2023 FSA Podium and Poster Abstracts
P011: POSTERIOR CRANIOTOMY: OVERCOMING AIRWAY CHALLENGES
Tilman Chambers, MD1; Kavan Clifford, MD, PhD2; Benjamin T Houseman, MD, PhD2; 1Memorial Hospital System; 2Envision Physician Services
Posterior Craniotomies require the use of rigid head positioning to prevent intraoperative trauma among other complications (1). This extreme positioning is known to cause complications like ventilation issues, eye damage, and airway pressure sores (2). Here we describe a case at a regional hospital where patient positioning lead to airway compromise and required the use of careful planning, fiberoptic scopes, and OR table repositioning necessitating teamwork between surgical and anesthetic teams.
51 y.o. Man with a PMH of AMS, cocaine, and alcohol use presented for a posterior fossa craniotomy for clipping of a ruptured aneurysm, resulting in a Hunt and Hess grade 4 subarachnoid hemorrhage. This presentation followed a previous grade 5 subarachnoid hemorrhage, status post coiling of an anterior communicating aneurysm and EVD placement days prior. Patient was transported from the ICU intubated, sedated, with two large bore IVs, and an arterial line for HD monitoring. He was rigidly attached in a prone position to the table with mayfield head clamp with extreme flexion for exposure of the posterior fossa. His anesthesia was maintained with a propofol, fentanyl, and remifentail drip with rocuronium, fentanyl, and propofol boluses. Hemodynamic support was maintained with crystalloids and albumin with boluses of phenylephrine and nicardipine. After initial incision and surgical exposure of the posterior fossa, the patient became increasingly difficult to ventilate. A soft tip suction tubing was unable to be passed through the oral ET tube due to head positioning in pins causing kinking within the posterior oropharynx. In concert with our neurosurgical colleagues, the case was paused, the head flexion relaxed in order to facilitate adequate ventilation orally while planning steps for conversion from oral to nasal intubation were taken. Here we describe how asleep nasal fiberoptic intubation was completed successfully in the prone position with an aintree catheter in place orally, to facilitate oral reintubation if unsuccessful nasally. The remainder of the case passed uneventfully, with the patient ventilating appropriately with the ET tube through the nose following completion of the surgical procedure, he was subsequently transferred to the ICU nasally intubated and eventually discharged to the acute rehab unit after regaining some function.
Prone positioning is associated with a wide range of complications and when combined with the extreme flexion required for a posterior craniotomy, it is a reminder of the need for caution and preparedness (3). The ET tube used for the oral intubation likely became kinked due to extreme flexion once the tube likely softened when heated to body temperature (4). When choosing an ET tube, it is important to pick a tube that is long enough to allow for adaptation to changes in positioning. Alternatives for traditional ET are armored ET tubes, which are more resilient to kinking (5). The change in OR bed orientation showed the flexibility and teamwork with our surgical colleagues required during challenging intraoperative events.
References:
1) doi: 10.3389/fsurg.2020.00009
2) doi: 10.1016/j.anclin.2007.05.009
3) doi: 10.9738/INTSURG-D-13-00256.1
4) doi: 10.2344/anpr-65-02-06
5) doi: 10.4103/0972-5229.198331