Do Not Underestimate the Difficulty of Reintubating a Patient Who Has Undergone Carotid Endarterectomy or Cervical Spine Surgery
Heath R. Diel MD
Randal O. Dull MD, PhD
Anesthesia providers do not always appreciate the potential difficulties in reintubating patients who have undergone carotid endarterectomy and cervical spine surgery. Because these patients do not have tumors and usually do not initially present with stridor or signs of vocal cord paralysis (unless there has been a previous stroke), the initial intubation often is uncomplicated. During the operative phase there are many important physiologic issues, such as management of hemodynamics and maintenance of organ perfusion, that compete with the anesthesia provider’s attention to airway issues. Prompt emergence and extubation is desired to facilitate postoperative neurologic checks and to avoid hypertension and coughing at the time of emergence. However, at all times, anesthesia providers must be alert for postextubation airway issues. It can be extremely difficult to get the airway secured after failed extubation even if the initial intubation was uncomplicated. This is a situation to consider very carefully before planning a “trial of extubation” or a “let’s see how he does without the tube” maneuver.
The causes of postoperative respiratory dysfunction after carotid endarterectomy or cervical spine fusion include laryngeal or pharyngeal edema, hematoma, cerebrospinal fluid (CSF) leak, recurrent laryngeal nerve dysfunction, carotid body dysfunction, cervical fusion, malalignment, and improperly applied bandages.
EDEMA/HEMATOMA
Postoperative cervical edema is present in every anterior neck procedure to some degree and occurs in cervical laminectomy because of prone positioning. In carotid endarterectomy patients, computed tomographic studies have shown a 25% to 60% reduction in airway volume and a 200% to 250% increase in retropharyngeal mass as a result of edema alone. Edema of the larynx and pharynx is thought to be caused by venous and lymphatic disruption, as well as direct tissue trauma with increased capillary permeability secondary to release of local inflammatory mediators. Tissue edema can be difficult to gauge clinically if the patient has remained in the supine position. There can be significant internal compression of airway structure with little
or no change in neck circumference, and stridor may not be heard until the airway has narrowed to 4 mm. Also, unilateral tissue disruption can cause bilateral edema. Edema is rarely the sole cause of respiratory distress leading to reintubation, but it compounds the effects of other problems that might arise (such as hematoma) and can make visualization of the vocal cords for reintubation extremely difficult. If the edema has occurred because of prone positioning, elevating the head of the bed to 30 degrees during emergence can reduce soft tissue edema.
or no change in neck circumference, and stridor may not be heard until the airway has narrowed to 4 mm. Also, unilateral tissue disruption can cause bilateral edema. Edema is rarely the sole cause of respiratory distress leading to reintubation, but it compounds the effects of other problems that might arise (such as hematoma) and can make visualization of the vocal cords for reintubation extremely difficult. If the edema has occurred because of prone positioning, elevating the head of the bed to 30 degrees during emergence can reduce soft tissue edema.
Significant hematoma occurs in about 1.4% to 10.0% of carotid endarterectomy patients, with higher frequency in cases involving coagulopathies and heparin use without reversal. Frequently, hematomas do not develop until several hours into the postoperative phase, and the “carotid take-back” patient is often hypertensive, hypercarbic, and partially obtunded as well. Reintubation in this situation can be one of the most difficult airway situations to manage, and the airway can quickly become a truly emergency situation. Surgical evacuation of the hematoma without regard for aseptic technique may be sufficient to relieve the obstruction until oral direct laryngoscopy can be performed. The authors recommend that anesthesia providers have available maximum airway support in terms of personnel and equipment when reintubating any patient who has developed significant hematoma after carotid or cervical neck surgery.
Related posts:
Never Neglect the Basics of Airway Management
Consider the Use of Lidocaine in the Cuff of the Endotracheal Tube, But Be Aware of the Risks and Alternatives
Do Not Start the Airway Management of a Ludwig Angina Patient Until Personnel and Equipment for a Definitive (Surgical) Airway Are Assembled
Do Not Use the Subclavian Vein for Central Access of Any Type in a Patient Planned for Dialysis
Consider the Use of Tris-Hydroxymethyl Aminomethane (THAM) to Treat Refractory or Life-Threatening Metabolic Acidosis
Be Aware of the Drugs that Require Slow Intravenous Administration
Full access? Get Clinical Tree
