was concerned and OSA scoring
was 4 suggestive of increased peri-operative risk.[1] The
patient retrospectively revealed a history of snoring,
getting up from sleep five to eight times and excessive
daytime sleepiness at work and while driving.
Prolonged sleep after alcohol intake was reported but
not loss of consciousness. Patient was discharged on
non-invasive ventilation, BiPAP mode, advised weight
reduction and tablet Amlodipine 5 mg twice daily.
OSA is a common finding in obese patients and
clinical features include loud snoring (95%), daytime
sleepiness (90%), unrefreshing sleep (40%), morning
headache, nocturnal choking, and mood changes. [2,3]
Sedation compromises arousal mechanism which
protects the patient from consequence of breathing
disturbance.[3] In this case altered level of consciousness
was because of hypercarbia, which cleared with
assisted ventilation. Alcoholic liver disease could
have prolonged the action of Alprazolam.
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Letters to Editor
Polysomnography is the gold standard for the
diagnosis of OSA.[1,2] Regional and local anaesthesia are
relatively safe. If sedation is considered, capnography
and Continuous Positive Airway Pressure (CPAP)
may be needed. In anticipated difficult airway, awake
fibreoptic intubation is optimal. Rapid sequence
induction is advisable in emergency cases.[4] Short-
acting drugs like Remifentanyl and Dexmedetomedine
are preferred. [3,5] Extubation should be in lateral or
semi-upright position when fully awake, after complete
recovery from neuromuscular block. Postoperatively
they should be managed in the high dependency area
in the above position. CPAP and oxygen is used to
keep saturation above 90% during sleep.[3]
High degree of suspicion of OSA should be maintained
in an obese patient as it is often missed. As Dodds
remarked, the question “Do you snore?” should be
asked in all preoperative assessments.[6]
Leena Rachel Koshy, Shaloo Ipe, Saramma P Abraham,
Grace Maria George
Department of Anaesthesiology,
MOSC Medical College, Kolenchery, Kerala, India
Address for correspondence:
Dr. Leena Rachel Koshy,
Department of Anaesthesiology,
MOSC Medical College, Kolenchery, Kerala - 682 311, India.
E-mail: leenarachel@hotmail.com
REFERENCES
1. Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT,
Coté CJ, et al. Practice guidelines for the perioperative
management of patients with obstructive sleep apnea: a report
by the American Society of Anesthesiologists Task Force on
Perioperative Management of patients with obstructive sleep
apnea. Anesthesiology 2006;104:1081-93.
2. Douglas NJ. The sleep apnoea/hypopnoea syndrome and
snoring. BMJ 1993;306:1057-60.
3. Loadsmam JA, Hillman DR. Anesthesia and sleep apnoea. Br J
Anaesth 2001;86:254-66.
4. Chung SA, Yuan H, Chung F. A systemic review of obstructive
sleep apnea and its implication for anaesthesiologists. Anesth
Analg 2008;107:1543-63.
5. Hofer RE, Sprung J, Sarr MG, Wedel DJ. Anesthesia for
patients with morbid obesity using dexmedetomidine without
narcotics. Can J Anaesth 2005;52:176-80.
6. Dodds C. Sleep apnoea and anaesthesia. Recent Adv Anaesth
Analg 1994;179-95.
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DOI:
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314
Use of intubating laryngeal mask
airway for intubation in patient
with massive goitrous thyroid
Sir,
Large thyroid masses are a nightmare for the
anaesthesiologist not only because of thyroid
endocrinal abnormality but also because of difficult
airway. [1] Fiberoptic bronchoscopy for tracheal
intubation is considered the gold standard in such
scenarios but may not be available sometimes.[2,3] We
report a successful airway management in a patient
with a large thyroid mass with distorted laryngeal
anatomy using an intubating laryngeal mask airway
(ILMA).
A 65-year-old male was scheduled for total
thyroidectomy for multinodular goitre. Patient
complained of progressively increasing swelling
over neck and difficulty in speaking, swallowing
and breathing since last six months. The
swelling extended superiorly up to the chin, laterally
up to the posterior border of sternocleidomastoid
and below up to the suprasternal notch (size, 30
× 20 cm) [Figure 1a and b]. There was prominence
of veins over the mass and also over the anterior
chest. Airway assessment revealed adequate mouth
opening, modified mallampati class MMC II and neck
movements were restricted. Investigations revealed
normal haemogram, biochemical and thyroid profile.
Indirect laryngoscopy revealed fixed left vocal cord
and left pyriform fossa was not opening up. Soft
tissue neck X-ray revealed compression and right
deviation of trachea [Figure 2]. Contrast-enhanced
computed tomography scan of neck and chest showed
compression and right anterior displacement of the
trachea. After overnight fasting, pantoprazole (40
mg) and glycopyrrolate (0.2 mg) was administered
in the morning of surgery. In the operation room,
routine monitors were attached. Lignocaine (4%)
gargles were done. Left radial artery was cannulated.
Anaesthesia was induced with sevoflurane (6%)
in 100% oxygen. After lignocaine spray (10%),
laryngoscopy revealed Cormack lehane CL Grade III.
Even after manipulating the thyroid mass externally,
the glottic chink could not be visualised. We could
only appreciate a small hole in the left lateral aspect
of the oral cavity and glottis was oedematous. We
tried to negotiate the tube with a stylet but could
Indian Journal of Anaesthesia | Vol. 55| Issue 3 | May-Jun 2011