137J.G. Brock-Utne, Case Studies of Near Misses in Clinical Anesthesia, DOI 10.1007/978-1-4419-1179-7_47, © Springer Science+Business Media, LLC 2011

A 48-year-old female (84 kg, 5 ft 8 in.) is scheduled for a rectal exam under monitored anesthesia care (MAC). Her main complaint at the moment is bleeding hemorrhoids. Her past history is relevant for hypertension, turbinate cancer (primary) which has been treated but she still gets occasionally epistaxis, hypothyroidism, noninsulin-dependent diabetes, and glaucoma. You see her in the preoperative area and place an IV and sedate her with 4 mg of midazolam. She is placed in a prone jackknife position on the operating table. You give her 50 mg of fentanyl and start a propofol infusion of 100 mg/kg/min. The surgeon uses a liberal amount of lidocaine and the surgery starts. Unfortunately, the procedure lasts longer than you have expected and it is now 1 h after the start and the patient is getting restless. You increase the propofol infusion, but to your dismay, you discover that the patient develops an upper airway obstruction. The oxygen saturation is falling. Things are not easy, as she is in the prone position. You turn the propofol off, place a facemask, and do a one-handed jaw thrust with one hand, while ventilating with the other hand. The oxygen saturation improves but only to 84%. You attempt to insert a Guedel airway but can’t open her mouth.

Question

The options you have are waiting for the propofol to wear of, turning the patient supine, and maybe even placing an endotracheal tube in her trachea. However, is there anything else you can potentially do to improve the airway situations while the patient is prone?

Chapter 47Case 47: An Airway Problem During Monitored Anesthesia Care

138 47 Case 47: An Airway Problem During Monitored Anesthesia Care

Solution

This is a tricky question. Remember that the patient has a turbinate cancer and has occasionally epistaxis. Hence a nasal airway (nasal trumpet) is contraindicated.

In this case the patient slowly woke up from her propofol sedation and with that her airway obstruction cleared. Glycopyrrolate 0.6 mg and Ketamine 50 mg boluses were given IV successfully until the surgery was completed 25 min later.

Recommendation

Always remember the patient’s comorbidities that may interfere or cause problems with your treatment. In this case, placing a nasal airway could have caused a major bleeding disaster.