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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 186-189

Post-burn facial contractures in pediatric patients: Challenging aspects of difficult airway management


1 Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Tripuri, Patiala, Punjab, India
2 Department of Plastic Surgery, Gian Sagar Medical College and Hospital, Ram Nagar, Tripuri, Patiala, Punjab, India

Date of Web Publication26-Dec-2012

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India
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Source of Support: Only departmental support, Conflict of Interest: None


DOI: 10.4103/2278-344X.105085

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  Abstract 

Pediatric burn injuries are the most challenging to handle especially when they involve the face as the airway compromise invariably occurs due to edema and inflammation of the soft tissues of pharynx and larynx. The healing of the facial burns causes development of contractures and deformities after survival from the initial insults. Such patients when presented for surgery of the affected area or for that matter any surgery under general anesthesia, poses unique challenges to the attending anesthesiologists. Not only there are technical difficulties, but the socio-behavioral aspects related to pediatric age group and the various side-effects of anesthetic drugs are the main concerns for the anesthesiologist during the entire operative intervention. We are presenting a case of an infant who was brought to our institute by his parents for the cosmetic correction of the contractures and deformities of the lower face and the neck and in whom we faced extensive airway challenges because of the nature of the surgery.

Keywords: Burns, difficult airway, fentanyl, ketamine, nasal intubation


How to cite this article:
Bajwa SS, Kaur J, Singh A, Singh G. Post-burn facial contractures in pediatric patients: Challenging aspects of difficult airway management. Int J Health Allied Sci 2012;1:186-9

How to cite this URL:
Bajwa SS, Kaur J, Singh A, Singh G. Post-burn facial contractures in pediatric patients: Challenging aspects of difficult airway management. Int J Health Allied Sci [serial online] 2012 [cited 2020 May 31];1:186-9. Available from: http://www.ijhas.in/text.asp?2012/1/3/186/105085


  Introduction Top


Pediatric burn injuries are the most difficult to handle for any surgeon, pediatrician or intensivist as these catastrophes invariably cause a widely deranged pathophysiology. Among these pediatric burn injuries, facial burns are the most dangerous as they invariably compromise the airway resulting from the inflammation and edema of the upper airway. [1] If a child survives these initial insults, the late complications are also equally troublesome for the patient and his parents. These injuries may result in hypertrophied scars and contractures of the affected area, which can severely restrict the movements of the head and neck and can impede the daily routine activities of the child including normal feeding and breathing. Any surgical procedure under general anesthesia in such subset of population is associated with great difficulties and challenges in securing the airway. [2] The mortality from difficult airway management is very high in neonates and young children and is estimated at 30-40% of all deaths related to anesthesia practice. [3] The loss of airway can prove extremely hazardous during anesthetic management of such cases as it can lead to a permanent neurological damage due to cerebral anoxia or intra-cerebral hemorrhage. We are reporting a case of difficult airway management during cosmetic surgery of the lower face and neck in an infant who survived the initial burns of the face and neck and presented to us with severe scars and contractures, which was restricting the normal motions of the neck and having impaired feeding.


  Case Report Top


An 8-month-old infant weighing 9.5 kg, presented to the pediatric surgery outpatient department with chief complaints of restricted neck movements from the last 5 months and an impaired feeding pattern due to this abnormality. On elicitation of history, it was revealed that the child had sustained accidental burns of the lower half of the face and neck 5 months back, which were attended to by a local practitioner. Thereafter, following healing of the burnt area, the infant developed severe progressive scars, which ultimately formed contractures and disfigured the entire anatomy of the lower face in addition to limiting the functional movements of the neck [Figure 1]. The peri-oral area was severely affected as it got anatomically altered with a gross disruption of the normal closure of the mouth. As per the details provided by the parents, the child had to be fed frequently as he was not able to take the breast feed completely during the early part and after the initiation of weaning he was able to take the feed only slowly. Moreover, parents were also worried about the speech of the child due to inappropriate closure of the lips as well as were worried about some unknown fears due to restricted neck movements in all the directions. The patient was referred to the plastic and cosmetic surgery department, where after complete examination, a decision to operate upon the child was planned, which included contracture release and skin grafting and the child was sent for pre-anesthetic check-up (PAC).
Figure 1: The deformed oral cavity from outside and difficult intubation

