• Users Online: 442
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 33-35

Anaesthetic Management of Difficult Airway and Intravenous Access due to Post Burn Contracture


Department of Anaesthesia, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India

Date of Web Publication12-Feb-2016

Correspondence Address:
Rajnish Kumar
Assistant Professor Dept. of Anesthesia IGIMS, Patna-14
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
  Abstract 


We describe anaesthetic management of 41-year-old female admitted for total abdominal hysterectomy having history of 35% full thickness burn with scar marks over face, neck, both upper limbs whole of anterior abdomen and inguinal region on both sides. Graft was taken from both thigh and right leg which had left scar mark. With burn contractures over neck and involvement of limbs she was difficult to intubate and difficult intravenous access as well. Keeping in view the difficult airway access she was planned for combined spinal epidural anaesthesia. Gaining intravenous access posed a challenge because of burns scars on upper limbs, graft scars on both thigh and right leg. Central venous cannulation was not attempted because of distorted anatomy of neck. Left leg was warmed by wrapping it in towels moistened with warm water to dilate veins and intravenous line secured. Because of pain experienced by patient after an hour of starting surgery general anaesthesia was given and airway secured with i- Gel, which went uneventful.

Keywords: Post burn contracture, Difficult airway, Difficult intravenous access


How to cite this article:
Kumar R, Quari H, Raj D. Anaesthetic Management of Difficult Airway and Intravenous Access due to Post Burn Contracture. J Indira Gandhi Inst Med Sci 2016;2:33-5

How to cite this URL:
Kumar R, Quari H, Raj D. Anaesthetic Management of Difficult Airway and Intravenous Access due to Post Burn Contracture. J Indira Gandhi Inst Med Sci [serial online] 2016 [cited 2022 Oct 2];2:33-5. Available from: http://www.jigims.co.in/text.asp?2016/2/1/33/303368




  Introduction: Top


Management of the difficult airway remain one of the most relevant and challenging task for anaesthesia care provider. The American Society of Anesthesiologists Difficult Airway Management Algorithm recommendation of initial direct laryngoscopy may not be appropriate for these complicated patients.[1]

Immediately after a burn the body undergoes complex pathological effects, influencing numerous body functions and leading to severe consequences for the affected patient. In industrial countries the number of severely burned patients is declining which may be partly due to developments in health and safety systems in companies and also due to technical innovations.[2] The outcome for both survival and quality of life, has improved dramatically for burn patients over the past 20 years. However, airway and respiratory complications remain a common cause of morbidity and mortality. The airway of the burn patient presents special problems and requires certain considerations, not only in the initial stage of the burn injury but also daily during the hospital course and, in some patients, even after the burn injury throughout their life.[3]


  Case Report: Top


41 year old female was admitted with complaints of menorrhagia since 2 year. She was on progesterone 5mg thrice daily since 4 months. Ultrasound abdomen showed fibroid uterus sized 18cm by 18cm. She was planned for total abdominal hysterectomy. She had history of 35 % full thickness burn in year 1997 and burn scar mark were found over face, neck, both upper limbs, partial Amputated fingers of upper limb, chest and whole anterior part of abdominal compartment including both inguinal regions and no burn was seen over back [Figure 1]. She had history of previous three surgeries under general anaesthesia for release of neck contracture, release of web around finger and amputation of multiple fingers till year 2000 which were uneventful. There was also scar mark of skin graft taken from large area of both right and left thigh and right leg and a scar mark of venesection was there on right foot.
Figure 1: Partially Amputated Finger both upper limb and post burn contracture

Click here to view


The patient had Mallampati grade IV on Preoperative check-up of airway examination. The mouth opening was approximately 2.5 cm, thyromental distance was 5cm, and she was unable to extend the neck [Figure 2]. She was known case of hypertension and blood pressure was controlled on Amlodipine 5mg once daily. Her hemoglobin was 9gm% but other laboratory investigations were unremarkable. She was anticipated as difficult intravenous cannulations and difficult airway. As it was an anticipated difficult airway, hence preoperative preparation for predicted difficult airway was done. Difficult airway cart was readied which included necessary masks of appropriate sizes, airways of appropriate sizes, endotracheal tubes, laryngeal mask airway, I Gel, stylets and bougie were kept ready. Surgeon was also available for emergency tracheostomy, if necessary. Keeping in view difficult intubation, we planned surgery under combined spinal epidural anaesthesia. The whole procedure was explained to patient and relatives and written informed high risk consent was obtained.
Figure 2: Post Burn Neck contracture and limited mouth opening

Click here to view


She was premedicated with oral pantoprazole 40 mg night before and on morning day of surgery. In operation room after monitoring parameter like ECG, NIBP and SPO2, we attempted for intravenous cannulations in both the upper limbs but it was not possible due to burn induced fibrosis. We also attempted cannulations in left leg but without success. Next Left leg was warmed by wrapping it in towels moistened with warm water to dilate veins over left calf muscle for 10 minutes. We applied tourniquet in left thigh and found two veins, two 20 G intravenous lines were inserted, secured with adhesive tape and intravenous fluid, ringer lactate was started. In sitting position in L2- L3 space, subarachnoid block was done with 0.5% bupivacaine 10mg and epidural catheter was inserted in same space. She complained of pain at surgical site after 1 hour of start of surgery and received epidural bupivacaine 0.5% 10ml incrementally and intravenous fentanyl 50 mcg, but pain was not controlled. Now we provided general anaesthesia using oxygen, fentanyl 50mcg, Propofol 150mg and isoflurane we inserted size three i-Gel. After confirming adequate ventilation, atracurium 25mg was given as muscle relaxant. Anaesthesia was maintained by a mixture of oxygen, nitrous oxide, isoflurane and intermittent dose of atracurium. Intraoperative period was uneventful. Reversal was given at the end of surgery using neostigmine and glycopyrolate and i- Gel was removed after reversal from muscle relaxation and appearance of airway reflexes. For Post operative analgesia, epidural morphine 3mg was given 12hrly along with intravenous infusion paracitamol lgram thrice daily, diclofenac 75 mg 12 hourly. After 72 hours epidural catheter was removed. In view of difficult intravenous access all drugs were given in diluted form and converted to all oral drugs after 72 hours. She was discharge on sixth postoperative day uneventfully.


