“Can’t intubate can’t oxygenate” situation in an elective patient in suspected sarcoidosis: a case report
  • Veronica Gerli
    Anaestesiology, Ospedale Regionale di Lugano - Civico e Italiano, Ente Ospedaliero cantonale, Lugano, Switzerland
  • Eva Koetsier
    Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
  • Nicola Ledingham
    Anaestesiology, Ospedale Regionale di Lugano - Civico e Italiano, Ente Ospedaliero cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
  • Paolo Maino
    Anaestesiology, Ospedale Regionale di Lugano - Civico e Italiano, Ente Ospedaliero cantonale, Lugano, Switzerland; Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland

Keywords

3rd generation laryngeal mask, CICO, curare, difficult airway ventilation, microlaryngeal tube

Abstract

Anaesthetists and pulmonologists are well trained to follow the “can’t intubate, can’t oxygenate” (CICO) protocol but the procedure is rarely practised. This case report concerns an elective patient scheduled for endobronchial ultrasound bronchoscopy (EBUS) because of suspected sarcoidosis. Based on known medical history, anaesthesia for EBUS procedure was initiated with a laryngeal mask. The airway turned out to be difficult and the patient was not ventilable despite several efforts including curarization and orotracheal intubation. Rapid desaturation imposed to apply the CICO protocol with emergency cricothyroidotomy as extreme measure but also failed. 6-handed face mask ventilation was continued. Eventually, introduction of a microlaryngeal tube of the 3rd generation laryngeal mask, placed on the fibrescope, allowed endotracheal intubation. The patient fell into pulseless electrical activity, and the CICO protocol was started. Immediate cardiopulmonary resuscitation totally recovered vital functions. In the post-operative follow-up, no temporary or permanent cardiological and neurological sequels were found, but new medical history such as inconstant use of C-PAP (Continuous Positive Airway Pressure) and a significant weight gain since the last notable difficult intubation were uncovered, which explained the patient’s compromised airways. Had this information been available prior to the scheduled operation, it would have indicated awake intubation with a local anaesthesia of the oropharynx and appropriate sedation of the patient.

VIEW THE ENTIRE ARTICLE

References

  • Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31-81.
  • Casso G, Savoldelli GL, Balmer C, Ravussin P, Schoettker P. Swiss Latin Airway Guidelines: a holistic approach for improving airway management. Swiss Medical Weekly 2022;152:w30225.
  • Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2018;120:323-352.
  • Douadi Y, Bentayeb H, Malinowski S, Hoguet E, Lecuyer E, Boutemy Met al. Anaesthesia for bronchial echoendoscopy: experience with the laryngeal mask. Rev Mal Respir 2010;27:37-41.
  • Nielsen JR. Difficult mask ventilation and muscle relaxation. Anaesthesia 2018;73:255.
  • Saastamoinen M, Larsson J, Frykholm P. Checking mask ventilation before neuromuscular block: A nation-wide survey of anaesthetists’ attitudes and thinking. Acta Anaesthesiol Scand 2019;63:1178-1183.
  • Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020;75:509-528.

    • Views: 441
    HTML downloads: 36
    PDF downloads: 321

    Published: 2023-09-26
    Issue: 2023: Vol 10 No 11 (view)

    How to cite:
    1.
    Gerli V, Koetsier E, Ledingham N, Maino P. “Can’t intubate can’t oxygenate” situation in an elective patient in suspected sarcoidosis: a case report. EJCRIM 2023;10 doi:10.12890/2023_004088.