Anesthetic Management of a Newborn With Severe Subglottic Stenosis
Inês Furtado, MD Anesthesiology Resident Centro Hospitalar de Lisboa Central Hospital Dona Estefânia Lisbon, Portugal
Dr Furtado reported no relevant financial disclosures.
Subglottic stenosis from endotracheal intubation (ETI) is a known iatrogenic complication. This implies difficulties in ventilation and endotracheal intubation for the pediatric age group. The incidence of pediatric patients undergoing ETI is less than 2%, and data on the anesthetic approach and airway management in newborns with this condition are virtually nonexistent.
The patient was a 21-day-old, full-term newborn boy with congenital bladder malformation. The patient was extubated when he was 17 days old—after 14 days of invasive mechanical ventilation. After that, he showed signs of stridor and clinical signs of respiratory effort. A laryngeal tracheomalacia after ETI was suspected. We proposed that the patient undergo an urgent endoscopy with subglottic dilation.
We chose inhalation sedation with sevoflurane. We administrated propofol in a sedative dose (2 mg/kg) after intravenous access catheterization while maintaining the patient with spontaneous ventilation. We did not use any airway adjuvant, and oropharyngeal lidocaine 0.1% was applied before the introduction of the fiberscope.
During the procedure, we diagnosed a severe subglottic stenosis with 70% lumen reduction (Figures 1 and 2). Laser ablation and balloon dilation were performed successfully. The surgical and anesthetic procedures elapsed without any complications.
http://www.anesthesiologynews.com/aimages/2016/ANSE0816_0002_a_600.jpg Figure 1. Visualization of severe subglottic stenosis with a fiberscope.
http://www.anesthesiologynews.com/aimages/2016/ANSE0816_0002_b_600.jpg Figure 2. Patient’s trachea with reduced lumen.
There were 2 major concerns: First, the patient was a newborn with a severe subglottic stenosis presenting for emergent surgery and requiring sedation; and second, the patient was also in spontaneous ventilation and at high risk for apnea. Then there was the probability of impossible ventilation, intubation, and surgical airway.
In this case, a multidisciplinary approach with collaboration with the otolaryngologist, the use of a sedative anesthetic technique associated with oropharyngeal local anesthesia, and the maintenance of spontaneous ventilation without the use of airway adjuvants proved to be a safe technique in a high-risk patient.
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