Anesth Pain Med.  2018 Jul;13(3):336-340. 10.17085/apm.2018.13.3.336.

“Spray-as-you-go” medical technique for awake intubation using a combination of an epidural catheter and the OptiScope in a patient with Ludwig's angina: A case report

• Nam DJ
• Cho JG
• Kang SH
• Kang S

• KMID: 2436045
• DOI: http://doi.org/10.17085/apm.2018.13.3.336

Abstract

A 73-year-old woman presented to the emergency department with submandibular pain and swelling. The patient was diagnosed to have Ludwig's angina, and she was planned to undergo urgent incision and drainage under general anesthesia. However, her physical examination revealed severe diffuse swelling extending from the bilateral submandibular spaces to the submental space and further down to the neck. As our view was blocked by the patient's neck swelling, we did not perform a regional anesthesia of the airway or a transtracheal block. Several non-invasive alternatives were considered. The "spray-as-you-go" technique was chosen, and it was performed using the OptiScope®. However, the OptiScope did not have a working channel or syringe adaptor for the administration of the local anesthetic solution. To solve this problem, we combined the OptiScope with a 27-G tunneled epidural catheter (100 cm) for the administration of lidocaine and this combination made the awake intubation successful.

Keyword

Awake intubation; Difficult intubation; Epidural catheter; Ludwig's angina; OptiScope; Spray-as-you-go

MeSH Terms

Aged
Anesthesia, Conduction
Anesthesia, General
Catheters*
Drainage
Emergency Service, Hospital
Female
Humans
Intubation*
Lidocaine
Ludwig's Angina*
Neck
Physical Examination
Syringes
Lidocaine

Figure

• 

  Fig. 1 Contrast-enhanced computed tomography scan of the neck showed a well-defined longitudinally oval, heterogeneously enhancing soft tissue lesion (6 × 4 × 3 cm) in the left carotid space (A) and retropharyngeal space (B) extending longitudinally between C1 and C4. The patient was diagnosed to have Ludwig’s angina (C).

• 

  Fig. 2 The OptiScope® (Clarus Medical, USA) was prepared for the “spray-as-you-go” awake intubation. A cutting epidural catheter (100 cm) (Portex®, Smiths Medical Ltd., Australia) was inserted into the endotracheal tube (A). The picture was taken to demonstrate the structures of the catheter and endotracheal tube. A tip of the epidural catheter was cut and the end of the catheter was not left poking out of the endotracheal tube (B).

• 

  Fig. 3 2% Lidocaine was administered below the glottis through the tip of the epidural catheter to anesthetize the mucosa of the epiglottis and vocal cords to prevent the gag reflex, cough, pain, nausea, and vomiting into her mouth and throat.

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