Anaesthesia
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Cannula cricothyroidotomy is recommended for emergency transtracheal ventilation by all current airway guidelines. Success with this technique depends on the accurate and rapid identification of percutaneous anatomical landmarks. Six healthy subjects underwent neck ultrasound to delineate the borders of the cricothyroid membrane. ⋯ Consultant and registrar anaesthetists were significantly more accurate than senior house officers at correctly identifying the cricothyroid membrane. Accuracy of percutaneously identifying the cricothyroid membrane was poor. Ultrasound may assist in identifying anatomical landmarks for cricothyroidotomy.
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We performed a study of 85 consenting anaesthetists to assess their ability to locate the right internal jugular vein using a landmark technique. Initially, a questionnaire was completed ascertaining previous user experience. An ultrasound probe, using the midpoint as an 'imaginary needle', was placed on the neck of a healthy volunteer (with previously confirmed normal anatomy) and the image recorded. ⋯ Three participants in each group would have hit the carotid artery (5% Pre-2002 and 11% Post-2002 respectively; p = 0.2). The advent of routine use of ultrasound has resulted in a cohort of anaesthetists who are unable to use a landmark technique effectively or safely. This has significant training implications.
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Cervical lesions compressing the spinal cord pose a significant risk of exacerbating the existing neurological condition during tracheal intubation and subsequent positioning. Awake fibreoptic-assisted intubation is a suitable option in such situations. We describe how the use of dexmedetomidine for sedation during awake fibreoptic intubation also facilitated self-positioning before surgery in a patient with a cervical cord compressive lesion and raised intracranial pressure undergoing excision of a cerebellopontine angle lesion in the lateral position, without any adverse neurological outcome.
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Tracheal extubation remains a critical and often overlooked period of difficult airway management. A 66-year-old man, scheduled for C5-C7 anterior fusion, with an easy view of the vocal cords, presented with a sublaryngeal obstruction that required a reduced tracheal tube size. Despite correct tube placement, intra-operative ventilation remained difficult. ⋯ After discussion with the attending otolaryngologist, neuromuscular blockade was antagonised and the patient was able to maintain normal minute volumes while spontaneously ventilating. With the otolaryngologist present, and with the patient conscious, the trachea was successfully extubated over an airway exchange catheter. A subsequent CT scan revealed an impingement of the trachea by the innominate artery and a mildly ectatic ascending and descending aorta that, in conjunction with tracheomalacia and neuromuscular blockade, could explain the observed signs and symptoms.