A challenging ventilation and intubation: a case report

¹Department of Anesthesiology, Mohammed 5 Military Training Hospital, University Mohammed 5 of Rabat, Rabat, Morocco

^&Corresponding author
Ilyass Hmadate, Department of Anesthesiology, Mohammed 5 Military Training Hospital, University Mohammed 5 of Rabat, Rabat, Morocco

Introduction    

Managing upper airway complications in the context of a large scalp mass presents considerable hurdles during intubation procedures [1]. The challenge is further intensified when the mass is prone to bleeding, amplifying the complexities of airway management. In critical scenarios, such as hemorrhagic shock ensuing from the manipulation of the mass during the ventilation with a face mask, the patient's prognosis is significantly jeopardized [2]. It underscores the urgent need for strategic interventions to navigate through such intricate airway scenarios, and, at the same time, the management of the hemorrhagic shock. We report a case experience of a patient who experienced a hemorrhagic shock triggered by bleeding from a scalp mass during the ventilation with a face mask. Through this case study, we delve into the intricacies of managing such challenging airway scenarios and shed light on the imperative measures necessary to mitigate risks and optimize patient outcomes.

Patient and observation     

Patient information: a 22-year-old female with no significant medical history, presenting with liposarcoma of the scalp, evolving for 1 year.

Clinical findings: on general examination, the patient is in good general condition, scalp examination revealed a friable, immobile, painless occipital mass, measuring approximately 6cm in the greatest diameter, without signs of inflammation. However, the pre-anesthetic evaluation found a conscious patient with no sensory or motor deficits, and no clinical convulsions, respiratory examination revealed a patient breathing normally at 18 cycles per minute, with no signs of respiratory distress, and oxygen saturation of 99% on room air, cardiovascular examination revealed a functional capacity exceeding 4 metabolic equivalents of task (MET), no exertional angina, blood pressure at 123/65 mmHg, and a heart rate of 76 beats per minute, and the anesthesia-focused examination revealed a good overall condition, a wide mouth opening of more than 35 mm, hyomental distance more than 65 mm, Mallampati class 2, supple neck, with the presence of a large occipital mass that may pose challenges during ventilation and intubation.

Timeline of current episode: on 28/11/2022: a CT scan of the skull and brain was performed, 30/11/2022: biopsy and histology of the scalp mass were performed, 01/12/2022: body scan, 02/12/2022: a bones' scintigraphy, 05/12/2022: surgery was indicated, 06/12/2022: pre-anesthetic consultation, 08/12/2022: day of the surgery.

Diagnostic and assessment: during the staging evaluation, a CT scan of the brain and skull was conducted, uncovering the presence of a scalp mass that did not invade the skull bone, and showed no abnormalities in the brain (Figure 1). Moreover, a biopsy with histology was performed, confirming the diagnosis of liposarcoma of the scalp, moreover, a body scan and bone scintigraphy performed showed no abnormalities. Finally, a surgical excision indication was established, and a complete blood count showed a Hemoglobin level of 14.5 with blood type A+ as part of the preoperative assessment.

Diagnosis: liposarcoma of the scalp, who deemed fit for surgery.

Therapeutic interventions: patient admitted to the operating room for surgical excision under general anesthesia, she was positioned in lateral decubitus and meticulously monitored: heart rate steady at 78 beats per minute, oxygen saturation at 99% on room air, and blood pressure measuring 125/67. An intravenous line was established, and preparations for potentially difficult intubation were made, including assembling a video laryngoscope, Eschmann guide, and a fast track. Oxygenation commenced with a high-concentration mask, followed by the administration of propofol (250 mg), fentanyl (200 mcg), and rocuronium (60 mg) for induction. However, during ventilation with a face mask, manipulation of the mass caused significant bleeding, resulting in hemorrhagic shock, making intubation impossible in the lateral position. Swiftly, the patient was carefully positioned in dorsal decubitus, with two individuals supporting the shoulders while another lifted the head placed beyond the table, facilitating a gentle extension of the neck. This positioning allowed the anesthesiologist to perform intubation using a size 7 cuffed tube with a video laryngoscope, as the patient presented with a Cormack-Lehane grade 2 view. The patient's condition rapidly deteriorated, with blood pressure plummeting to 82/43 mmHg and a heart rate soaring to 146 beats per minute, to stabilize the patient, we administered 1g of acid tranexamic, noradrenaline infusion was commenced through a peripheral line, and a second external jugular line was established to facilitate transfusion with 4 units of packed red blood cells and 1000 ml of saline solution. Then, a central venous line was skillfully inserted into the right internal jugular vein, complemented by the placement of a right radial arterial line for continuous hemodynamic monitoring. After stabilization, and securing the intubation tube while compressing the tumor, the patient is positioned in the ventral decubitus for surgical hemorrhage control and excision of the tumor.

