Indian Journal of Anaesthesia

LETTER TO EDITOR
Year
: 2013  |  Volume : 57  |  Issue : 2  |  Page : 203--204

Successful use of air-Q intubating laryngeal airway after failed rapid sequence intubation in a child with Rubinstein-Taybi syndrome


Puneet Khanna1, Dalim Kumar Baidya1, Vinay Tomar2, Anil Agarwal3,  
1 Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anaesthesia, Mata Chanan Devi Hospital, New Delhi, India
3 Department of Anaesthesia, Fortis Hospital, Noida, Uttar Pradesh, India

Correspondence Address:
Dalim Kumar Baidya
Department of Anaesthesia, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
India




How to cite this article:
Khanna P, Baidya DK, Tomar V, Agarwal A. Successful use of air-Q intubating laryngeal airway after failed rapid sequence intubation in a child with Rubinstein-Taybi syndrome.Indian J Anaesth 2013;57:203-204


How to cite this URL:
Khanna P, Baidya DK, Tomar V, Agarwal A. Successful use of air-Q intubating laryngeal airway after failed rapid sequence intubation in a child with Rubinstein-Taybi syndrome. Indian J Anaesth [serial online] 2013 [cited 2020 Sep 30 ];57:203-204
Available from: http://www.ijaweb.org/text.asp?2013/57/2/203/111870


Full Text

Sir,

Rubinstein-Taybi syndrome (RTS) is a rare autosomal dominant disorder characterised by mental and growth retardation, craniofacial, vertebral, ocular and cardiac anomalies, gastro-oesophageal reflux and difficult airway [Table 1]. [1],[2]{Table 1}

A 4-years-old 14 kg boy with bilateral ptosis was scheduled for corrective ocular surgery. He had a history of recurrent regurgitation and respiratory tract infection. However, his effort tolerance and developmental milestones were normal. He had broad thumbs, pectus excavatum, hyperteleorism, micrognathia, retrognathia, prominent incisors and high arched palate. The modified Mallampatti class was III and neck movements were normal. Vital parameters were stable. Haematological and biochemical investigations, chest X-ray, electrocardiography (ECG) and echocardiography were normal.

He was made to fast for 8 hours for solids and 2 hours for clear liquids and premedicated with intravenous ranitidine 20 mg and metoclopramide 2.5 mg. In the operating room, he was preoxygenated for 3 minutes and propofol 50 mg and Rocuronium 15 mg were injected as cricoid pressure was applied. Direct laryngoscopy revealed Cormack-Lehane grade IIIb; gum elastic bougie could not be negotiated. Gentle mask ventilation with 100% oxygen and sevoflurane was initiated maintaining cricoid pressure. Second attempt using McCoy laryngoscope also failed. Subsequently, air-Q intubating laryngeal airway (ILA) #2 was inserted and adequate ventilation was achieved. Uncuffed endotracheal tube #5 mm was successfully inserted through the air-Q ILA in the first attempt and the latter was removed. Pharyngeal packing was done. Cricoid pressure was maintained throughout the entire procedure till intubation.

Anaesthesia was maintained with 50% oxygen-air mixture and sevoflurane. Fentanyl 30 mcg and intravenous paracetamol 200 mg were administered for analgesia. At the end of surgery, residual neuromuscular blockade was reversed with neostigmine and glycopyrrolate and trachea was extubated after the child was fully awake. Postoperative course was uneventful and the child was discharged home after 3 days.

In view of severe gastro-oesophageal reflux and recurrent aspiration, rapid sequence induction of anaesthesia with endotracheal intubation was planned. Muscle relaxant was deemed necessary for rapid sequence intubation and rocuronium was used as succinylcholine is known to cause serious arrhythmia in RTS patients. [3] Air-Q ILA was chosen as it is easy to insert and provides good conduit for intubation. Air-Q ILA has been successfully used as a rescue airway device following failed rapid sequence intubation in two children with airway haemorrhage. [4] In the present case, air-Q could be placed easily and endotracheal tube was passed successfully. Spontaneous inhalational induction with fibre optic bronchoscope (FOB) guided intubation could be safer option in such cases of difficult airway, but due to risk of aspiration this was not done. However, FOB was kept ready. Abnormal narrowing of upper and lower airway and tracheomalacia may be present in patients with RTS and relatively smaller size tube should be chosen. [5] Anticholinesterase and anticholinergic drugs can precipitate arrhythmia in RTS patients with associated cardiac anomalies. [1] This patient did not have any cardiac anomaly and neostigmine was used under continuous ECG monitoring. Postoperative oxygen therapy and vigilant monitoring is important as postoperative respiratory distress with copious secretion and recurrent desaturation episodes have been reported even after uneventful anaesthesia in these patients. [3],[5]

To conclude, difficult airway along with risk of pulmonary complications and cardiac involvement are main concerns in children with RTS. Air-Q intubating laryngeal airway is a useful airway device in children with difficult airway and it should be readily available in theatres where high-risk children with difficult airway are regularly anaesthetized.

References

1Stevens CA, Bhakta MG. Cardiac abnormalities in the Rubenstein-Taybi syndrome. Am J Med Genet 1995;59:346-8.
2Roelfsema JH, Peters DJ. Rubinstein-Taybi syndrome: Clinical and molecular overview. Expert Rev Mol Med 2007;9:1-16.
3Stirt JA. Anaesthetic problems in Rubinstein-Taybi syndrome. Anesth Analg 1981;60:534-6.
4Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in paediatric patients with airway haemorrhage. J Emerg Med 2011;41:369-73.
5Agarwal S, Haidar Y, Talpesh M, Zestos M. Anaesthetic management of children with Rubinstein-Taybi syndrome. Middle East J Anesthesiol 2011;21:309-13.