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During PAC, the child was found to be playful but with limited motion of the neck area. On examination, pulse rate was observed to be 102/min and the examination of the chest and cardiovascular system did not reveal any abnormality. His hemoglobin was estimated at 11.2 gm/ dl while all other investigations were within normal limits including the serum electrolytes. Considering the extent of area to be operated upon and the severity of surgery, 2 units of blood were arranged.

Since the child had restricted neck movements and the oral cavity was disfigured externally, a difficult airway management was anticipated. The major concern during the planned surgical procedure was that the child had to be operated upon in an area of peri-oral cavity, so oral intubation was out of question. The only alternative for securing the airway was to go for nasal intubation as tracheostomy was not only difficult but almost impossible considering the short neck and contractures present. Nasal fiberoptic bronchoscopy was also not feasible since the child was very young and other methods of securing an airway like retrograde intubation, etc. were also discarded owing to the younger age. So, various plans were formulated before proceeding for the surgery to secure the airway.

On the day of surgery, a trolley carrying all the equipment for pediatric difficult airway management and a tracheostomy set was made available by the side of the operation table and an ENT surgeon was requested to scrub for any eventuality. An intravenous (IV) line was secured with 22 G venous cannula in the ward using eutectic mixture of local anesthetic (EMLA) cream. The child was not administered any sedative premedication in lieu of development of respiratory obstruction. In the operation theater, after attaching the monitoring gadgets for heart rate (HR), ECG, non-invasive blood pressure (NIBP), pulse oximetry (SpO 2 ) and end tidal carbon dioxide (EtCO 2 ), induction of anesthesia was carried out using 15 mg of ketamine, 10 μg of fentanyl, 2% of sevoflurane and oxygen and the child was ventilated with Jackson Rees circuit. The dose of the anesthetics was kept on a lower side so as not to make the child apneic as it would have been difficult to secure the airway without checking for the adequacy of ventilation and an ability to administer positive breaths. After establishing the assisted ventilation with face mask, we administered 5 mg of ketamine and 5 μg of fentanyl more to increase the depth of anesthesia and at the same time preserving the breathing of the child. Thereafter, we proceeded with nasal intubation of the child with a 3.5 mm size uncuffed endotracheal tube (ETT) and using the breath sounds of the child and airflow through proximal opening of the tube as a guide we advanced the tube in the trachea. We were able to intubate the child in the first attempt and during this whole procedure a continuous vigil was maintained on the vital parameters. Thereafter, a check laryngoscopy was tried but unfortunately we could not properly visualize the internal structures as the interior view of the oral cavity could best be described as Cormack-Lehane grade III view. After confirming the position of the endotracheal tube in trachea with the help of a chest auscultation and EtCO 2 reading, we administered 0.9 mg of vecuronium bromide and fixed the nasal ETT [Figure 2]. The oral packing was performed by the plastic surgeon to prevent any possible aspiration of blood during the peri-operative period. Maintenance of anesthesia was carried out with 60% nitrous oxide in oxygen, 3-4% sevoflurane and 0.2 mg of vecuronium bromide as and when required. Fluids were administered as per fasting status and maintenance requirement as well as 1 unit of blood (100 ml) was transfused during the peri-operative period. The entire surgical period was uneventful and at the end of the surgical procedure, all anesthetic gases were turned off and the residual neuromuscular blockade was antagonized with injection neostigmine 0.5 mg and injection glycopyrrolate 0.1 mg. The child was extubated only when he got fully awake and after establishing the return of adequate airway reflexes. The child was kept in the recovery room for 2 hours where a strict vigil monitoring was carried out with an emphasis on airway. Thereafter, the child was transferred to the pediatric intensive care unit for observation during the next 24 hours. Post-operative analgesia was maintained initially with intravenous infusion of paracetamol 10 mg/kg administered slowly during the recovery period and later on with oral syrup of paracetamol. The rest of the hospital stay was uneventful and the child was discharged on the seventh post-operative day with an advice to the parents to come for a follow-up after 15 days.
Figure 2: The successful intubation in a difficult airway scenario

