[Downloadedfreefromhttp://www.saudija.orgonSaturday,March30,2013,IP:117.227.190.
61]||ClickheretodownloadfreeAndroidapplicationforthisjournal
Letters to Editor
As induction of inhalation is preferred in children with a
difficult but uncompromised airway, sevoflurane was used
so that the child could be induced rapidly and later changed
over to halothane so that adequate time was available for
laryngoscopy. Laryngeal mask airway(LMA) was not used
in our case as it has a higher rate of failure and may not be
able to protect the airway against reflux that is commonly
seen in these patients.
Laryngospasm and laryngeal edema are common causes
of postextubation upper airway obstruction in children.[3]
Endotracheal intubation in neonates can lead to subglottic
edema, especially common after traumatic intubation or those
lasting longer than one hour.[4] Subglottic edema of 1mm
in neonates can reduce the laryngeal crosssection by 35%.
Patients with congenital or acquired airway pathology are
known to have difficult extubation and difficult reintubation.[5]
Our child had been treated for hypocalcemia but was
still hypocalcemic on the day of surgery. This could have
increased the incidence of perioperative laryngospasm and
bronchospasm. Also, the neuromuscular blockade may
have been prolonged in the presence of hypocalcemia,
necessitating postoperative ventilation.
The use of regional anesthesia must be made with caution
in children with difficult airways, depending on the skill
of the anesthesiologist. Hence, we decided to proceed
with regional anesthesia, keeping ourselves prepared for a
difficult airway in case of any complication.
In conclusion, spinal anesthesia can be used in a child with a
difficult airway aiming to reduce the airway manipulationrelated
complications. We should always be prepared for the
management of a difficult airway in an emergency.
Failure to ventilate: Technical error
Sir,
A 22yearold girl having history of brochial asthma
with nor mal preanesthetic checkup and nor mal
airway examination was posted for surgery for bilateral
fibroadenama breast under general anesthesia. On the
day of surgery, she was premedicated with fentanyl 50g
and midazolam 2mg 30minutes before operation. In
the operation theatre monitoring was started as per the
American Society of Anaesthesiologist(ASA) standard.
Saudi Journal of Anaesthesia Vol. 7, Issue 1, January-March 2013
Page | 99
Rohini Bhat Pai, Sameer Desai, Raghavendra Rao,
Venkatesh Annigeri1
Deparments of Anaesthesiology and 1Pediatric Surgery, SDM College
of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
Address for correspondence:
Dr.Rohini Bhat Pai,
Deparments of Anaesthesiology, SDM College of Medical Sciences,
Dharwad, Karnataka, India.
Email:docpai@rediffmail.com
REFERENCES
1. WilliamsR, AdamsDC, AladjemEV, KreutzJM, SartorelliKH,
VaneDW, etal. The Safety and Efficacy of Spinal Anesthesia
for Surgery in Infants: The Vermont Infant Spinal Registry.
Anesth Analg 2006;102:6771.
2. SivanY, BenAriJ, SofermanR, DeRoweA. Diagnosis
of Laryngomalacia by Fiberoptic Endoscopy: Awake
Compared With AnesthesiaAided Technique. Chest
2006;130:14128.
3. OlssonGL, HallenB. Laryngospasm during anesthesia.
Acomputeraided incidence study in 136,929patients. Acta
Anaesthesiol Scand 1984;28:56775.
4. DarmonJY, RaussA, DreyfussD, BleichnerG, ElkharratD,
SchlemmerB, etal. Evaluation of risk factors for laryngeal
edema after tracheal extubation in adults and its prevention
by dexamethasone: Aplacebocontrolled, doubleblind,
multicenter study. Anesthesiology 1993;78:60910.
5. Karmarkar S, Varshney S. Tracheal extubation. Contin Educ
Anaesth Crit Care Pain 2008;8:21420.
