CONCLUSION •Proper planning and

preparations are essential

elements in the management

of extubation of a patient with

difficult airway.

•A difficult airway management

committee should be organized

in each tertiary hospital in

Nigeria to formulate protocols

and manage patients with

anticipated airway difficulty as

found in developed worlds.

•Safety has no border hence at

every stage of management of

a patient with difficult airway

optimum manpower and

equipment must be available to

prevent catastrophic outcome

DISCUSSION •Airway obstruction is a potentially life threatening

complication following cleft palate repair

•Tracheal intubation alone does not define an endpoint in

airway management.

•Poor preparation extending to the process of extubation was

the cause of death in this patient.

•In this report there was no rescue plan made by the resident if

failure to maintain the airway following extubation occurred .

This may be because essential equipment was unavailable or

the anaesthetist did not have the requisite skills or training to

use rescue equipment provided.

•Management of the obstructed airway is a significant clinical

challenge as reported by the National Confidential Enquiry into

Peri-Operative Deaths published in 1998 [2].

•Complex problems managed by trainees lacking the

appropriate airway skills, should be discouraged.

•A more senior anaesthetist especially paediatric anaesthetist

or other clinicians performing airway management should be

present also during extubation to manage crisis.

ABSTRACT Introduction: Cleft palate occurs in 1 in 2000 live births

[1].. The majority of anaesthetic morbidity related to

these procedures relate to the airway: either difficulty

with intubation, inadvertent extubation or postoperative

airway obstruction. An experienced anaesthetist is

required to provide the optimm management needed by

these patients at any level of care.

Objective: To show that management of difficult airway

goes beyond the intubation period, it is a continuum

including maintenance of intubation as well as adequate

planning of extubation

Summary: We present a sixteen month old female child,

with isolated cleft palate for repair. She had a history of

recurrent upper respiratory tract infections and failure to

thrive. Surgery had been cancelled on two previous

occasions because of difficulty in intubating the trachea.

Successful intubation of the trachea occurred on the third

occasion. Surgery was uneventful. The patient

subsequently developed airway obstruction after

extubation. Attempts at re-intubating the trachea and

mask ventilation failed and the child developed

cardiopulmonary arrest and could not be resuscitated.

PRE-ANAESTHESIA MANAGEMENT •The patient was pre-oxygenated with 100% oxygen for 5minutes

•Laryngoscopy was carried out under deep inhalational anaesthesia using

halothane

•The Comarck and Lehine was grade 3, successful tracheal intubation occurred

after the third attempt with Optimal external laryngeal manipulation (OELM) and

shoulder support. This was confirmed by capnography

•Uneventful intraoperative period and surgery lasted one and half hours with

mininal blood loss

•During the procedure the importance of a controlled planned extubation was

discussed with the resident.

•However while attending to another patient, the resident reversed and

extubated the patent awake

•Immediately post-extubation, the child had airway obstruction which could not

be relieved.

•All attempts to re-intubate and manually ventilate to maintain adequate

oxygenation was ineffective

•This resulted in deterioration of the child’s condition and a cardiac arrest from

hypoxia.

PRE-ANAESTHESIA MANAGEMENT

•Scheduled for repair of cleft palate at one year

•She was found to have an upper respiratory tract infection

necessitating treatment

•There had been two previous history of difficult intubaton

attempts

•Was informed in the management of airway on the third

attempt.

•The patient was categorized according to the American

Society of Anesthesiologists Physical status Class II.

•The laboratory results were within normal limits except for

sinus tachycardia on the electrocardiogram.

•Contingency plans for airway management were made

available

REFERENCES •R. C. Law and C. de Klerk. Anaesthesia For Cleft Lip And Palate Surgery, Update in Anesthesia: Volume 14 (2002), 27-30

•Gray AJG, Hoile RW, Ingram GS, Sherry KS. The Report of the NaAonal ConfidenAal Enquiry into PerioperaAve Deaths 1996 ⁄ 1997. London:

NCEPOD, 1998.

CASE PRESENTATION S A, a sixteen month old 6Kg female child with cleft

palate for repair presented at the age of four

month

There was history of failure to thrive, poor sucking

of breast and recurrent chest infections

Examination revealed a clinically ill-looking infant,

small for age

There was a cleft of the secondary palate, the

gingiva were normal.

The cardiovascular and central nervous systems

were normal.

The respiratory system showed tachypnoea,

40cycles/minute, no dyspnoea with transmitted

sounds on both lung fields

AIRWAY OBSTRUCTION IN AN UNPLANNED EXTUBATION IN A CHILD WITH CLEFT PALATE AND

ANTICIPATED DIFFICULT INTUBATION Oyedepo Olanrewaju Olubukola MD1, Adeyemi Moshood Folorunsho MD2

Department of Anaesthesia1, Department of Surgery2, University of Ilorin Teaching Hospital, Ilorin. Kwara

State. Nigeria.

Keywords: Airway obstruction, unplanned extubation, child, cleft palate, difficult intubation