I recently visited Honduras with a Head and Neck surgical team where we had a close call with a potential airway obstruction due to a blood clot. The case illustrates how a provider should never make assumptions, because if those assumptions are wrong, you can endanger your patient.
After a long day in the OR, while we were packing up to leave, a nurse from the ward ran in and said that one of the patient’s who had had a septoplasty that day for chronic sinusitis was bleeding. I immediately started setting up the OR again while our surgeon went over to the ward.
He quickly reappeared with the patient, a 6 ft tall, 100 kg man who had had a good airway earlier in the day when I intubated him for his surgery. Bleeding based on the surgeon’s looking inside the mouth did not appear to be serous at that time, but it had apparently been going on for a few hours before the patient complained. Our surgeon wanted to do an exam and then place Anterior epistaxis balloons: Rapid Rhino consists of an outer layer of carboxycellulose that promotes platelet aggregation, with an inflatable balloon that compresses the nasal cavity upon inflation tamponading the bleeding site. The plan was local anesthesia with some light sedation. I didn’t repeat an exam or an interview because I knew the patient and it was clear what was happening.
As we were positioning the patient, he said calmly, in Spanish, that he felt like he was drowning. I have to admit that I thought this was an exaggeration from a nervous patient because we were not suctioning much blood out of the oropharynx. We played him flat on the OR table with the head of the bed raised about 30 degrees. With this change in position his oxygen saturation fell from 98% to 95%. Things were happening quickly and I attributed this change in saturation to a loose and recycled oxygen saturation probe. We were reusing the probes as our supply was limited and the patient was fully awake. He had not received any sedation as yet.
I gave the patient 1 mg of versed and 50 mcg of fentanyl. I was going slow because I wanted the patient awake, cooperative and able to protect his airway. After another 5 minutes he was still restless but fully awake. The surgeon asked for a little more sedation and I gave another 1 mg of versed. At this point the patient relaxed and became more cooperative. However, his oxygen saturation fell to 92%. I asked him to take deep breaths, which he did. He was following all of my commands. Yet his saturation did not increase. I started adjusting the probe, looking for a technical reason for the change.
Suddenly, the patient coughed forcefully. A large organized clot about the size of a peach pit flew out of his mouth and onto the surgical drape. He looked up at me and smiled and said he didn’t feel like he was drowning any more.
I felt a chill run up my back. Where had that clot been? It was not in his mouth or our surgeon would have seen it or suctioned it. His voice had sounded normal with the few words I had heard him say, making it unlikely that it was above the cords. If it was esophageal, I don’t thinking coughing would have brought it out. That left intratracheal.
I’ve previously described an episode with a large organized clot in the trachea which complicated nasal surgery that had been done under conscious sedation. It’s possible that this patient’s slow and steady nasal bleeding had trickled down his trachea while he was sleeping after surgery. If I’m correct about where that clot was, that was a very close call. Had we done general anesthesia, my endotracheal tube might have either obstructed with the clot, or forced the clot down and onto the carina. Dealing with that in a small Honduran volunteer hospital is a scary thought.
In Hindsight
- I should have taken the time to do a quick history of what had happened during the day and after the surgery. My failure to do so was caused by my familiarity with the patient. It was also effected by the fact that we would have had to conduct that discussion in Spanish. I’m afraid that after several days of speaking Spanish my brain was tired of translating, so I took the easier path — I thought I knew everything I needed to know. Had I better explored what he meant by “feeling like he was drowning” I might have had some suspicions.
- I should have had Magill Forceps out on my station in case I did have to intubate. It’s possible that the clot might have been visible. But I should have been prepared for such a clot.
Would those steps have made any difference? I don’t know. We had no advanced resources available to us in Honduras. However, knowledge is power and it would have made diagnosis of a clot in the trachea much easier had problems occurred.
Even after 37 years of anesthesia practice it’s easy to get lulled into a false sense of security.
May The Force Be With You
Christine Whitten MD, Author Anyone Can Intubate, 5th Edition