Rev. Bras. Anestesiol. vol.67 número6

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RevBrasAnestesiol.2017;67(6):659---662

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia

www.sba.com.br

CLINICAL

INFORMATION

Dissection

of

the

wired

endotracheal

tube’s

lumen

during

general

anesthesia:

a

case

report

Fabricio

Tavares

Mendonc

¸a

∗

_,

_Leonardo

_Damasceno

_Martins,

_Rodrigo

_Gazzi,

Jose

Tadeu

dos

Santos

Palmieri

CentrodeEnsinoeTreinamentodoHospitaldeBasedoDistritoFederal,Brasília,DF,Brazil

Received16January2015;accepted11February2015 Availableonline22September2017

KEYWORDS

Airwayobstruction;

Complicationof

intubation;

Obstructionin

ventilation

Abstract

Objective: Theaimofthisstudyistoreportacaseofaclinicallysignificantobstructionduring mechanicalventilationcausedbythedissectionofthewiredendotrachealtube’slumenduring generalanesthesiainapediatricpatient.

Casereport: A12-yearsoldpatientundergoinggeneralanesthesiaforopenappendectomywas intubatedwithawiredendotrachealtubeanddifficultremovaloftheguide.Afterstartingthe mechanicalventilation,therewasincreasedexpiratoryfractionofCO2andneedforincreased inspiratorypressure.Chanceofcomplicationswithhigherincidenceswereraisedandtreated unsuccessfully. Finally,duringpatient reintubation, thedissectionoftheendotrachealtube lumenwasobserved,andventilationwasrestoredtonormal.

Conclusion: Anesthesiainvolvesnumerouspossiblecomplications.Suspicionandconstant vigi-lanceareessentialforearlydiagnosisandtreatmentofanythreattotheindividualintegrity. Thiscaseisrelevantforemphasizingapossibleveryrarecomplicationrelatedtoairway,which canquicklycausehypoxiaandirreversibledamage.Thus,thiscasecontributestothedetection ofthiscomplicationmorefrequently.

PALAVRAS-CHAVE

Obstruc¸ãodevia

aérea;

Complicac¸ãona

intubac¸ão;

Obstruc¸ãona

ventilac¸ão

Dissecc¸ãodelúmendetuboendotraquealaramadoduranteanestesiageral:relato decaso

Resumo

Objetivo: Relatarumcasodeobstruçãoàventilaçãomecânicaclinicamentesignificativa cau-sadapordissecçãodolúmen dotuboendotraquealaramadoduranteanestesiageralem um pacientepediátrico.

∗_{Corresponding}_author.

E-mails:fabriciotmendonca@hotmail.com,fabricio.tavares@me.com(F.T.Mendonc¸a).

https://doi.org/10.1016/j.bjane.2015.02.006

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660 F.T.Mendonc¸aetal.

Relato:Paciente de 12 anos submetido à anestesia geral para apendicectomia aberta foi intubado comtuboendotraquealaramado e retiradadeguia dotubodifícil. Apósiniciara ventilaçãomecânicahouveaumentodafraçãoexpiratóriadeCO2enecessidadedeaumento dapressãoinspiratória.Hipótesesdecomplicaçõescommaioresincidênciasforamaventadas etratadassemsucesso.Finalmente,aoreintubarodoente,foiverificadadissecçãodolúmen dotuboendotraquealeaventilaçãofoirestauradaànormalidade.

Conclusão:Oatoanestésico envolve inúmeraspossíveiscomplicações. A suspeiçãoe a vig-ilânciaconstantessãoessenciaisparadiagnosticaretratarprecocementequalquerameaçaà integridadedoindivíduo.Opresentecasoérelevanteporenfatizarumapossívelcomplicação muitoincomumrelacionadaàsviasaéreascapazdecausarhipóxiaedanosirreversíveis rapida-mente.Dessaforma,ocasocontribuiparaqueessaintercorrênciasejadetectadacommaior frequência.

Introduction

Tracheal intubation in general anesthesia is an

essen-tial technique for numerous surgical procedures. Airway

protection and mechanical ventilation enable the safe

administrationofanestheticstoensureadequatehypnosis,

paininhibition,andmusclerelaxation.1

However,theuseofthistechniquedependsonthe

cor-rectoperationofasetofequipmentandmaterialsrelated

to the anesthesia. Any defect in any of these materials

can compromise the intubation technique and determine

apotentially tragicevent due toventilation problemand

airway protection. Defects may appear anywhere on the

ventilator(bellow,corrugatedpipe,capnography,gasinput)

andendotrachealtube (mucus,foreignbody, kinking,cuff

herniation or leakage). Because the problem

manifesta-tioniscommontoseveralclinicalcomplications,itisoften notreadilyidentifiedand corrected, whichleads torapid

deterioration of respiratory symptoms and may lead to

death.2

Wereportanuncommoncaseofdeformityand

obstruc-tionofthewiredendotrachealtubecausedbyaverydifficult removaloftheguidewireinsertedintothetube.

