Abstract

AET-23

Backed Into a Corner: Awake Tracheostomy in a 3-year-old

¹Patel J, ²Nause-Osthoff R
¹University Of Michigan, Ann Arbor, MI, USA; ²University of Michigan, Ann Arbor, MI, USA

Background: Awake tracheostomies have been described in the adult population when securing the airway has failed and other methods are inappropriate. 1 Awake tracheostomy in pediatric patients have seldom been described in literature aside from one case report 2 and anecdotal reports from history. This case report describes the anesthetic considerations of an awake tracheostomy performed on a 3-year-old boy who had previously sustained multi-trauma injuries and failed extubation.

Case Description: A healthy 3-year-old male presented after a motor vehicle accident with severe traumatic brain injury, depressed skull fractures, and multiple facial fractures. The patient was intubated and underwent emergent decompressive craniectomies and repair of fractures. The patient started having fluid drainage from ears and rhinorrhea that was positive for beta-2-transferrin indicating a CSF leak. Episodes of neuro-storming or sympathetic storms were noticed that involved jaw clenching to the point of tongue lacerations and edema. An immobile bite block was inserted to protect the tongue. The patient was extubated on hospital day 9 and developed increased work of breathing, stridor, and desaturations. Otolaryngology was consulted for airway evaluation and a joint decision with anesthesiology staff was made to proceed with urgent tracheostomy.

The presence of a rigid bite block prevented suctioning or airway placement. The recent CSF leak made positive pressure by mask ventilation or blind nasopharyngeal manipulation unsafe. Given the history of intermittent neuro-storming and the success of alpha-2 agonism in decreasing severity of these episodes, IV dexmedetomidine was our first line agent. In terms of airway management, it was felt that the safest possible options were intubating nasally over a flexible fiberoptic bronchoscope or tracheostomy. The trismus and jaw clenching prevented any oropharyngeal interventions.

In the operating room, tracheostomy landmarks were infiltrated with local anesthesia with no anesthetic medications administered. A tracheostomy tube was inserted. After placement of the tube, the patient was sedated with a propofol bolus and 3% sevoflourane inhalation. A dexmedetomidine infusion was initiated and continued on transport to PICU.

Discussion: Awake tracheostomies are generally performed when a patient is considered unsafe to be safely intubated under general anesthesia. Common indications include acute airway obstructions secondary to head and neck neoplasms, specifically pharyngeal and laryngeal tumors, deep neck infection, and bilateral vocal fold paralysis. This case unique in that there were multiple comorbidities that prevented non-surgical airway management. Communication between the anesthesiology and otolaryngology team were paramount in decision making to formulate a safe yet effective plan.

1. Urgent awake tracheotomy for impending airway obstruction. Otolaryngol Head Neck Surg. 2007;136:838–842.
2. Emergent awake tracheostomy—the five-year experience at an urban tertiary care center. Laryngoscope. 2015;125:2476–2479.
3. “(DASH After TBI Study: Study Protocol for a Randomized Controlled Trial.” Trials 13 (2012): 177. PMC. Web. 7 Nov. 2017.