Sir,
Endotracheal tube (ETT) suction is a routine procedure done for the removal of tracheobronchial secretions thereby improving oxygenation. An unusual case of suction catheter (SC) impaction during ETT suction is reported here.
A 7-year-old, 25 kg American Society of Anesthesiologists physical status 1 male patient of traumatic fracture shaft of the left femur was posted for titanium elastic nail system procedure in elective orthopedics operation theater. His preanesthetic check-up was unremarkable except that he was treated with capsule amoxicillin 250 mg thrice daily and syrup cetirizine 5 mg once in the night for 5 days for upper respiratory tract infection (URTI) 1 week back. Patient had no signs and symptoms suggestive of URTI at present and his clinical investigations were within normal limits. General anesthesia was administered as per the standard guidelines and trachea intubated with size 6 uncuffed ETT. On chest auscultation, bilateral rhonchi were present with sound of secretions heard on bag ventilation. Patient was shifted to 100% oxygen with halothane for ETT suction using 12 French gauge SC. During the suction, the catheter got impacted inside the ETT. Even with moderate pressure or rotating movement, catheter could neither be pushed in nor pulled out. There was fear of breaking the SC on applying further pressure. As the patient could not be ventilated, the oxygen saturation started falling gradually. With immediate realization of an impending emergency, decision to remove the ETT, followed by mask ventilation was taken. Meanwhile, patient was given injection hydrocortisone 50 mg intravenous (i.v.), injection etophylline 25.3 mg and injection theophylline 84.7 mg i.v. To our great relief, on removing the ETT, the SC was also pulled out intact along with it. Patient was immediately reintubated and ventilated with 100% oxygen, saturation increased, and vitals remained stable; chest was clear on auscultation. After completion of surgery, anesthesia was reversed, and trachea extubated successfully.
Careful inspection revealed that the SC was intact with no shearing, but its tip was around 2 cm beyond the distal end of the ETT. Some viscous secretions were seen inside the ETT and on the SC. It is suggested that a SC is used that occludes <50% the lumen of the ETT in children and adults and <70% in infants.[1] Though we used a slightly bigger sized catheter, it could easily be maneuvered through the ETT. On deep suctioning, it probably got wedged in the constricted tracheobronchial tree (due to hyper-reactive airway) and impacted further due to the tenacious secretions. As the constriction was relieved with medications and suctioning of secretions done, catheter could now be pulled out. Instillation of normal saline for lubrication or dilution of secretions is doubtful. American Association for Respiratory Care guidelines suggest that it should not be performed routinely.[1] In a case reported by Takrouri et al., impacted SC in a preformed nasal ETT was cut into two parts during forceful pulling.[2]
As rightly said, endotracheal suctioning, although necessary to maintain the patency of airways, is not a benign procedure.[3] Such a complication can lead to a life-threatening situation if immediate and appropriate action is not taken.
REFERENCES
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