Wednesday, January 20, 2010

Third Case in Kigali

(This is for anesthesiologists only)

On Monday 18th we did our first day of work at CHUK (pronounced See-atch-ka), the Kigali University Hospital.

After the briefing it was decided that we should do a case of a facial tumour with one of the residents. It sounded like a good case - a patient with a golf-ball size tumour inside the cheek. Did I mention that it was a child, about a year old, weighing 10 kg? No- I don't think I heard that until later, either.

They have brand new anesthesia machines in CHUK which would not be out of place in a Canadian hospital, but for this small a child the plan was to intubate and then use an Ayre's T Piece and manually ventilate on halothane and oxygen. I thought a 4.0 oral Rae tube would be handy, so everyone searched. We found a 3.5 and a 4.5 but no 4.0. So we looked for a 4.0 normal tube, but we could not find one. We found a paediatric laryngoscope blade - not one of my favourite designs, but a fairly standard one.

The kid was healthy, and from the lower lip down the airway looked normal, but the tumour looked like it might make bag and mask ventilation difficult. We decided on a gas induction, start an IV, give atropine, then intubate. We had a small LMA available for back-up. The induction went smoothly but the kid had no veins. Took about 15 mins to find one. The senior Rwandan resident let the junior resident try to intubate but he could not, so the senior took over. He inserted the 3.5 tube, but the bend was almost a full centimeter out of the mouth. However, the kid was easy to ventilate and there was minimal leak, so the tube was secured, end tidal CO2 monitoring instituted, 10 mcg of fentanyl were given, the surgeon inserted a throat pack and surgery began. The surgeon kept moving the head and his assistant kept telling me not to worry about the tube. I discussed with the residents how we would know if the tube was displaced and what we would do.

After an hour the end-tidal CO2 dropped to zero. I bagged the patient and there was no air entry. Told the surgeon to stop, he removed the throat pack, and I looked in. I could see the larynx did not have a tube in it any more! Tried to reintubate with a clean normal 3.5 tube but was not able to. Got the patient deeper and had the senior resident re-intubate, which went OK. The rest of the case went smoothly until….

After the surgery was over we waited till the kid was wide awake before extubation. Took the tube out and the kid was thrashing around in pain. Clearly the fentanyl given 90 minutes ago had worn off, so we gave another 10 mcg. The kid stopped breathing. No big deal, just some narcotic-induced respiratory depression, nothing that a little bag and mask ventilation or a small dose of naloxone would not fix. WRONG. The kid was impossible to ventilate, there was a laryngospasm I could not break. The pulse oximeter had fallen off but the kid was clearly blue and the heart rate had fallen into the 60s. Fortunately I had insisted on their being a spare dose of sux available (I brought my own supply from Canada!) and the Canadian resident gave a dose, the spasm broke immediately, and all was well.

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