Postoperative Airway Complication After Sinus Surgery
A 28-yr-old man (American Society of Anesthesiologists physical status 1) with chronic sinusitis is scheduled for functional endoscopic sinus surgery (FESS). He has failed medical management. He is 84kg and 5′10″ tall. He has had one previous general anesthetic for an acute appendix at age 10. Otherwise, his medical history and physical exam is unremarkable. He is presently not taking any medication and has no known allergies to medicines. He has a normal white cell count and his Hb is 14mg%. After sedation with midazolam 2mg IV, he is taken to the operating room, where a routine general anesthetic is induced uneventfully. Tracheal intubation (grade 1 view) is done atraumatically on the first attempt after ensuring that the patient is fully paralyzed with a nerve stimulator (vecuronium 7mg). The pharynx is deemed normal both preoperatively and during endotracheal intubation. The endotracheal tube (ETT) is secured and bilateral air entry is recorded with the presence of CO2 on the capnograph. General anesthesia is maintained with oxygen, nitrous oxide, isoflurane, morphine, and fentanyl. The operation lasts 90min, and the vital signs throughout the surgery are within normal limits. The estimated blood loss is 900ml. No airways or oral packs are used during the surgery, except for a nasal posterior pack that was placed before the FESS commenced and removed after surgery. The inferior nasal vault was not packed, but small hemostati sponges were placed in the ethmoid cavities. Before the patient fully awoke, the pharynx was gently suctioned using a Yankauer suction and an oral-gastric tube placed on its first attempt. Suction was applied, and the tube was withdrawn completely. With the patient fully awake and able to follow commands, the ETT is removed. Initially, in the recovery room, the patient is comfortable with stable vital signs. However, within 10min he complains of difficulty in breathing. Despite supplemental oxygen (61/min) via an oxygen mask, his oxygen saturation decreased to 86%. You are called back, and when you examine the patient’s chest you can hear only minimal scattered expiratory noises (stridors). Racemic epinephrine is given with minimal improvement. You put another saturation monitor on his finger but the saturation is still 86%. What will you do now?
KeywordsEndotracheal Intubation Chronic Sinusitis Functional Endoscopic Sinus Surgery Anesthesiologist Physical Status Respiratory Obstruction
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