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Geleophysic Dysplasia, Difficult Airway, and Needle Phobia: Threading the Needle, Balancing Patient Autonomy & Safety
Abstract Number: F-52
Abstract Type: Case Report/Case Series
A 23 year old non-laboring gravida 1 at term, with geleophysic dysplasia and dwarfism, scoliosis, chronic pain, and tracheal stenosis presented for elective cesarean delivery. Two prior intubations were successful, but difficult, requiring a 5.0 ETT, first using a videoscope and bougie (grade 4 view), then a fiberoptic scope. Unfortunately, she had extreme needle phobia. For her, risks of both neuraxial and general anesthesia (GA) were considerable, yet uncertain, including unpredictable spread of intrathecal local anesthetics, potential need for urgent intubation, and risk of failed intubation. Despite thorough and supportive discussion of risks/benefits of general and spinal anesthesia (SA), she refused our strong recommendation for SA, insisting on GA. She agreed to attempt tracheal intubation under GA, and possible need to awaken her and perform SA should intubation be impossible.
After GI prophylaxis, meticulous positioning, and pre-oxygenation, GA was induced with propofol and succinylcholine (1mg/kg). Intubation was impossible after two attempts with a video laryngoscope and 5.0 ETT. Mask ventilation was acceptable, but challenging. She emerged from GA with self-limited stridor that resolved. She was informed of the difficulty and agreed to neuraxial anesthesia, which was successful, but also proved very difficult. Tuohy needle placement took 46 min, after failed attempt at CSE placement. Achieving adequate surgical block took 88 min more.
This case illustrates challenges anesthetizing a parturient with geleophysic dysplasia with dwarfism and tracheal stenosis. It also highlights the equally difficult balance physicians, especially anesthesiologists, must strike between patient autonomy and safety when counseling patients regarding anesthetic options. Regarding patient autonomy in medical decision making, advocates suggest that physicians should guide, not dictate, patient decisions, while others champion the belief that “respect for autonomy does not require suspending the physician’s or ethics committee’s own critical analysis”.1 Most agree on the importance of providing patients with knowledge adequate to make informed decisions, whether or not decisions are made collaboratively. In this case, we chose a collaborative approach to attempt to preserve patient autonomy without jeopardizing safety.
1. Mcnutt RA. JAMA 2004;292:2516
2. Aggarwall A, et al. BMC Med Ethics 2014;15:31
3. Hall A. HEC Forum 2002;14:241
4. Oliveira VC, et al. J of Physiother 2012;58;215
5. Stark M. Hastings Center Report. 2014;44:44
6. Ubel, PA. Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. HarperOne, 2012