Barely an airway in a decompensating premie

[Doc Dutch]

You are on-call all night and you get paged to the L and D suite emergently. There you find a mother who has just delivered a 32 week old premie. The nurse practitioner goes to intubate the premie due to a low APGAR and discovers that there is a mass off the left tongue which has grown into the roof of the mouth, occluding 2/3 of the oropharynx, with leftward tracheal deviation of the upper trachea by the cricoid cartilage but mid-line just above the sternal notch by palpation. Astutely, the NP abandons the oral ETT route and goes the nasopharyngel route hoping to have a straighter shot at the vocal cords. Saturations that had dropped into the 50's are no hovering in the low 80's to upper 70's. Temporarily satisfied, the child is moved to the NICU (neonatal intensive care unit). On arrival the saturations are noted to have dropped into the 60's but with agrressive bagging the saturations come up into the 70's.

Now, anesthesia arrives. They take a look and cannot see the vocal chords around the mass orally and do not want to dislodge the nasopharnygeal ETT already in place although clearly it is not in. There are bubbles from the mouth and if you close the mouth the saturations improve slightly. The NICU attending tries to intubate orally and cannot pass the tube, even with position change of the level of the head and back. Suctioning the mucous causes desaturations. There is the tiny ETT that the NP had placed initially which is really a nasopharyngeal airway, even an LMA if you will, at best. The anesthesiologist again tries to pass a small ETT (uncuffed) orally but fails. Now the airway is getting "bloody". The premie has destaurated into the 40's and the HR drops into the 60's as well. There is one IV access route. We are able to bag up to the 60's with a flicker of 70 on the SaO2 monitor with a return of the HR into the 130's. Again, the intermittent suctioning leads to bloody output mixed with mucous and greeted with desaturations. The pediatric surgeon has been called in but is 30 minutes away at least.

Anesthesia and NICU physicians try again and again the SaO2 drops. Only able to bag up into the low 50's to high 50's. The premie is bradycardiac and there is cardiac ectopy. The pediatric bronchoscope will not fit down the nasopharyngeal ETT.

The pediatric surgeon will not make it in time for this one and something must be done as they cannot keep the saturations up and the bradycardia becoming more persistent. There are about 25 various well-intentioned health-care practitioners gathered around now looking at you with that look: The look of, "Do something now . . . please!!!"

Now, what?

Remember this is a 32 week premie airway with a mass that goes from the tongue to the roof of the mouth and posterior to who knows where and the trachea is deviated. The chest x-ray which is really a baby-o-gram does not reveal much diagnostic information.

So, where would you go? (This happened last night.)

DM

[adal]

Needle Cric with Jet insuffilation (sp?) See if you can find a Boogie small enough to fit in the ETT if not try a wire guide. Seriously contemplate surgical trach do to poss damage of the cricoid rings and trachea and the ensuing edema. What a yucky call, NRP at its worst. How'd it turn out?

[cold1]

I would go to the little church and pray for all the good people doing their best to keep the baby alive and healthy.

No smartassedness intended, yall Docs get put in some tight places with heavy decisions to make. I dont envy you at those times.

God bless.

[Doc Dutch]

Yes. I pretty much realized that this was going to be a first in what was a rough spot. A first on something the size of my hand! But I figured it was even rougher for the little patient . . .

Well, we took an 18 gauge angiocath with a syringe of saline on the end. The saline in the syringe will let you know when you are in the trachea as you advance the needle and aspirate as you advance. Once you are in the airway, you get air bubbles. To be honest with you, it took several passes. Could not get the angiocath to pass over the needle. Would next time upsize to a 16 gauge or even 14 gauge if we could find one. After the last pass, got air, and were finally able to pass the catheter. Had an adaptor for the needle that would connect to a BVM. Bagged the child up to 90 percent. That bought the pediatric surgeon time to get into the NICU.

Another lesson is that whomever holds the needle in place, be careful not to kink the needle off once it is in. At one point we started to desaturate all of a sudden. Trouble shot quickly and found the catheter was being kinked by the person holding plastic angiocatheter. So, we sutured it in to secure it. That obviated the need for a second set of hands to hold the angiocatheter in place. Now the only person needed was the person bagging the premie which was fine considering the small area that we had to work. The NICU physician was the one bagging and hold complete control.

Next lesson, we left the nasopharyngeal airway in place even though we may not have needed it. We left it as a "just in case" as it got us that far. If the needle cric did fail, we could go back and see if it might work again. We removed it after the formal tracheostomy.

