1Department of Cardiothoracic Anaesthesia, Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN, UK. 2Directorate of Anaesthesia and Intensive Care, City General, Newcastle Road, Stoke-on-Trent ST4 6QG, UK.*Corresponding author
Accepted for publication: March 19, 2001
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Abstract |
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Br J Anaesth 2001; 87: 3025
Keywords: veins, central vein cannulation; equipment, catheters, haemodialysis; complications, haemorrhage; intubation tracheal, gum-elastic bougie; coil embolization; measuring techniques, ultrasound
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Introduction |
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Case report |
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After 3 days, the patient required haemodialysis as her serum urea and creatinine concentrations were elevated (urea, 41 mmol litre1; creatinine, 587 µmol litre1). Insertion of a haemodialysis catheter was attempted via the internal jugular vein. After two unsuccessful attempts on the right side and one on the left, the dialysis catheter was inserted via the right femoral vein.
After the procedure, the patient developed a rapidly enlarging swelling round the neck. Two hours later, the patient was referred to the anaesthetic team for assessment of her airway. On examination, the patient was conscious and orientated but anxious. The neck swelling was huge and firm. It extended round the neck and up to the ears. The patients cardiovascular condition was stable. SpO2 was 93% on air. There was no evidence of stridor and the patients chest was clear to auscultation. However, the patient was drooling saliva and had dysphagia and hoarseness because of compression of the neck veins by the swelling with oedema and obstruction in the pharynx and larynx. After discussion with the consultant anaesthetist, it was felt that the safest course would be to transfer the patient to the operating theatre, as difficulty with intubation was anticipated and an attempt at awake fibre-optic intubation was planned. It was also planned to have a full range of equipment available for managing difficult airways.
An operating theatre was organized and the patient immediately transferred there from the ward. During the transfer, the patient developed sudden airway obstruction, became cyanosed and had a cardiorespiratory arrest. Cardiopulmonary resuscitation was commenced. On arrival in the anaesthetic room, epinephrine 1 mg was administered intravenously and resuscitation was continued. Direct laryngoscopy was performed but no landmarks (including the epiglottis) could be seen because of the oedematous soft tissue swelling. A 7 mm tracheal tube was passed blindly but failed to enter the trachea. A gum-elastic bougie was then passed blindly through the soft tissue and an 8 mm tracheal tube was railroaded over the bougie. The tube was confirmed to be in the trachea by capnography. Cardiac output was restored on establishing artificial ventilation. The patient made spontaneous attempts to breathe, but was sedated, paralysed and transferred to the intensive care unit for further management.
In the intensive care unit, the patient was positioned with head-up tilt and dexamethasone 8 mg was given. Investigations showed abnormal blood clotting (international normalized ratio, 1.8; activated partial thromboplastin time ratio, >5 (the normal range is 0.81.17); Hb, 6 g dl1) and it was realized that the patient had received heparin 5000 i.u. intravenously before insertion of the haemodialysis catheter. Red blood cells, fresh frozen plasma and protamine sulphate 50 mg were given. Coagulation tests were repeated after 2 h and were within the normal range. However, the neck swelling continued to increase in size, extending to the chest, shoulders and occiput (Figure 1). Chest x-ray showed a widened mediastinum.
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Discussion |
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Though the abnormal clotting profile was not the main cause of bleeding in this case, we feel that it would have been a compounding factor in the rapid progression of the neck haematoma. This emphasizes the desirability of ensuring normal clotting function before attempting to cannulate the central vein.
Ultrasound-guided insertion of a central line has been shown to be safe and reliable, and can minimize several of the complications associated with central venous puncture.13 14 The technique may be especially beneficial in high-risk patients, e.g. those with coagulation defects (inherited and acquired), obesity or haemodynamic instability. Moreover, inability to position the patient in the supine or Trendelenburg position (e.g. because of head injury or high intracranial pressure) or inability to rotate the neck (e.g. in patients with cervical spine injury) make insertion of a central line technically difficult with an increased risk of complications. It has been shown that ultrasound guidance increases the success rate and reduces the complication rate of central venous access in patients at high risk of complications or with unusual anatomy.15 We, therefore, recommend that the technique should be adopted to gain central venous access in difficult and high-risk cases.
This case highlights the importance of recognizing impending airway obstruction and the need for prompt referral to the anaesthetic team.
The management of patients with obstructed airway has been criticized in recent years16 and it is suggested that each patient should be managed according to the level and nature of the obstruction and the clinical circumstances.17 Fibreoptic intubation may not be the answer for every airway problem and anaesthetists should be able to use other options. There have been several case reports where the gum-elastic bougie has been helpful in managing the difficult airway.1820 It has also been shown that tracheal intubation can be achieved more quickly and safely with the help of the bougie21. Although the gum-elastic bougie is commonly used in the UK, it is seldom used in the USA.22 We believe that rapid tracheal intubation in our patient could not have been achieved by any other means. Similar circumstances may arise from a haematoma following carotid artery surgery, thyroid surgery, cervical spine surgery, radical neck dissection or trauma. The gum-elastic bougie may be useful in such circumstances and we recommend that every anaesthetist should be familiar with it.
Finally, this case illustrates the successful management of ruptured superior thyroid artery by interventional radiology. Though surgical exploration was considered as a means of controlling the haemorrhage, the surgeons were not sure whether the haemorrhage was from the right or left side of the neck. Moreover, the chest x-ray showed a widened mediastinum which raised the suspicion of possible injury to a major blood vessel such as the arch of the aorta, innominate vessels or subclavian vessels. Carotid angiography was helpful in the diagnosis and treatment of the haematoma. Cases of vascular accidents and intractable haemorrhage have been managed by coil embolization.23 24 We feel that this appears to be a rapid and effective method of treating vascular accidents and can be particularly helpful in cases with difficult diagnoses.
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References |
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