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Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 453-454

Acute airway obstructions after heparin-free hemodialysis: management outside comfort zone

Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur, Jharkhand, India

Date of Submission06-Dec-2014
Date of Acceptance14-Apr-2015
Date of Web Publication29-Jul-2015

Correspondence Address:
Tushar Kumar
Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur - 831 001, Jharkhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-7934.159005

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Acute airway obstruction can be caused by many conditions. Here is a case of severe spasm of upper airway leading to acute airway obstruction and its anaesthetic management in the emergency setting.

Keywords: airway, heparin free hemodialysis, tracheostomy, hypoxia

How to cite this article:
Kumar T. Acute airway obstructions after heparin-free hemodialysis: management outside comfort zone . Ain-Shams J Anaesthesiol 2015;8:453-4

How to cite this URL:
Kumar T. Acute airway obstructions after heparin-free hemodialysis: management outside comfort zone . Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 Oct 26];8:453-4. Available from:

  Introduction Top

As anesthesiologists, our job is not only confined to practicing as perioperative physicians but also as rescuers during emergency even in unconventional places. Of all the procedures that we perform, endotracheal intubation is one of the earliest skills that we learn. Endotracheal intubation is key to maintaining airway and demands planning and organized coordination among the staff. Recently, we encountered a case that will be discussed here.

  Case report Top

A 54-year-old woman with end-stage kidney disease and hepatitis C sera positive was undergoing hemodialysis. Towards the end of the hemodialysis, the patient developed severe dyspnea. We were called to deal with this condition. On arrival, we found the patient in severe respiratory distress. Her vitals were pulse rate of 130/min, blood pressure 150/90 mmHg, and SpO 2 88% on a venturi mask with oxygen flow at 6 l/min. On quick examination, the patient had severe sweating, gross facial edema, buck teeth, neck stiffness, and decreased air entry into the lungs. Immediately 100% oxygen was administered through Bain's circuit so that we could buy some time and to prevent hypoxia. The patient continued to desaturate with an SpO 2 of 85%. An attempt at direct laryngoscopy was made under sedation with propofol (50 mg) intravenously. I was unable to visualize anything except the anterior third of an edematous tongue. Our aim was to maintain oxygenation at any cost; thus, without any delay, 100% oxygen was continued through Bain's circuit. Airway obstruction was worsening with time and so patient the continued to desaturate. The patient had an episode of seizure and bradycardia. It was treated with atropine (0.6 mg) intravenously and diazepam (10 mg) intravenously stat. A second attempt at laryngoscopy was made; simultaneously, the BURP maneuver was used and I had a glimpse of the epiglottis. A gum elastic bougie was introduced, which was preloaded with endotracheal tube ID No. 6.0 mm. The tube was advanced further into the trachea. Bougie was withdrawn, cuff was inflated, and bilateral air entry was confirmed with auscultation. The patient was set up on a ventilator with an FiO 2 of 40% and an SpO 2 of 94%. The patient was managed in the critical care unit and was discharged on the fourth day after intubation.

The procedure of securing the airway took ~8 to 10 min. It was then learnt that there was a failed attempt at right internal jugular vein cannulation 4 days back [Figure 1] and [Figure 2].
Figure 1: Acute airway obstruction

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Figure 2: Neck hematoma in radiograph

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  Discussion Top

Although hemodialysis was heparin free, even the use of a small amount of heparin for priming of the circuit probably caused rebleed from the venipuncture site. This caused irritation of the neck muscles and mass effect on the airway, which was further confirmed on radiography of the neck. As a consequence, sudden rapid worsening of airway obstruction resulted. In places such as dialysis rooms or wards, sometimes resources are limited. Patients with sudden airway compromise are dealt with by examination of the airway, maintenance of oxygenation, formulation and execution of a plan, and treatment of complications, if any. The examination must be quick, but elaborate enough to recognize difficult airway. Airway examination described by El-Ganzouri et al. [1] is rapidly performed and quantifiable, but in such an emergency condition, buying time was not enough. A examination of the patient for facial edema, teeth, mouth opening, intraoral examination, neck mobility, and oxygenation status were the mainstay [2] . The second step was to maintain oxygenation at all costs. Invasive and noninvasive techniques are the options available and one should not hesitate to use these [3] . In such cases, flexible fiberoptic intubation is a gold standard but in places outside the operation theater or the ICU, resources are limited [4] . The next step is to formulate a plan according to the equipment and staff available. The initial approach with direct laryngoscopy failed, but the second attempt with bougie was successful. One complication encountered was seizure, which indicated hypoxia to the brain and required urgent commencement of oxygenation. Patients with end-stage renal disease with chronic liver disease undergoing hemodialysis are prone to bleed. Even heparin-free hemodialysis contains 5000 U of heparin in the priming fluid, which can trigger bleeding from the venipuncture site [5] . Supraglottic devices and gum elastic bougie provides a faster and safer way of securing airway. Fiberoptic scopes require expertise to use in emergency conditions. Patient in this case had deranged coagulation profile due to which emergency surgical approach to secure the airway was listed as the second choice. Recognizing and rapid action on airway compromise reduces morbidity and mortality in such patients. Basic airway manoeuvres like chin lift & jaw thrust with supplemental oxygen may improve the patency of an obstructed airway. Before definitive control of the airway is possible, provide 100% oxygen with a tight-fitting mask to prevent hypoxia.

  Conclusion Top

Emergent conditions away from our comfort zone are challenging. Prevention of hypoxia, treatment of complications, and securing airway with limited resources are the mainstay of management.

  Acknowledgements Top

Conflicts of interest

None declared.

  References Top

El-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 1996; 82:1197-1204.  Back to cited text no. 1
Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75:1087-1110.  Back to cited text no. 2
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251-270.  Back to cited text no. 3
Bokhari A, Benham SW, Popat MT. Management of unanticipated difficult intubation: a survey of current practice in the Oxford region. Eur J Anaesthesiol 2004; 21:123-127.  Back to cited text no. 4
European Best Practice Guidelines. Section V. Chronic intermittent haemodialysis and prevention of clotting in the extracorporal system. Nephrol Dial Transplant 2002; 17:63-71.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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