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  Discussion Top


Airway management has always been like a nightmare for the anesthesiologist and the emergency medicine physicians even with so much advancement in the techniques and availability of sophisticated equipments. Pediatric airway management is all the more challenging as compared to that of the adults because of so many anatomical and physiological variables. The relatively larger size of the head invariably flexes the neck and causes respiratory obstruction especially during anesthesia. The short neck, large size of the tongue, anterior location of the larynx, small oral aperture, short and stubby epiglottis are few of the anatomical landmarks that causes a difficult airway management in normal pediatric population. Any blind intubation can make the endotracheal tube lodge into the anterior commissure as the vocal cords are angled in this age group. [4] The lack of cooperation from a child, anxiety due to separation from the parents, generalized restlessness in a strange atmosphere and over-crying are few of the social concerns that make the task of the anesthesiologist difficult. Above all, if the facial anatomy is disfigured or dismantled such as in facial fractures, dislocations, injuries, burns, etc. as was in the present case, the degree of difficulty in securing the airway increases manifold for the attending anesthesiologist. Also, all the tests valid for an evaluation of the airway in adults such as Mallampatti grade, etc. are not always feasible among the younger population due to inadequate mouth opening, lesser mobility of neck and sometimes facial lesions in addition to the earlier mentioned factors. [5],[6],[7] The literature has supported that predicting difficult airway in children between the age of 0-15 years have invariably proved inaccurate in spite of applying Samson and Young's modification of airway assessment. [8],[9]

In the present cases, in addition to the difficulties mentioned earlier, there were few other challenges that made our task of establishing the airway very difficult and hazardous. First, the child could not be intubated orally as the main area for surgery included the lower face and peri-oral region. Second, planning for nasal intubation was also not that easy as the child had to be either anesthetized or we had to go for awake intubation thus avoiding anesthesia. Since the child was quite young, awake intubation was out of question. Also, the amount of cooperation the awake intubation demands was not possible from such a young patient. Now the 2 choices left with us were either to go for nasal intubation with anesthetics alone or to go with combination of anesthetics and muscle relaxants. The most dreadful concern at this stage was a fear of loss of airway if the child could not have been ventilated or intubated. Therefore, we proceeded with the titrated doses of ketamine and fentanyl so as to preserve the breathing and simultaneously checking for the ability to ventilate.

Another significant point of discussion in the present case is the use of muscle relaxant. Though in such difficult airway management cases, succinylcholine (Sch) is the drug of choice, we avoided Sch for the possible side effects of it especially hyperkalemia, which has been a well-observed side-effect of Sch in post-burn patients. [10],[11] Though the maximum risk of Sch causing hyperkalemia is in the first 3-4 weeks of post-burn state; there are reports that have documented this complication even after a long time. [12] The choice of non-depolarizers was out of question at this stage because the prolonged paralysis, difficulty in intubation, and ventilation and gradual weaning from the blockade effect were the main concerns.

The partial breathing preserved with the titrated dose of ketamine and fentanyl assisted remarkably in securing the nasal endotracheal tube as the breath sounds acted like a guide in reaching to the glottis and eventually securing the tube in trachea. Propofol is supposed to decrease the laryngo-tracheal activity causing muscular relaxation to ease out the intubation but it is highly controversial whether it can provide optimal intubating conditions in low doses. [13],[14] The higher dose of propofol required to achieve these ideal conditions could have caused apnea and would have defeated our basic goal. Dexmedetomidine and fentanyl can not only decrease the dose of propofol but effectively attenuate the stress response also. Therefore, we used a low dose combination of ketamine and fentanyl so as to preserve the breathing as well as at the same to attenuate the stress response associated with intubation in addition to providing the ideal conditions for intubation. [15],[16]

