A Case of Difficult Airway Management during an Invasive Procedure

: It is the mission of an anesthesiologist in periopera- tive management to secure the airway safely. In a recent case we encountered a difficult airway manage- ment (DAM) situation that could not be settled by usual DAM algorithm. A 69-year-old man underwent a carotid endarec- tomy (CEA) operation. The procedure lasted six hours and his initial awakening from anesthesia was excel- lent Thirty minutes later, a neck swelling was noticed during a scheduled CT follow-up examination and there was a leakage of contrast medium from a blood vessel. To stop the bleeding a re-operation was required but the patient's breathing gradually deteriorated. Even though a supraglottic device -(SGD ; air-Q04.5) was inserted to ensure airway management, the situation progressed to CICV (cannot intubate cannot ventilate). An abnormal anatomical orientation made it difficult to perform an invasive airway access by a cricothyroid- otomy and it took over 20 minutes to access the crico- thyroid membrane and insert an endotracheal tube through the membrane whilst the patient was in a hypoxic state. Invasive airway access is positioned as the final res- cue procedure when less-invasive methods failed to manage a difficult airway. In the above situation where the rapidly progressing CICV state could not be resolved smoothly by a surgical airway approach due to the cervical anatomic abnormality, it is necessary to secure the airway immediately when the neck is swelling with the possibility of airway obstruction.