  Discussion Top


Potential risk of the difficult airway was primary concern in the present case. Contractures of the mouth, lead to limited mouth opening of 2.5 cm only causing a potentially difficult airway. There was possibility of hypoxia and increased morbidity or mortality with Difficult airway[4],[5], hence It was also decided before hand that if successful ventilation and intubation is unsuccessful , an emergent tracheostomy will be done right away for securing the airway. In our case, we used general anaesthesia after an hour of start of surgery, as the patient complained of pain, which could have occurred because the large sized fibroid uterus lead to increase in skin incision size. We do not have Fiberoptic bronchoscope which is ideal for intubation in this difficult airway situation and we also didn't attempt for intubation as well. We used supraglottic device i- gel because it can provide easy insertion, better airway seal and can prevent aspiration. Singh J et al compared the performance of i-gel supraglottic airway with classic LMA (Laryngeal Mask Airway) in difficult airway management in post burn neck contracture patients and assessed the feasibility of i-gel use for emergency airway management in difficult airway situation with reduced neck movement and limited mouth opening. The study shows i-gel was successfully inserted in all patients and allowed effective controlled ventilation in 91.7% in the first attempt as against classic LMA use, whereas it was possible only in 79.16%.[6] It was shown that the i-gel is easier and quicker to insert at the first attempt than the classic LMA which correlates with the study done using various manikins for the beginners compared with LMA insertion.[7] In another study done by Shin WJ et al. Reported that the airway seal pressure achieved with the i-gel was greater than that with classic LMA.[8]

Difficult intravenous access in this case was due to post burn contracture at most sites. We applied moist heat in left leg for venous access because it produces vasodilatation which increased the blood flow to the affected area by bringing more oxygen and nutrients. There appears to be a direct effect on the state of dilatation of the capillaries, arterioles and venules when there is temperature elevation. The moist heat therapy in the current study was effective in improving the status of veins, though different percentages of subjects have different vein status score. Following the intervention 40% had vein status score of 5 i.e. their veins were clearly visible and easily palpable. Keeping the patient warm for the success of intravenous insertion has been suggested by Rosenthal.[9] Ultrasound guidance for venous access was initially studied for central access and shown to increase success rates and decrease complications. Ultrasound guidance provides real time 2-D image of blood vessels.[10]


  Conclusion: Top


Post burn contracture of the neck with limited neck movement pose significant challenges to the anaesthetist. Before taking up such cases there should be a thorough understanding of difficulty and meticulous planning by a team for difficult airway. A surgeon should be called before hand to intervene for emergent tracheotomy placement if needed. In such type of cases, i-gel is a good alternative to maintain airway in intraoperative period.



 
  References Top

1.
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98:1269-77.  Back to cited text no. 1
    
2.
Timo A. Spanholtz, Dr. med., M.D, Panagiotis Theodorou, Dr. med., Peymaneh Amini, Dr. med., Gerald Spilker, Prof. Dr. med. Dr. habil. Severe Burn Injuries Acute and Long-Term Treatment.deutsches arzteblatt international 2009 sep;106(38) 607-613  Back to cited text no. 2
    
3.
Airway Mannagement in Burn Patients in: Carin A. Hagbergs , Hagberg: Benumof’s Airway Management, 2nd ed (1)  Back to cited text no. 3
    
4.
Kaur K, Taxak S, Hooda S, Chowdary G, Johar S. Airway management of Post burn contracture neck - An anaesthesiologist’s challenge. Egypt J Anaesth 2012;28:233-6  Back to cited text no. 4
    
5.
Sahajanandhan R, Saravanam PA, Ponnaiah M, Jacob Jl, Gupta AK, Nambi GI. Post burn contracture neck with extreme microstomia and fibrosed obliterated nose - A unique airway challenge! J Anaesth Clin Pharmacol 2010; 26:267-9.  Back to cited text no. 5
    
6.
Singh J, Yadav MK, Marahatta SB, Shrestha BL. Randomized crossover comparison of the laryngeal mask airway classic with i-gel laryngeal mask airway in the management of difficult airway in post burn neck contracture patients. Indian J Anaesth 2012; 56:348-52.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Livitan R M, Kinkle W C. Initial anatomic investigations of the airway: A novel supraglotic airway without inflatable cuff. Anaesthesia 2005; 60:1022-6.  Back to cited text no. 7
    
8.
Shin WJ, Cheong YS, Yang HS, Nishiyama T. The supraglottic airway i- gel in comparison with ProSeal Laryngeal mask airway and classic laryngeal mask airway in anaesthetized patients. Eur J Anaesthesiol 2010;27:588-601  Back to cited text no. 8
    
9.
Rosenthal K. Tailor your IV insertion technique for special populations. Nursing 2005 May: 35(5):36-41.  Back to cited text no. 9
    
10.
Costantino, T. G., Parikh, A. K., Satz, W. A., & Fijtik, J. P. (2005). Ultasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Annals of Emergency Medicine 2004; 46(5). 456-461.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction:
Case Report:
Discussion
Conclusion:
References
Article Figures

 Article Access Statistics
    Viewed772    
    Printed26    
    Emailed0    
    PDF Downloaded41    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]