Case

report

Malepatient,12yearsold,35kg,referredtotheoperation

room (OR) by the emergency service to receive an open

appendectomy. He arrived at the OR accompanied by his

motherwhodeniedallergies,comorbiditiesor regularuse

ofmedications.Patient’sphysicalstatusASAI,HR110bpm,

bloodpressure(BP)108×52mmHg,SpO2 96%inroomair;

goodgeneralconditionnormalskincolor,milddehydration, eupneic,lucidandoriented.Regardingairway,hehad appro-priatemouthopeningandneckmobility(MallampatiI).

IntravenousinfusionwasmadeinleftarmwithJelco20G. Afterintravenous induction withfentanyl (250mcg), lido-caine(20mg),propofol(110mg)andcisatracurium(7mg), ventilationunderfacemaskwasstarted.

Figure1 Theguidewireused.

After intubation with the help of a Macintosh curved

blade #3 and the introduction of the wired endotracheal

tube(ETT)#6,thetubeguidewasremovedwithgreat

dif-ficulty (Fig. 1). The cuff was inflated and confirmed the positionbysymmetricalbilateralauscultationand

compat-iblecapnographiccurve.

Coupledtothe automaticmechanical ventilator in the

PCVmode, theinspiredpressurewas17cmH2Oat

respira-toryrate(RR)16rpmandpositiveendexpiratorypressure (PEEP)5cmH2O,FiO240%with3%sevoflurane.After20min,

atidalvolumeof120mLwasseen.Therefore,theinspired pressurewasincreasedto25cmH2Otoobtainatidalvolume

of280mL.Subsequently,thegasanalyzerindicated increas-ingrateofETCO2upto68mmHg.Symmetricalandbilateral

auscultation was performed, with reduction of murmurs.

Administration ofketamineIV(25mg),didnotchange the

ventilatorypattern.RRwasreducedto10rpmandaratio

of1:5inexpiratorytime.

Aftercollectingarterialbloodgases,intravenous propo-fol(50mg)wasadministeredaswellasanincreasingfraction ofinspiredsevoflurane.Atthatpoint,BPwas97×54mmHg.

Arterial blood gas measurement showed pH 7.2; PCO2

56.6mmHg;HCO3---22.3;Hb10.7;Na+143;K+3.9;Cl−101;

Ca2+_0.7.

It was decided to change the endotracheal tube to

another wired #6. Intubation was performed with no

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Dissectionofthewiredendotrachealtube’slumenduringgeneralanesthesia 661

Figure2 Wiredendotrachealtube,outsideview.

Figure 3 Sectioned wired endotracheal tube, lumen view withdissection.

modewithinspiredpressureof16cmH2Oandtidalvolume

of260mL.TherewasarapidreductionofETCO2ratefrom

70to50mmHg.

Evaluation of the removed ETT indicated that there

was a deformity with irregular reduction of its internal

gauge, which caused obstructiveventilation and required

highinspiratorypressures(Figs.2and3).

Discussion

Inadequateairwaymanagement remains avery important

element, as it is associated with perioperative

morbid-ity andmortality. It may include problems relatedto the

patient or anesthesia equipment failure and anesthetic

agentcomplications.

Amongthecasesofairwaycomplicationsreportedinthe

literaturethereareinjuriesoccurred duringthe

introduc-tionof theintubation tube; inadequateimmobilizationof

patients; difficulties relatedto humidifiers;complications

relatedtoendotracheal tube involving the reuseof these

devices;heatexposure;stretchingthetubebyuseof anes-theticssuchasnitrousoxide(N2O);detachmentofpartsof

theendotrachealtube,whichgenerateavalvemechanism

and,rarely,dissectionoftheinternal wallofthe endotra-chealtube,asshowninthiscase.3---9

Mercanoglu etal.8 _reported_a_case _of _dissection_of_the

innerwallofawiredETTafteritsreuse.Itwasconcluded thatthe resterilization and reuseof this material

predis-posethereportedcomplication.Based onpublisheddata,

aswellasonthisreport,measuresforbronchospasm treat-mentwereinitiated,withunsatisfactoryresults.Weopted forexchangingtheETTandthereturningtotheparameters priortotubedissection.8

In the case described here, becauseit is a rare

situa-tion,therewasnoimmediatesuspicionofthewired tube

innerwall dissection. Thus, assoon as the patientbegan

toshowthementionedsymptoms,thefirsthypothesiswas

bronchospasm that was treated with deeper anesthesia,

administrationof vasodilators, and ventilator adjustment

withlowerrespiratoryrateandincreasedexpiratorytime.

Afterthesemeasuresandwithnoreversalofsymptoms,it

wasdecidedtochange thedisposable wiredendotracheal

tube.Onlyafterinspectionofthisdevice,itwasnotedthat itsinnerwallsweredissected.

Amongthepossiblecausesreportedintheliterature,the wiredtubedissectionmayoccurduetothereuseor rester-ilizationofthedevice.7_Once_the_{aforementioned}_situations

donot apply tothis case report, it can be assumed that

therewasquality controlproblems inthe manufactureof

theendotrachealtube.

Conclusion

Knowledgeofpossiblecomplications,suchastheone

pre-sented in this report, as well as careful evaluation of

patientsandroutinemakingtheanesthetic---surgical

check-list enables doctors to predict unwanted situations and

allows immediate intervention to decrease repercussions

imposingrisktothepatient’slife.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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