CONCLUSION •Proper planning and
preparations are essential
elements in the management
of extubation of a patient with
difficult airway.
•A difficult airway management
committee should be organized
in each tertiary hospital in
Nigeria to formulate protocols
and manage patients with
anticipated airway difficulty as
found in developed worlds.
•Safety has no border hence at
every stage of management of
a patient with difficult airway
optimum manpower and
equipment must be available to
prevent catastrophic outcome
DISCUSSION •Airway obstruction is a potentially life threatening
complication following cleft palate repair
•Tracheal intubation alone does not define an endpoint in
airway management.
•Poor preparation extending to the process of extubation was
the cause of death in this patient.
•In this report there was no rescue plan made by the resident if
failure to maintain the airway following extubation occurred .
This may be because essential equipment was unavailable or
the anaesthetist did not have the requisite skills or training to
use rescue equipment provided.
•Management of the obstructed airway is a significant clinical
challenge as reported by the National Confidential Enquiry into
Peri-Operative Deaths published in 1998 [2].
•Complex problems managed by trainees lacking the
appropriate airway skills, should be discouraged.
•A more senior anaesthetist especially paediatric anaesthetist
or other clinicians performing airway management should be
present also during extubation to manage crisis.
ABSTRACT Introduction: Cleft palate occurs in 1 in 2000 live births
[1].. The majority of anaesthetic morbidity related to
these procedures relate to the airway: either difficulty
with intubation, inadvertent extubation or postoperative
airway obstruction. An experienced anaesthetist is
required to provide the optimm management needed by
these patients at any level of care.
Objective: To show that management of difficult airway
goes beyond the intubation period, it is a continuum
including maintenance of intubation as well as adequate
planning of extubation
Summary: We present a sixteen month old female child,
with isolated cleft palate for repair. She had a history of
recurrent upper respiratory tract infections and failure to
thrive. Surgery had been cancelled on two previous
occasions because of difficulty in intubating the trachea.
Successful intubation of the trachea occurred on the third
occasion. Surgery was uneventful. The patient
subsequently developed airway obstruction after
extubation. Attempts at re-intubating the trachea and
mask ventilation failed and the child developed
cardiopulmonary arrest and could not be resuscitated.
PRE-ANAESTHESIA MANAGEMENT •The patient was pre-oxygenated with 100% oxygen for 5minutes
•Laryngoscopy was carried out under deep inhalational anaesthesia using
halothane
•The Comarck and Lehine was grade 3, successful tracheal intubation occurred
after the third attempt with Optimal external laryngeal manipulation (OELM) and
shoulder support. This was confirmed by capnography
•Uneventful intraoperative period and surgery lasted one and half hours with
mininal blood loss
•During the procedure the importance of a controlled planned extubation was
discussed with the resident.
•However while attending to another patient, the resident reversed and
extubated the patent awake
•Immediately post-extubation, the child had airway obstruction which could not
be relieved.
•All attempts to re-intubate and manually ventilate to maintain adequate
oxygenation was ineffective
•This resulted in deterioration of the child’s condition and a cardiac arrest from
hypoxia.
PRE-ANAESTHESIA MANAGEMENT
•Scheduled for repair of cleft palate at one year
•She was found to have an upper respiratory tract infection
necessitating treatment
•There had been two previous history of difficult intubaton
attempts
•Was informed in the management of airway on the third
attempt.
•The patient was categorized according to the American
Society of Anesthesiologists Physical status Class II.
•The laboratory results were within normal limits except for
sinus tachycardia on the electrocardiogram.
•Contingency plans for airway management were made
available
REFERENCES •R. C. Law and C. de Klerk. Anaesthesia For Cleft Lip And Palate Surgery, Update in Anesthesia: Volume 14 (2002), 27-30
•Gray AJG, Hoile RW, Ingram GS, Sherry KS. The Report of the NaAonal ConfidenAal Enquiry into PerioperaAve Deaths 1996 ⁄ 1997. London:
NCEPOD, 1998.
CASE PRESENTATION S A, a sixteen month old 6Kg female child with cleft
palate for repair presented at the age of four
month
There was history of failure to thrive, poor sucking
of breast and recurrent chest infections
Examination revealed a clinically ill-looking infant,
small for age
There was a cleft of the secondary palate, the
gingiva were normal.
The cardiovascular and central nervous systems
were normal.
The respiratory system showed tachypnoea,
40cycles/minute, no dyspnoea with transmitted
sounds on both lung fields
AIRWAY OBSTRUCTION IN AN UNPLANNED EXTUBATION IN A CHILD WITH CLEFT PALATE AND
ANTICIPATED DIFFICULT INTUBATION Oyedepo Olanrewaju Olubukola MD1, Adeyemi Moshood Folorunsho MD2
Department of Anaesthesia1, Department of Surgery2, University of Ilorin Teaching Hospital, Ilorin. Kwara
State. Nigeria.
Keywords: Airway obstruction, unplanned extubation, child, cleft palate, difficult intubation