Access this article online
Quick Response Code:
Website:
www.saudija.org
DOI:
10.4103/1658-354X.109852
A venous cannula was inserted and was given 100%
oxygen. After giving propofol 100 mg, she went into
apnea immediately; we tried to ventilate the patient with
bag and mask. While mask ventilation we found that the
bag was too tight and the patient was not at all ventilating.
Despite all efforts, it was not possible to ventilate the
patient. Her saturation started dropping, immediately
we intubated the patient and connected the anesthesia
ventilator. Now the patient was nicely ventilating with
peak airway pressure of 18cm of H2O. On auscultation
 [Downloadedfreefromhttp://www.saudija.orgonSaturday,March30,2013,IP:117.227.190.61]||ClickheretodownloadfreeAndroidapplicationforthisjournal
Letters to Editor
Page | 100
the chest was clear, no rhochi or spasm was detected and
saturation rose to 100%. While investigating the cause
of airway obstruction, we checked the circuit which was
found to be absolutely obstruction free. While checking
the mask, to our surprise we found that the cap of the
ventilator circuit was fitting to the mask [Figure 1].
While investigating about the technical checkup before
assembling the circuit, we found that the technician who
had assembled the circuit, forgot to remove the cap from
the ventilator circuit[Figure2].
There are numerous reports of obstruction of anesthesia
breathing circuits by different foreign bodies and due
to technical errors.[13] Most of these instances are due
to inadequate checkup of the equipments. In our case
the technician checked and assembled the circuit. Before
induction of anesthesia, we checked the circuit for any
Figure 1: Cap fitting to the mask
Figure 2: Cap obstructing the circuit
Vol. 7, Issue 1, January-March 2013 Saudi Journal of Anaesthesia
leakage and obstruction by removing the mask, we found
that the circuit was obstruction free as the cap, which
was tightly fitting to the mask, also got removed with the
mask. However, we did not check the mask. While again
reassembling the circuit due to cap in the mask it caused
total obstruction of the circuit leading to impossible
ventilation. When, after intubation, we removed the
mask from the circuit the cap remained in the mask and
problem remained unnoticed. While thoroughly checking
the equipments we finally found the obstructing cap fitting
to the mask.
Here, we emphasize on sticking to the basics and
thoroughly follow the preuse check guidelines to prevent
critical incidents and improve patient safety. [4,5] The
nontechnical staff of the operation theatre should be
educated and trained about correct assembling and
preuse checks and lastly the anesthetist should check and
confirm the proper working of the equipments before
anesthetizing the cases.
Vivek Chowdhry, Arun Rath
Department of Anaesthesiology and Critical Care, Care Hospital,
Bhubaneswar, Odisha, India
Address for correspondence:
Dr.Vivek Chowdhry,
Department of Anaesthesiology and Critical Care, Care Hospital,
Chandrasekharpur, Bhubaneswar, Odisha, India.
Email:vivek.chowdhry@gmail.com
REFERENCES
1. RoyK, KundraP, RavishankarM. Unusual foreign body
airway obstruction after laryngeal mask insertion. Anesth
Analg 2005;101:2945.
2. Foreman, MJ, MoyesDG. Anaesthetic breathing circuit
obstruction due to blockage of tracheal tube connector by
a foreign bodytwo cases. Anaesth Intensive Care 1999;
27:735.
3. SethiAK, MohtaM, SharmaP. Breathing circuit obstruction
by a foreign body. Anaesth Intensive Care 2004;
32:13941.
4. DorschJA, DorschSE. Equipment checking and maintenance.
In: DorschJA, DorschSE, editors. Understanding anaesthesia
equipment. 5thed. NewDelhi: Lippincott Williams and
Wilkins a Wolters Kluwer Business; 2008. p.93154.
5. Brockwell RC, Andrews JJ. Complications of inhaled
anesthesia delivery systems. Anesthesiol Clin North America.
2002;20:539-54.
Access this article online
Quick Response Code:
Website:
www.saudija.org
DOI:
10.4103/1658-354X.109853