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Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 279-280  

As the old saying goes, two heads are better than one

Department of Anaesthesiology, Seth G.S. Medical College, K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Ketan Sakharam Kulkarni
Near Janata High-School, Mahadeonagar, Islampur - 415 409, Sangli, Maharashtra
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Kulkarni KS, Saran A, Dave NM, Garasia M. As the old saying goes, two heads are better than one. Med J DY Patil Vidyapeeth 2018;11:279-80

How to cite this URL:
Kulkarni KS, Saran A, Dave NM, Garasia M. As the old saying goes, two heads are better than one. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2021 Jun 12];11:279-80. Available from: https://www.mjdrdypv.org/text.asp?2018/11/3/279/235561


A 2-year-old male child, weighing 10 kg, diagnosed case of Pierre Robin Sequence was scheduled for tongue tie release. Airway examination revealed severe retrognathia and mandibular hypoplasia with a mouth opening of approximately 2 cm with a large tongue. He had undergone a cleft palate repair a year back and was a documented case of difficult intubation then. An I-gel ® (Intersurgical Ltd, Wokingham, Berkshire, UK) laryngeal mask (size-1.5) was used as a conduit for fiberoptic intubation (FOI) in the previous surgery. The time required for endotracheal intubation was approximately 30 min with 2 episodes of severe desaturation (SpO2 <70%) mandating temporary termination of intubation procedure. We decided to execute a different intubation plan considering the previous anesthetic experience.

Injection midazolam 0.05 mg/kg was administered intravenously in the preoperative holding area. After instituting standard monitoring, injection propofol was given in titrated doses and injection atracurium 0.5 mg/kg was administered after confirming ventilation. Optiflow™ nasal cannula (OPT316 Infant) and Airvo™ (Fisher and Paykel Healthcare Limited, Panmure, Auckland, New Zealand) oxygen delivery system were then applied for apneic oxygenation (FiO2 95% and flow rate 12 L/min) during laryngoscopy. The anatomy of epiglottis and glottis could not be appreciated on first intubation attempt with Macintosh laryngoscope (blade no. 2). The saturation was maintained at 100%, so we proceeded with the second attempt of laryngoscopy using C-Mac ® (Karl Storz GmbH and Co. KG, Tuttlingen, Germany) video-laryngoscope (VL). A redundant, hypoplastic epiglottis was seen with a Cormacke-Lehane view Grade II b (video 1). Endotracheal intubation was performed using a 4.5 mm uncuffed endotracheal tube. The time lag between the cessation of bag-mask ventilation to appearance of capnograph was 3 min 40 s. No positive pressure ventilation was required throughout this apneic period as oxygen saturation was maintained at 100% with Optiflow nasal cannula. The patient maintained stable hemodynamics during the establishment of definitive airway. Heart rate was maintained between 120 and 125 beats/minute, and mean blood pressure was between 50 and 55 mm of Hg. The rest of the intraoperative course and recovery from anesthesia was uneventful.

Considering a history of previous fiberoptic-guided intubation through an I-gel ® which took prolonged period and was complicated with hypoxic events, it was decided to look for alternative techniques. Nagamine and Kurahashi [1] had tried FOI under inhalational anesthetic with endoscopy mask. However, we thought laxity of oropharyngeal tissue after induction of anesthesia could restrict the movement of the fiberscope. Sinha et al.[2] reported the use of C-Mac ® for a child with large parapharyngeal mass. After the first failed attempt with direct laryngoscopy, we tried C-Mac ® VL which magnified the view of intraoral structures and also helped the assistant to provide optimum external laryngeal manipulation. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) technique prolongs the safe apnea time in healthy children with normal airway.[3] Oxygenation in this technique is maintained by gaseous exchange through flow-dependent deads pace flushing.[4] In our case, the ability of THRIVE technique to buy more apnea time combined with the superior view offered by VL was the major reason for successful intubation without any episodes of desaturation. In the indexed case, the combination of Optiflow™ and C-Mac ® have given superior results than fiberoptic bronchoscope guided intubation; which is otherwise considered as a gold standard for difficult intubations for syndromic children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Nagamine Y, Kurahashi K. The use of three-dimensional computed tomography images for anticipated difficult intubation airway evaluation of a patient with Treacher Collins syndrome. Anesth Analg 2007;105:626-8.  Back to cited text no. 1
Sinha R, Rewari V, Varma P, Kumar A. Successful use of C-mac video laryngoscope in a child with large parapharyngeal mass. Paediatr Anaesth 2014;24:531-3.  Back to cited text no. 2
Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A, et al. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: A randomized controlled trial. Br J Anaesth 2017;118:232-8.  Back to cited text no. 3
Patel A, Nouraei SA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): A physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia 2015;70:323-9.Sir,  Back to cited text no. 4


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