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Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH)
BACKGROUND: Bochdalek congenital diaphragmatic hernia (CDH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the developing lung parenchyma and lung hypoplasia. We describe a case of an adult patien...
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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BioMed Central
2023
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Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10199628/ https://www.ncbi.nlm.nih.gov/pubmed/37210500 http://dx.doi.org/10.1186/s12871-023-02140-x |
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author | Dahaba, Ashraf A. |
author_facet | Dahaba, Ashraf A. |
author_sort | Dahaba, Ashraf A. |
collection | PubMed |
description | BACKGROUND: Bochdalek congenital diaphragmatic hernia (CDH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the developing lung parenchyma and lung hypoplasia. We describe a case of an adult patient with a Bochdalek hernia who underwent minimally invasive right thoracotomy Perceval bioprosthetic aortic valve replacement (AVR) requiring one-lung ventilation (OLV) on the side of the hernia. This is a complex and challenging case that brings up numerous thought-provoking anesthetic implications. To the best of our knowledge, a Pubmed search did not reveal any publication to date of difficult airway management in an adult patient with CDH. CASE PRESENTATION: The first major problem encountered was patient’s crus habitus anatomical condition (exceedingly ventrally displaced trachea) Mallampati Class IV and Cormack-Lehane grade IV extremely difficult endotracheal intubation. Neither glottis nor epiglottis was visible on laryngoscopy; resulting in failed placement of the double-lumen endobronchial tube (DLT) following numerous attempts. The DLT was eventually placed via GlideScope videolaryngoscopy. Whereas the endobroncheal right lung block for left OLV was successfully placed using fiberopticscopy. The crus habitus encroached on OLV tidal volume by the cranially displaced ascending colon and left kidney. Anesthesia was maintained with remifentanil /sevoflurane; adjusted to maintain bispectral index (BIS) at 40–60. Digitally recorded BIS was 38–62 except when BIS precipitously declined to 14–38 (SR, suppression ratio < 10) for 25 min after termination of the cardiopulmonary bypass. CONCLUSIONS: We report a case essentially dealing with an anatomically distorted difficult airway in a patient with left Bochdalek CDH undergoing a complex AVR. We describe anesthetic difficulties and unforeseen issues encountered; such as an extremely difficult DLT placement. |
format | Online Article Text |
id | pubmed-10199628 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2023 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-101996282023-05-21 Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) Dahaba, Ashraf A. BMC Anesthesiol Case Report BACKGROUND: Bochdalek congenital diaphragmatic hernia (CDH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the developing lung parenchyma and lung hypoplasia. We describe a case of an adult patient with a Bochdalek hernia who underwent minimally invasive right thoracotomy Perceval bioprosthetic aortic valve replacement (AVR) requiring one-lung ventilation (OLV) on the side of the hernia. This is a complex and challenging case that brings up numerous thought-provoking anesthetic implications. To the best of our knowledge, a Pubmed search did not reveal any publication to date of difficult airway management in an adult patient with CDH. CASE PRESENTATION: The first major problem encountered was patient’s crus habitus anatomical condition (exceedingly ventrally displaced trachea) Mallampati Class IV and Cormack-Lehane grade IV extremely difficult endotracheal intubation. Neither glottis nor epiglottis was visible on laryngoscopy; resulting in failed placement of the double-lumen endobronchial tube (DLT) following numerous attempts. The DLT was eventually placed via GlideScope videolaryngoscopy. Whereas the endobroncheal right lung block for left OLV was successfully placed using fiberopticscopy. The crus habitus encroached on OLV tidal volume by the cranially displaced ascending colon and left kidney. Anesthesia was maintained with remifentanil /sevoflurane; adjusted to maintain bispectral index (BIS) at 40–60. Digitally recorded BIS was 38–62 except when BIS precipitously declined to 14–38 (SR, suppression ratio < 10) for 25 min after termination of the cardiopulmonary bypass. CONCLUSIONS: We report a case essentially dealing with an anatomically distorted difficult airway in a patient with left Bochdalek CDH undergoing a complex AVR. We describe anesthetic difficulties and unforeseen issues encountered; such as an extremely difficult DLT placement. BioMed Central 2023-05-20 /pmc/articles/PMC10199628/ /pubmed/37210500 http://dx.doi.org/10.1186/s12871-023-02140-x Text en © The Author(s) 2023 https://creativecommons.org/licenses/by/4.0/Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. |
spellingShingle | Case Report Dahaba, Ashraf A. Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) |
title | Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) |
title_full | Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) |
title_fullStr | Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) |
title_full_unstemmed | Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) |
title_short | Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH) |
title_sort | difficult airway management and low bispectral index (bis) in a patient with left bochdalek congenital diaphragmatic hernia (cdh) |
topic | Case Report |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10199628/ https://www.ncbi.nlm.nih.gov/pubmed/37210500 http://dx.doi.org/10.1186/s12871-023-02140-x |
work_keys_str_mv | AT dahabaashrafa difficultairwaymanagementandlowbispectralindexbisinapatientwithleftbochdalekcongenitaldiaphragmaticherniacdh |