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Novel Use of Nylon Epidural Catheter for Airway Topicalization During Video Laryngoscopy in a Critically Ill Post-Partum Patient
Abstract Number: S-56
Abstract Type: Case Report/Case Series
Introduction: Intubation for postpartum patients can be challenging. In the immediate post-partum period there is a significant increase in Mallampati score compared to the pre-labor airway. Decrease in pharyngeal area and edema may be contributing factors. These changes do not seem to reverse in the immediate post-partum period and can precipitate difficult or lost airway. When awake intubation is indicated, techniques for anesthetizing the airway may include transtracheal block or topicalized lidocaine. This invasive technique may not be suitable for all patients or providers. Use of a nylon epidural catheter through a fiberoptic bronchoscope for airway topicalization is described, but relies on patient cooperation. We report the novel use of a nylon epidural catheter for airway topicalization during video laryngoscopy in a critically ill post-partum patient.
Case: Patient is a 26 yo G3P2 at 40 weeks gestation who presented with profound dyspnea and repeated fetal decelerations. After emergent cesarean delivery under general anesthesia she was admitted to the ICU due to hemodynamic instability and pulmonary edema. She developed spontaneous pneumothorax, pneumonia, sepsis and renal failure. Post-operative day 2 the patient self-extubated and quickly deteriorated to respiratory distress. Cursory exam noted a morbidly obese woman in extremis, altered mentation, Mallampati 4, short TMD. Given immediate post-partum period, pneumothorax, tenuous hemodynamics, difficult airway and inability to cooperate with awake fiberoptic intubation, decision was made to topicalize the airway and intubate while maintaining spontaneous ventilation. 2% lidocaine was transorally applied to the oropharynx via a nylon epidural catheter, which was advanced until cough reflex was elicited. 50 mg of Ketamine was given as an amnestic agent. Patient was intubated quickly and atraumatically using a GlideScope under good conditions with minimal hemodynamic changes.
Discussion: The post-partum airway is challenging to anesthesia providers, particularly since the time to resolution of pregnancy changes are ill defined. Awake fiberoptic intubation is the gold standard in anticipated difficult airway, but may not be feasible in uncooperative patients or when time constraints exist. It is also suggested that awake fiberoptic intubation may have no benefit over awake video laryngoscopy when adequate topicalization is used. Use of epidural catheter with a bronchoscope to anesthetize the airway has been described, but not during video laryngoscopy in a spontaneously ventilating patient. This case describes the novel, efficacious and safe use of a nylon epidural catheter to facilitate airway topicalization during intubation in a post-partum patient in respiratory distress.
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