Use of suction catheter as an aid to intubation in emergency situation of intraoral bleeding

A 37-year-old, ASA physical status II male, weighing 80 kg was posted for examination and biopsy of an intraoral mass under general anaesthesia. The patient was placed on operation table with monitoring for SpO 2, non invasive blood pressure and ECG. He was a patient of difficult airway with intraoral mass, obesity and Mallampati score of III. Our institution does not have the facility of fibre optic intubation. Difficult intubation cart was ready with Laryngeal Mask Airway, light wand and other adjuncts of airway management. Endotracheal intubation by laryngoscopy was planned as a usual procedure. After mask ventilation with 100% oxygen and induction with thiopentone and suxamethonium, direct laryngoscopy was performed. Mouth opening was adequate; so, as practiced for routine procedure, thiopentone and suxamethonium were used for intubation. The glottis was visible but suddenly untoward happened. With the manoeuvring of laryngoscope, the intraoral mass started to bleed Letters to Editor

an emergency situation. Routinely, the Jackson-Rees modification of Ayre's T-piece breathing circuit with a Rendell Baker Soucek mask [1,2] is preferred for ventilation in neonatal anaesthesia, as this mask has a malleable edge to fit on the face with low dead space. [2] Following an unfortunate electric short-circuit in one of the paediatric emergency OT, we had to shift the paediatric surgical emergencies to another OT. At midnight, a 3-day-old neonate requiring emergency laparotomy was posted for surgery and as the preparation for anaesthetic induction took place, the neonatal face mask was found missing. This piece of equipment seems to have been left inadvertently in the disabled OT. Since there was no replacement at that time of the night we created our own indigenous neonatal face mask from empty disposable PVC-made fluid bottle.
The upper part of the bottle (tapering part) was cut transversely [ Figure 1a], keeping the diameter of the bottle such that it comfortably covered the nose and mouth of the baby. Now the cap of the bottle, through which the intravenous drip-set spike is inserted, was cut to fit the patient end of Jackson-Ree's circuit with an angle piece (15 mm) [ Figure 1b].
Cotton and an adhesive tape were fixed to the circumference of the 'face mask' to prevent injury to the face. We were thus able to ventilate the neonate and proceed with anaesthesia uneventfully. Sir, Intraoral pathology poses a great challenge to the anaesthesiologists in terms of oral intubation. Endotracheal intubation is difficult because of restricted space for larygyscopy and non-visualisation of glottis. The problem gets compounded if the oral mass is vascular. We present a case where use of suction catheter helped in achieving oral endotracheal intubation in emergent situation.
A 37-year-old, ASA physical status II male, weighing 80 kg was posted for examination and biopsy of an intraoral mass under general anaesthesia. The patient was placed on operation table with monitoring for SpO 2 , non invasive blood pressure and ECG. He was a patient of difficult airway with intraoral mass, obesity and Mallampati score of III. Our institution does not have the facility of fibre optic intubation. Difficult intubation cart was ready with Laryngeal Mask Airway, light wand and other adjuncts of airway management. Endotracheal intubation by laryngoscopy was planned as a usual procedure. After mask ventilation with 100% oxygen and induction with thiopentone and suxamethonium, direct laryngoscopy was performed. Mouth opening was adequate; so, as practiced for routine procedure, thiopentone and suxamethonium were used for intubation. The glottis was visible but suddenly untoward happened. With the manoeuvring of laryngoscope, the intraoral mass started to bleed Letters to Editor profusely. There was imminent risk of aspiration of blood by the patient. Suction was ready and suctioning was started. During suctioning, the glottis became visible. In this kind of emergent situation, suction catheter was deliberately inserted into the glottis and left in situ [ Figure 1]. Oxygen was connected to this suction catheter. Another suction catheter was used for further suctioning. Distal end of the first suction catheter was cut and a cuffed oral endotracheal tube no. 8.0 mm was "railroaded" over it. Cuff of endotracheal tube was inflated and endotracheal tube was secured by tape. Oxygenation through first catheter was continued till the situation was under control. Suction catheter was taken out and the correct placement of the endotracheal tube was confirmed. From laryngoscopy to intubation it took about 4 minutes. Oxygen saturation and other hemodynamic parameters were within normal limits throughout the emergent situation. The patient was under anaesthesia during intubation attempt. Surgery was completed uneventfully.
Endotracheal intubation in a difficult airway is always a challenge to anaesthesiologist. The problem gets compounded if the difficult airway is due to bleeding mass in oral cavity. [1] Laryngeal mask airway is a useful adjunct of airway management in situation of intraoral mass. [2] Light wand and fibre optic intubation are an alternative but it needs prior expertise and some time may be a difficult alternative in emergent and active bleeding situation. In this case, even if adjuncts of airway were present there was no time to use them. The situation needed immediate action. Presence of mind and use of common and easily available resources may be life saving in certain situations as it was seen in this case report. Sir, Elderly patients are most vulnerable to fractures due to osteoporosis. [1] Often anaesthesia for these set of patients is associated with higher risk. [2] We report a case of a 99-year-old fragile lady, who was to undergo hemi-arthroplasty for fractured neck of the left femur. Her poor cardiovascular status with severe left ventricular dysfunction and kyphoscoliosis of thoracolumbar spine made for a challenging anaesthetic management.

Centenarians: Hip fractures and peripheral lower limb nerve blocks
The patient was bedridden for last 2 days and must have been weighing around 45 kg, was having basal crepitations bilaterally on auscultation of the chest and fragile osteoporotic bones. Her other investigations were within normal limits except for serum creatinine (1.6 mg/dl), which was slightly above normal. Previously, she had come to us 6 months back, with a supracondylar fracture of the left humerus and had undergone fracture reduction and plating under a left brachial plexus block by the supra-clavicular approach using a peripheral nerve stimulator.
Informed consent was taken from the patient as Letters to Editor