An example of difficulties caused by large parcels under children's tongues

The child, male, 1 year 5 months, 13kg, because of "discovery under the tongue of the bag block more than 3 months" hospital, proposed full hemp downstream block excisionPreoperative physical examination: the child breathing a little effortless, pack hard, obviousprotruding of the skin, Mallampati for class IVLab examination: No obvious abnormalitiesImaging inspection: CT shows that the lower jaw slightly to the left can be seen a package of shadow, size 44mm x 37mm, the rear airway sized lightly under pressure narrow, the rest of the checks did not see significant anomaliesConsiderthe difficult airways, prepare the pharynx duct, nasopharyngeal vent, the throat cover, visual laryngoscope, fiber bronchoscopy, and various trachea ducts, etcpre-surgery 30min muscle injection atropine 0.01mg/kg, after entering the room routine electrocardiogram, in turn slow intravenous injection of midazolam 0.1mg/kg, propofol 3mg/kg, Shufentani 0 .3 sg/kg induction, retain autonomous breathing, try mask auxiliary positive pressure ventilation, confirm the difficulty of mask ventilation, by the right side of the mouth placed in the visual laryngoscope observation: only visible overhang, can not detect and will be tired, small space in the mouthExit larynx, mask-assisted ventilation, add propalphenol 20mg, static amber choline 10mg relaxation muscles in order to increase oral space, again, found a little bleeding and secretions, immediately attracted, and under the laryngoscope assisted by the mouth into the fiber bronchoscopy observation: adjust the angle visible will be tired, but can not dig deep into the sound doorexit laryngoscope and fiber bronchoscopy, try 1.5 larynx cover into, poor ventilation effect, then remove, add propofol 20mg, to epinephrine 10 sgFinally abandoned the laryngoscope, directly to the fiber bronchoscopy through the nasal placement, many adjustments to the final examination and sound door, successfully placed in the fiber bronchoscopy on the 4.5 trachea catheter, hearing double lung breathing sound symmetry after proper fixationThe operation went smoothly, hemorrhage was not much, after the operation with tube transferred to the surgical intensive care unit (SICU) to continue treatment, 5d after the tube pulled smoothly, breathing smoothly, no serious complicationsPathological return is myofibre mablastal tumor, the child then transferredto the bloodfurther treatment in the oncology departmentdiscussion
the frequent occurrence ofperioperative airway problems seriously threatens the patient's inoperative safety and prognosis, early identification of anatomy or functional ventilation difficulties, the selection of ventilation devices suitable for children and other measures can significantly improve the prognosis of children Perfect preoperative assessment and pre-anaesthetic preparation are the basis for solving difficult airways Any factors that prevent the completion of intubation operations on any airway path (mouth, nastale, pharynx, throat, trachea) may cause difficult airways Patients with open mouth, armagia, chest spacing, head and neck activity, Mallampati airway classification, laryngoscope exposure classification, etc can help anesthesiologists to determine the need to prepare for difficult intubation before anesthesia induction The problems faced by anaesthetic in this case are: the child's breathing efforts, the reading show edire large block, indicating that the airway is pressured, Mallampati is class IV; the preparation of the anaesthetic needs to be prepared for a variety of visual intubation equipment as well as sound door ventilation equipment Reasonable anesthesia induction is the guarantee to solve the difficult airway: (1) induced body position: difficult airway of the child should be induced to maintain the passive position or its natural sleep preference position, the child's preoperative visit when the family did not inform the child there is a passive position, so the induction to take a classic olfactory position, to increase the pharynx space, open airway (2) To retain the choice of autonomous respiratory anaesthetic-induced drugs: propofol plus sufentanil intravenous induction or heptafluorone ether inhalation induction, can be achieved to retain autonomous breathing Compared with inhalation induction, intravenous induction has the advantage of fast," can quickly regulate the depth of anesthesia, and can effectively reduce the restlessness of children with inhalation induction this case of difficult airway children, because of the compression of the under-tongue block so that the child's oral space is small, visual laryngoscope can not be observed will be tired, because blind insert may cause bleeding, throat edema and other serious complications blocking the upper respiratory tract, from intubation difficulties into ventilation difficulties, so immediately withdraw from the laryngos This case of children under the laryngoscope-assisted through the mouth fiber bronchoscopy tube, although visible will be tired, but the fiber bronchoscopy can not detect the sound door, and through the nasal fiber bronchoscopy tube, after adjustment can be successfully into the airway Tip when the mouth intubation due to small throat cavity, can not provide sufficient adjustable space for fiber bronchoscopy, and through the nasal intubation, fiber bronchoscopy can be along the throat wall down, the space required for adjustment is small, the angle is also small, easier to enter the sound door The treatment of children with difficult airways in this case is prompted, for children with difficult tracts with narrow throats, compared with the passage, the intubation is simpler and more difficult to guide the intubation through the nasal fiber bronchoscopy, and more successful