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Use of a Macintosh blade in extrahepatic portal vein obstruction with difficult intubation: two case reports
Azho Kezo1,2, Rajendra D Patel3, Shraddha Mathkar3
1Department of Anaesthesiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, 400012, India. kuzhonulu@gmail.com.
Background:
We report the management of two patents from the Indian subcontinent with extrahepatic portal vein obstruction presenting with anticipated difficult airway. A Macintosh blade was used to secure the airway after using various instruments designed for difficult airway. To the best of our knowledge, no case has previously been reported in which a Macintosh blade was used successfully in patients with extrahepatic portal vein obstruction with a difficult airway.
Case Presentation:
Two women (case 1 and case 2) of South Asian ethnicity with extrahepatic portal vein obstruction presented for an elective splenorenal shunt. They both had micrognathia and restricted mouth openings. They had similar airway profiles with mouth openings of just 2 cm, Mallampati class IV, a thyromental distance <4 cm, a hyomental distance <2.5 cm, and a sternomental distance of 10 cm. Awake intubation was attempted in both patients after standard airway preparation in the form of preoperative 4 % lignocaine nebulization and 2 % viscous lignocaine gargle along with an on-table supralaryngeal nerve block using 2 % lignocaine and transtracheal infiltration with 4 % lignocaine. The patient in case 1 tolerated the procedure well whereas the patient in case 2 had to be given propofol 60 mg. Endotracheal intubation with a 6.5 mm polyvinyl chloride endotracheal tube was attempted using a Truview EVO2, an Airtraq, and a Miller blade no. 3 but was unsuccessful. Finally, a trial intubation was performed successfully with a Macintosh blade with a stubby handle assisted by a Frova Intubating Introducer in case 1 and a gum elastic bougie in case 2.
Conclusions:
Although many instruments have been introduced to manage difficult airways, our experience in these cases suggests that the Macintosh blade can be used first when attempting endotracheal intubation before using other instruments. Patients from the Indian subcontinent with extrahepatic portal vein obstruction are often found to have associated temporomandibular joint ankyloses (hence difficult airways). We hypothesize that a difficult intubation should be anticipated in these patients. Such an association has not been made before.
Insights
This study highlights the successful use of a Macintosh blade for endotracheal intubation in patients with extrahepatic portal vein obstruction and difficult airways. This approach offers a valuable alternative for managing challenging airway cases in this specific patient population.
Area of Science:
- Anesthesiology
- Gastroenterology
- Otolaryngology
Background:
- Extrahepatic portal vein obstruction (EHPVO) can present with difficult airway anatomy.
- Patients from the Indian subcontinent with EHPVO often have associated temporomandibular joint ankylosis, leading to anticipated difficult airways.
- Standard difficult airway management protocols may require adaptation for this specific patient group.
Observation:
- Two South Asian women with EHPVO presented for elective splenorenal shunt with severe airway limitations (e.g., Mallampati IV, restricted mouth opening).
- Multiple intubation attempts with specialized devices (Truview EVO2, Airtraq, Miller blade) were unsuccessful.
- Awake intubation with Macintosh blade and an introducer (Frova or bougie) proved successful in both cases.
Findings:
- A Macintosh blade, often considered a standard laryngoscope, can be effectively used as a first-line instrument for endotracheal intubation in EHPVO patients with difficult airways.
- Successful intubation was achieved after failed attempts with other advanced devices.
- The use of a stubby-handled Macintosh blade with an intubating introducer facilitated airway management.
Implications:
- This case series suggests a potential shift in the initial approach to difficult airway management in EHPVO patients.
- Anticipating difficult airways and considering the Macintosh blade as an initial tool may improve patient outcomes.
- Further research is warranted to validate the efficacy of this technique in a larger cohort.
