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Difficult intubation and brain-stem anaesthesia

  • Chidambaram Ananthanarayan
  • A. F. D. Cole
  • Martin Kazdan
Clinical Reports

Abstract

Purpose

To present a case of difficult intubation with brainstem anaesthesia after retrobulbar block with bupivacaine and lidocaine and sedation with midazolam and to point out that dose monitoring and timely treatment is important in preventing an unfavourable outcome.

Clinical features

An 82-yr-old man with treated hypertension and stable angina was scheduled for cataract extraction. Physical examination revealed a class 2 airway. He had a retrobulbar block after topical tetracaine drops, with bupivacaine 0.5% and lidocaine 2% with hyaluronidase under sedation with 1 mg midazolam. Five minutes after the block, respiration slowed, he became unresponsive and oxygen saturation decreased to 80%. Immediate ventilation with mask without additional oxygen improved saturation. Attempted tracheal intubation failed: the epiglottis could not be visualized despite flaccid jaw and extremeties. A laryngeal mask airway was placed which was leaking and adequate ventilation could not be achieved but a second laryngeal mask airway was placed successfully.

Conclusion

This case emphasizes the need for dose monitoring and personnel capable of managing the difficult airway when intra-orbital anaesthesia is used.

Keywords

Bupivacaine Tracheal Intubation Laryngeal Mask Airway Difficult Intubation Cataract Extraction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Objectif

Presenter un cas d’intubation difficile avec anesthésie accidentelle du tronc cérébral consécutive à un bkx rétrobulbaire à la bupivacaïne et à la lidocaïne avec sédation au midazolam en mettant l’accent sur l’importance du monitorage et d’un traitement opportun dans le but de prévenir une complication désastreuse.

Éléments cliniques

Un angineux stable de 82 ans et hypertendu sous traitement était programmé pour une extraction de cataracte. L’examen physique révélait des voies aériennes de dasse 2. Après une anesthesie de contact à la tétracaïne. il recevait un bloc rétrobulbaire à la bupivacaïne 0,5% et à la lidocaine 2% associées à de l’hyaluronidase sous sédation avec 1 mg de midazolam. Cinq minutes après le block, la respiration ralentissait, il devenait inconscient et la saturation en oxygène tombait à 80%. La ventilation immédiate au masque sans oxygène permettait d’améliorer la saturation. Une tentative d’intubation échouait, l’épiglotte n’étant pas visualisée malgré la flaccidité de la mâchoire et des extrémités. Un masque laryngé était inséré mais à cause d’un manque d’étanchéité, il était impossible de ventiler. On réussissait finalement à insérer un autre masque laryngé fonctionnel.

Conclusion

Cette observation souligne la nécessité d’un monitorage rigoureux et d’un personnel capable de prendre charge de voies aériennes difficiles quand une anesthésie intraorbitale est administrée.

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Copyright information

© Canadian Anesthesiologists 1997

Authors and Affiliations

  • Chidambaram Ananthanarayan
    • 1
    • 2
  • A. F. D. Cole
    • 1
    • 2
  • Martin Kazdan
    • 1
    • 2
  1. 1.Department of AnaesthesiaMount Sinai Hospital, University of TorontoToronto
  2. 2.Department of OphthalmologyMount Sinai Hospital, University of TorontoToronto

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