No Fiberoptic Intubation System: A Potential Problem

You are to anesthetize a 19-yr-old Indian woman (42 kg) who is otherwise healthy, but is coming in for the removal of a large keloid scar (7 cm × 8 cm) on the front of her neck. This was caused 2 yr before by hydrochloric acid (HCl). She tried to drink it in an attempt to commit suicide. Someone prevented her from doing so, but during the tussle that ensued, the large cup of HCl spilt down the front of her neck causing a severe third degree burn. She survived, but is now left with a large keloid scar that has pulled her chin down so that it nearly touches the sternum, and she can only open her mouth slightly (0.5 cm between the top and bottom teeth). You see this young woman in the preoperative area and decide that an awake nasal or oral fiberoptic intubation is needed. Unfortunately, there is no scope available, and the surgeon tells you that if we don’t do it today the young woman will not come back. You decide to proceed and take her back to the operating room after an IV is started and 1 mg of midazolam. After routine monitors are placed, you attempt an inhalation induction with sevoflurane, to be followed by a blind oral or nasal endotracheal intubation. Unfortunately, you lose her airway during the induction and she stops breathing. The saturation falls to 82%. You turn the sevoflurane off and attempt to ventilate with 100% oxygen, but with great difficulty. With the sevoflurane off, she slowly begins to breathe again and her saturation improves. Your attempt at an awake nasal intubation also fails. There is no other airway equipment available, e.g., a Trachlight (Laerdal Medical A/S, Stavanger, Norway). You suggest to the surgeon that he does a tracheostomy under local. The surgeon says that will be impossible, as there are no landmarks and it is very difficult to anesthetize the keloid scar with local anesthesia. More important is the fact that the tracheotomy will be in the surgical site, and therefore it is not an option. You attempt to place the smallest pediatric laryngeal mask airway (LMA) that you can find. Unfortunately, even that LMA is too big. In desperation, you now try to pass a pediatric gum-elastic bougie blindly into her trachea both through the mouth and nose. This also fails. Understandably, she is now getting very upset and agitated. The surgeon looks at you and wonders if anything else can be done to secure the airway without doing a tracheostomy. What will you suggest?