Follow-up and outcome of interventions: after 15 minutes, surgical hemostasis was successfully achieved, followed by the completion of the mass excision. Moreover, the patient's need for noradrenaline ceased after the transfusion and hemorrhage control. After the procedure, the patient was transferred to the postoperative recovery room, where successful extubation was accomplished within 2 hours, with a routine clinical examination following extubation revealed normal findings. Finally, the postoperative CT scan exhibited no signs of tumor.

Patient perspective: I felt burdened by the mass, and ashamed to venture out and engage with others; the psychological toll was profound. Upon learning, it was a liposarcoma, fear of its potential metastasis loomed large. Thankfully, with the dedicated care of the hospital team, I was able to rid myself of this burden and reclaim my social life.

Informed consent: the patient gave his approval for this publication.

Discussion     

A challenging airway refers to a clinical scenario where a physician specializing in anesthesia care encounters anticipated or unexpected difficulty or failure. This difficulty may manifest during various procedures such as face-mask ventilation, laryngoscopy, using supraglottic airways for ventilation, tracheal intubation, extubation, or managing invasive airways. These specific clinical situations are further elaborated as follows [3]. In reviewing the literature, it's evident that no professional society addresses the presence of a scalp or cervical mass in their algorithms for managing difficult airways [4]. Yet, such scenarios pose considerable risks, including intubation failure or complications like hemorrhagic shock from mass manipulation, as observed in our clinical case, or encephalocele rupture, as documented in pediatric cases [5].

In our case, we effectively addressed both the hemorrhagic shock and intubation challenges. Positioning the patient in dorsal decubitus, with the head extending beyond the table, facilitated optimal intubation conditions, aided using a video laryngoscope. Fortunately, no further complexities regarding difficult intubation were encountered. However, we found a similar case to ours, but with a different approach, it involves a 60-year-old ASA 1 male with a painful occipital tumor, rendering the dorsal position unfeasible. In the operating room, local anesthesia was administered using 0.25% bupivacaine to block the great auricular, lesser occipital, and greater occipital nerves bilaterally. This localized anesthesia enabled the patient to extend his neck and comfortably rest on two stacked pillows beneath the occipital region, alleviating pressure on the tumor. Subsequently, a bilateral superior laryngeal nerve block was performed following lidocaine nebulization, preceding an awake fiberoptic intubation [1]. Moreover, in a neonatology case mirroring ours, a newborn with an encephalocele was initially placed in a lateral position for induction and ventilation. However, during laryngoscope exposure, a Cormack-Lehane grade 3 view was encountered, resulting in unsuccessful intubation in the lateral position with a major risk of encephalocele rupture. Subsequently, the patient was repositioned into dorsal decubitus with assistance from multiple individuals, positioning the head beyond the examination table. This adjustment notably improved the Cormack-Lehane score to 2, and intubation was successful [5]. In another neonatology case, a newborn presenting with a giant cervical hydrocele as part of a Dandy-Walker syndrome, positioned laterally with the head extending beyond the table, intubation was successfully performed in this position [6].

In addition to lateral positioning or dorsal positioning with the head extending beyond the operating table, an alternative approach is awake fiberoptic intubation, aimed at minimizing manipulation of the mass. Another innovative technique, awake fibrocapnic intubation, enhances intubation success rates, particularly in cases of challenging airway visualization, by enabling simultaneous monitoring of capnography alongside visual control [7]. Intubating a patient with a scalp or cervical mass presents a challenging task in airway management, with potentially life-threatening consequences if complications occur. A standardized approach is essential for managing such cases, with the safest technique being awake fiberoptic intubation in dorsal position using pillows or head beyond the table, associated with scalp nerves block if needed. However, this procedure demands the expertise of an experienced anesthesiologist.

Conclusion     

This case highlights the critical necessity of rapid and proficient airway management in challenging surgical scenarios. Intubation in the supine position with the head beyond the operating table, along with the medical-surgical management of hemorrhagic shock, allowed the patient's rescue. However, a method involving awake fiberoptic intubation combined with local scalp anesthesia may offer improved management and increased safety for such patients.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Ilyass Hmadate, Mustapha Bensghir: study concept, data curation, formal analysis, methodology, project management, and writing (original draft, review, and editing). Abderrahmane Elwali, Brahim Chikhi, Youssef Aarjouni, Mohamed Benani: study concept, data curation, formal analysis, methodology, project management, and writing (review and editing). All authors have read and approved the final manuscript.

Figure     

Figure 1: axial computed tomography scan of the skull and brain.

References