Another lesson, make sure that the OR staff (nurses and techs) are setting up the closest OR to the premie and that they have all the equipment needed (sizes of neonatal/pediatric trachs), so that while you are stabilizing the premie, they are busy setting up and getting ready. So, remember to call the OR. That seems like a no brainer, but in all of the tension . . .

Next lesson, this was an emergency but make sure you or someone makes the time to speak to the mom for procedures and keep her informed. Preferably before the procedure, but speak to the parents and let them know. Even for the premie's next procedure, the tracheostomy. Moms and dads must be informed at all times and keep them in the consent/decision making process. With all the people around, someone can do that. We managed it. But if you do not think ahead about it, in the rush to get the premie stabilized, parents can be forgotten. Once you remember, it can delay going to the OR and that can delay getting the needle cric converted over to a formal tracheostomy.

Finally, make sure that the needle cric gets converted over to a formal tracheostomy within 45 minutes. Why? Acidemia develops quickly as the needle cric is for oxygenation not for ventilation and CO2 builds up quickly. At one point the premie's pH was 6.7. It began to normalized post-op tracheostomy with ventilation and blowing of the CO2 and with better access through lines placed in the umbilicus for a larger resuscitation.

Phew! Where are the NICU team and premie now? The premie is alive but has a long road ahead of it and is not out of the woods by a long shot. If I hear any more, I will pass it along. When I left this morning the premie was alive.

Oh, one last thing. This also represents what I call, knowing when to "pull the trigger". "The trigger" is moving to provide the surgical airway. Once you decide, be decisive and move! It is often knowing when to push ahead despite others stating, "Hey, I want to try one more time." There comes a moment that you face the decision to provide a surgical airway. I will steal this phrase and say, when that time comes, "Just do it!" Pull the trigger and stick with your decision. I have never been disappointed when I have pulled it. I have been disappointed when I did not pull it soon enough (desaturations with cardiac ectopy or bradycardia with the airway physician begging that he almost has it in).

Time for a nap . . .

Thank you,

DM

[Red Flag 1]

Dutch,

Bad bad case!! Premies don't give you much time. Bradycardia in kiddies still makes the hair on my neck stand up! You are right about the nasal ETT as a nasal airway now and probably whistling in the graveyard at best. Nearly all neo-natal intubations are awake with no relaxants, the tongue on a neo-nate is very strong and the oral mass adds to your nightmare. With the left tracheal displacement, I have to wonder what else is going on that I can't see.

Two things I would probably try. First as adal suggested, needle cricothyrotomy using as large an IV intercath you are comfortable using; maybe an 18ga. Once in the airway pull the needle and leave the cath pointing caudad. I believe a 4.0 mm ET adapter will fit snugly into the hub of the intercath. Jet ventilate. This is not the total answer but can buy some time. I have done this in the ER with success on adults, CO2 buildup will become a problem but it can provide oxygenation in the short trem. In that small window of time, your surgeon will be nearer, and get Pedi Bronch stuff together. Mobilize the nearest surgeon to do a trach if needed.

Second would be for a more perm solution such as pedi bronch slide inside a pedi ETT. I think this is the best answer for ETT placement and a better look at the subglottic airway. Something has pushed the trachea to the left and it would be important to RO and subglottic airway mass!

Last resort, emergent trach.

Soft tissue studies of the neck to RO other masses. I'm willing to bet there may be another mass in the area of the glottis. I'd like to hear how this turned out. Bad Bad juju here.

RF 1

ps: It is possible to pull off a retrograde intubation using an epidural needle ( cricothyrotomy) with bevel oriented cephlad. Pass an epidural cath up into the oropharynx and grab it with a pair of clamps. Thread ETT over cath and down the cath through the cords. This is not easy and only a remote possibility. I doubt you will have enough room in the oropharynx given the mass your are dealing with. Kiddie may not have enough time for you to struggle through attempt; but it is possible.
rf

[Red Flag 1]

Dutch,

I type slow! Glad the outcome was positive for all!

RF 1

[Doc Dutch]

RF,

I do think next time (because there is always a next time or so it seems) I will go with the 16 or 14 gauge if I can find it readily. Bigger would have been better as it probably affords less kinking. I also agree with you that pointing the angiocatheter caudal and sliding the needle out once the angiocath is in or pushing in the catheter and removing the needle. I am not sure as to why for the first few attempts I could not pass the catheter over the needle and into the trachea. That was frustrating.

