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Decision Making at the Extremes of Airway Management
Abstract Number: SU-84
Abstract Type: Case Report/Case Series
Case: A 30yo G2P1001 woman with a BMI of 51.7 arrived via EMS at 30 weeks estimated gestation after being found at home unresponsive. She had no prenatal care and later reported that she had not been aware she was pregnant. With a working diagnosis of eclamptic seizure, the FHR remained reassuring, but the decision was made for a Cesarean delivery due to maternal condition. She was postictal with marked tongue and oropharyngeal edema accompanied by blood and secretions. In addition to her baseline morbid obesity, her tongue was protuberant, bloody, and edematous, making visualization of any part of her oropharynx impossible.
Airway Management: Fiberoptic intubation was first considered, however several factors posed significant potential challenges. The distortion of her upper airway made glossopharyngeal nerve blocks unobtainable, and the presence of concurrent thrombocytopenia (32,000/uL) introduced an increased risk of bleeding after superior laryngeal nerve blockade or transtracheal puncture. In addition, adequate topicalization would have been extremely difficult due to the lack of access to the posterior pharynx, inability of the patient to cooperate, and the degree of mucosal edema. Due to the fact that she had not yet received her magnesium bolus, which might have prolonged the action of succinylcholine, and that her SAO2 remained 100% with the use of a non-rebreather face mask, the decision was made to proceed with a RSI and Glidescope facilitated intubation, with confidence that she would be able to resume spontaneous ventilation if intubation were unsuccessful. A #4 Glidescope was utilized with immediate availability of a fiberoptic scope, AirQ, and Fastrach LMA. After induction she was successfully intubated on the first attempt with the Glidescope, but substantial tissue distortion was observed along with blood and secretions throughout the oropharynx. The epiglottis was visualized and part of the cords identified for a Cormack-Lehane grade 2a view. Four minutes after intubation a 1230g neonate was delivered with Apgar scores of 2 and 8. Post-operatively she was transported to the ICU, where she was extubated on post-op day 6 and discharged home post-op day 8.
Discussion: This case represents the nightmare scenario of a potentially extremely difficult airway, and the management decisions required when Cesarean delivery is planned. Although awake fiberoptic intubation is very commonly advocated as the first choice in this scenario1, prior experience (unpublished) with attempts to topicalize the swollen, bloodied airway in a morbidly obese postictal parturient has proven to be almost impossible. With this case report, we have demonstrated that video laryngoscopy after RSI might also be a reasonable choice under these circumstances.
1. Collins SR, Blank RS. Fiberoptic intubation: an overview and update. Respir Care. 2014;6:865-78.