Airway Management Failure after Delayed Extubation in a Patient with Oral Malignant Melanoma Who Underwent Partial Mandibulectomy and Reconstruction with a Free Flap

Maxillofacial surgery may cause severe complications in perioperative airway management. We report a case of failed airway management in a patient who underwent segmental mandibulectomy, radical neck dissection, and reconstruction with a free flap. The patient was extubated approximately 36 hours after surgery. Approximately 7 hours after extubation, the patient complained of dyspnoea, and respiratory failure followed. Bag-mask ventilation, direct laryngoscopy, video laryngoscopy, and supraglottic airway access were ineffective. The surgical airway was secured with an emergency tracheostomy while performing cardiopulmonary resuscitation. However, the patient experienced permanent hypoxic brain damage. The airway of patients with oral cancer may be compromised postoperatively due to surgical trauma and bulky flap reconstruction. Patients should be closely monitored during the postoperative period to prevent airway failure. Early diagnosis and airway management before airway failure occurs are important. Medical staff should be aware of airway management algorithms, be trained to perform difficult airway management, and have the required equipment readily available.

Comparison of laryngeal mask airway and endotracheal tube in preterm neonates receiving general anesthesia for inguinal hernia surgery: a retrospective study

Background Preterm neonates are at higher risk of developing inguinal hernia, and have an increased risk of perioperative adverse events. Laryngeal mask airway (LMA) is claimed to be associated to decreasing perioperative respiratory complications compared to endotracheal tube (ETT) in infants under one year of age receiving minor surgery; thus, we conducted a retrospective survey in former preterm neonates below 5000 g to compare the respiratory complications between LMA and ETT in general anesthesia for inguinal hernia surgeries. Methods The inclusion criteria were: gestational age at birth under 37 weeks, body weight at surgery below 5000 g, and receiving scheduled inguinal hernia repair under general anesthesia with LMA or ETT. Infants who were dependent on mechanical ventilation preoperatively were excluded. The postoperative respiratory complications including delayed extubation, re-intubation, and apnea within postoperative 24 h were compared between groups. Results From July 2014 to December 2017, 72 neonates were enrolled into final analysis. There were 57 neonates managed with LMA, and only 15 neonates intubated with ETT during the study period. The gestational age at birth and post-menstrual age at surgery showed no significant difference between groups, although in the ETT group, the body weight at birth and at surgery were lower, and more infants had history of severe respiratory distress syndrome and had received oxygen therapy within two weeks prior to surgery. Surprisingly, none one of the infants developed delayed extubation, re-intubation, or postoperative apnea in the LMA group. In the ETT group, 40 percent of the neonates could not be successfully extubated in the operation theater. Conclusion In preterm neonates, even in those younger than 52 weeks post-menstrual age who undergoing inguinal hernia repair in their early infancy, LMA appears feasible and safe as the airway device during general anesthesia in specific patient group. However, anesthesiologist might prefer ETT rather than LMA in some complex situation. In neonates with lower body weight at birth and at surgery, and with a history of severe RDS and oxygen-dependence, further prospective study is required.

Anaesthetic management of maxillofacial surgeries: A cross-sectional survey to analyze current trend of practices

Anaesthetic management of maxillo-facial surgeries considered as special subset of surgery where the airway management needs proper attention. Most of the time it varies depending on the resources and skill availability. We tried to evaluate the current trend of practices in managing maxilla-facial surgeries among various practicing anaesthesiologists. This is a retrospective questionnaire based survey conducted among practicing anaesthesiologists to determine the trend of practices and institutional protocols followed for maxillo-facial surgeries. A set of questionnaires prepared to ask about the preferred mode of securing airway, frequency of facing complications and plan for extubation and post-operative management. Total of 86 responses were collected which were analyzed. A total of 91% evaluated the airway with history and physical examination. Fiberoptic broncoscope available in 46% of cases, 51% cases video laryngoscope was preferred as gadget. Naso-tracheal is the commonest route for securing the airway which was preferred by 53% respondents. Only 38% respondents were in favor of extubation of the patients inside the operation theatres after surgery for patients without head injury. In patients with head injury 90% responders believed either a delayed extubation in the ICU or elective ventilation for some hours before extubation is a better option. Most of the anaesthesiologists (61%) preferred shifting the patients to the ICU for post-operative care. Theanaestheticmanagement ofmaxillo-facial surgeries need special attention. It necessitates proper pre-operative evaluation, shared decision making with the surgeons, timely decision of extubation and post-operative care are keys to successfully manage the airway.