The retrograde intubation is a great idea. I have actually used this in another pediatric case (10 year old with c-spine and a t-spine fractures in a halo that lost his airway). The anesthesiologist and I did it together. Now that was "un-fun", but is really good to have in your arsenal of airway tools.

D-

[Red Flag 1]

Dutch,

If memory serves me correctly, each change in cath sizes changes resistance to flow to the fourth power. As true for liquids as it is for air flow.

RF 1

[Doczilla]

What a nightmare scenario! Premie, oral mass, deviated trachea, blood in the airway. I think all you would need is some screaming parents and maybe accurate hostile fire to make it a complete disaster. I agree that pulling the trigger is often the most difficult call, and that folks who are uncomfortable with surgical airways tend to shy away, preferring instead to continue futile intubation attempts rather than cowboy up and cut. It sounds like this kid would have been doomed without your hard work and quick thinking. :lifter

I've never been in a situation where I needed to consider a surgical airway in a neonate. If memory serves, the baby's thyroid obscures the landmarks and cricothyroid membrane. Is this true, and does it therefore make a traditional surgical cric more difficult and more prone to bleed? Also, does the infralaryngeal narrowing of the airway in the baby complicate this procedure?

'zilla

[adal]

Think a Cook kit would have worked? they have a wire coil around them to keep them from collapsing. adal

[Red Flag 1]

Dutch,

As a routine, all the anesthesia machines in all anesthetizing locations in my departments had Needle Cricothyrotomy and Retrograde intubation equipment located in the top drawer of every machine. All were sterilized, all equipment was there and ready to go. The times I faced using these items were in the ER @ 0 dark:30 and in radiology with no light and no room!

You are right, this can happen again!

RF 1

[Doc Dutch]

RF 1,

I am going to look and ask about the retrograde kits. I am not certain if we have the kits in the OR or ED but I know we have used it or something like it in the past. I will add it to my arsenal for "next time" by having the OR nurses order them if we do not. Resistance does change to the 4th power and I should have gone larger.

ADAL, I have used the Cook kit before at another institutions on adults. It is a good kit to have around but not sure if we have them where I am. I know we have used the wires out of a triple lumen kit before to go retrograde. As I recall we passed a tube exchanger over the wire once we nicked the skin with a scapel and grabbed it in the mouth with a McGill foriceps and then were able to intubate over the tube exchanger.

Doczilla, the thyroid, as you know, loves to bleed, so anything to stay away is helpful as blood in the field is the enemy especially in these tight cases!

I took our craniofacial plastic surgery specialist to see the child today. He thinks it is a hamartoma. We could see hair and skin and what looks like a hemangioma on the lateral side of the mass (that is what was probably bleeding as it had a clot on it). He said that once the child stabilizes they will get some CT's or MRI's. Looking at it on PE, he thinks that he will have to split the mandible to get it all out.

The child is on vasopressors and has pulmonary hypertension today on the oscillatory vent. Also found out the child had other genetic issues (imperforate anus). So, this may all be for not. Time will tell.

Anyway, great discussion.

Thanks,

D-

[Doc Dutch]

Final note on this little one . . . the tumor was an oro-nasopharyngeal teratoma. It was entirely removed in the OR in one entire segment by breaking the infant's mandible per the ENT neonatal surgeon at a local children's hospital. Nothing else further to report . . .

Dutch

[Red Flag 1]

RF,

I do think next time (because there is always a next time or so it seems) I will go with the 16 or 14 gauge if I can find it readily. Bigger would have been better as it probably affords less kinking. I also agree with you that pointing the angiocatheter caudal and sliding the needle out once the angiocath is in or pushing in the catheter and removing the needle. I am not sure as to why for the first few attempts I could not pass the catheter over the needle and into the trachea. That was frustrating.

The retrograde intubation is a great idea. I have actually used this in another pediatric case (10 year old with c-spine and a t-spine fractures in a halo that lost his airway). The anesthesiologist and I did it together. Now that was "un-fun", but is really good to have in your arsenal of airway tools.

D-

Just re-read this thread, and focused on the trouble you had threadding the cath.

With over the needle caths, the cath is larger than the needle puncture. It is not uncommon for the cath to become distorted as it trys to pass through the skin. It does happen on periph lines and can cause phlebitis after a day or so. The neck tissues in the newborn could well have distorted the cath to the point the cath just would not thread for you.

A small trick I generally did on all ONC line placements was to use the needle tip to make a small skin nick, or incision, to allow for the larger cath to pass without distortion. Try this if you have to do another needle thyrotomy again.

Best regards.

RF 1