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Use of a laryngeal mask in acute airway obstruction after carotid endarterectomy

Sherbrooke, Québec

To the Editor:

A potential complication associated with carotid endarterectomy is airway obstruction requiring intubation of the trachea in the postoperative period. This is the result of tissue swelling and/or bleeding into the neck.^1,2 Fifteen hours after right carotid endarterectomy, a 67-yr-old gentleman developed a hematoma of the neck, with stridor. He was immediately transferred to the adjacent operating room in a left lateral semirecumbent position in order to secure his airway and perform hemostasis. Monitoring employed was electrocardiography, pulse oxymetry, capnography, and invasive arterial blood pressure. Without any sedation and with the patient in the same position, awake endotracheal intubation was attempted with fibreoptic bronchoscopy after three lidocaine sprays on the pharyngeal structures. Generalized massive swelling of the airway was observed, and two minutes after the beginning of the procedure, the patient developed a complete airway obstruction with acute blood desaturation. The neck wound was opened and blood clots evacuated without improvement. Direct laryngoscopy confirmed massive bilateral airway swelling, especially in the posterior aspect of the pharynx, without any visualization of laryngeal structures. External mask ventilation was impossible. Blood saturation fell to around 50% at that time; a 14G needle was inserted through the cricothyroid membrane and connected to the anesthesia circuit (F_iO₂ 1.0) with rapid improvement of blood saturation. A #5 laryngeal mask was then inserted and spontaneous ventilation of the patient resumed without difficulty. The patient, who had lost consciousness at the time of blood desaturation, woke up again. Anesthesia was then induced with sevoflurane and a tracheotomy was performed. Recovery was complete and uneventful. We postulate that insertion of the laryngeal mask helped alleviate airway obstruction secondary to massive tissue swelling and may be attempted in the urgent management of airway obstruction after carotid endarterectomy.

References

1 Carmichael FJ, McGuire GP, Wong DT, Crofts S, Sharma S, Montanera W. Computed tomogragphic analysis of airway dimensions after carotid endarterectomy. Anesth Analg 1996; 83: 12–7.[Abstract]

2 Hughes R, McGuire G, Montanera W, Wong D, Carmichael FJ. Upper airway edema after carotid endarterectomy: the effect of steroid administration. Anesth Analg 1997; 84: 475–8.[Abstract]

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