To conclude, beyond the anatomical and physiological purview of the present guidelines stating the management of difficult airway in the pediatric age group, there are many instances such as the present one, where one has to apply all of his or her clinical acumen, knowledge and experience to achieve the said targets. Similar cases or other difficult pediatric cases with regard to airway management have to be dealt subjectively by the attending anesthesiologists and the physicians applying all their skills and knowledge so as to successfully secure the airway in addition to giving full respect to the existing guidelines of the difficult pediatric airway management.

 
  References Top

1.East MK, Jones GA, Feller I, Saxon MI, Wolfe RH. Epidemiology of burns in children. Paediatric burn management Chicago year book Medical Publisher; 1988. p. 3-10.  Back to cited text no. 1
    
2.Pakira BB, Acharjee RS, Mukerjee P. Anaesthetic management of paediatric patients with compromised airway - A review article. Ind J Anaesth 2000;44:30-5.  Back to cited text no. 2
    
3.Miglani H, Vashist M. Approach to difficult and compromised airway in neonatal and paediatric age group patients. Indian J Anaesth 2008;52:273-81.  Back to cited text no. 3
  Medknow Journal  
4.Benumof JL. Management of the difficult airway. Anesthesiology 1991;75:1087-110.  Back to cited text no. 4
[PUBMED]    
5.Riazi J. The difficult paediatric airway. Anesthesiol Clin North America 1998;16:707-923.  Back to cited text no. 5
    
6.Bajwa SJ, Gupta S, Kaur J, Panda A, Bajwa SK, Singh A, et al. Anesthetic considerations and difficult airway management in a case of Noonan syndrome. Saudi J Anaesth 2011;5:345-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Bajwa SS, Panda A, Bajwa SK, Singh A, Parmar SS, Singh K. Anesthetic and airway management of a child with a large upper-lip hemangioma. Saudi J Anaesth 2011;5:82-4.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Gupta S, Sharma R, Jain D. Airway assessment: predictors of difficult airway. Ind J Anaesth 2005;49:257-62.  Back to cited text no. 8
    
9.Gregory GA, Riazi J. Classification and assessment of the difficult paediatric airway. Anes Clin North Am 1998;16:725-41.  Back to cited text no. 9
    
10.Scheller MS, Zornow MH, Saidman LJ. Tracheal intubation without the use of muscle relaxants. A technique using Propofol and varying dose of alfentanil. Anesth Analg 1992;75:788-93.  Back to cited text no. 10
[PUBMED]    
11.Srivastava U, Kumar A, Gandhi NK, Saxena S, Agarwal S. Comparison of Propofol and Fentanyl with thiopentone and suxamethanium for tracheal intubation in children. Indian J Anaesth 2001;45;263-6.  Back to cited text no. 11
    
12.Gronert GA. Succinylcholine Hyperkalemia after Burns. Anesthesiology 1999;91:320-2.  Back to cited text no. 12
[PUBMED]    
13.Shah TS. Tracheal intubation without neuromuscular block in children. J Postgrad Med 2004;18:117-23.  Back to cited text no. 13
    
14.Sussan SM, Farhood T. Comparison of Propofol - remifentanil with thiopentone- remifentanil for tracheal intubation without using muscle-relaxants, a double blind randomized and clinical trial study. Int J Pharm 2006;2:265-7.  Back to cited text no. 14
    
15.Bajwa SJ, Bajwa SK, Kaur J. Comparison of two drug combinations in total intravenous anesthesia: Propofol-ketamine and propofol-fentanyl. Saudi J Anaesth 2010;4:72-9  Back to cited text no. 15
    
16.Bajwa SS, Kaur J, Singh A, Parmar SS, Singh G, Kulshrestha A, et al. Attenuation of pressor response and dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine. Indian J Anaesth 2012;56:123-8  Back to cited text no. 16
    


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