When a Small Miss in Anesthesia is as Good (or as Bad) as Being Miles Away…

To the Editor, Efficient airway management is at the cornerstone of safe anesthesia, which in difficult scenarios particularly mandates an amalgamation of sound clinical skills, optimal techniques, and appropriately functional equipment. While faulty technique or device failure has been described to be independently associated with catastrophic events,[1,2] the index case features an “undetected” equipment malfunction compounding peculiarly difficult airway management. A 45-year-old male (60kg) belonging to American Society of Anaesthesiologist physical status I was scheduled for release of submucous fibrosis under general anesthesia. On airway examination, mouth opening was 1 finger-breadth, upper lip bite test class 2 with other airway parameters within normal limits. Hence, an awake fibreoptic intubation was planned. The nasal patency was adequately examined, and a prechecked “sterile” portex cuffed endotracheal tube (ETT) ID 7.5 mm was kept ready and loaded over the flexible bronchoscope. The patient was sedated using dexmedetomidine infusion (1 mcg/kg IV over 10 minutes followed by 0.5 mcg/kg/hr IV). The trachea was successfully intubated, employing a “spray as you go” technique. After railroading the ETT over the bronchoscope, the cuff was inflated, and anesthesia was induced using propofol-atracurium. After confirming bilaterally equal air entry, the ETT was fixed, and the lungs were ventilated using volume-controlled mode. However, the ventilator started showing an air leak of 100-110 ml/breath; therefore, the ETT cuff was further inflated with air, given the circuit did not demonstrate any evident leak. Additional cuff inflation reflected a moderate increase in the cuff manometer pressures with a turgid pilot balloon. Subsequently, on administration of a larger tidal volume, an audible leak became evident, after which a decision to change the ETT was made. Foreseeing the high probability of losing an already “difficult” airway, preparation for front-of-neck access was performed side-by-side. Nonetheless, with some minor difficulty, the ETT could be successfully changed over an airway exchange catheter, and the case was handed over to the surgeons. Following removal, the ETT cuff was subsequently examined, anticipating a traumatic rupture. However, there was no apparent cuff rupture, and to our surprise, the air injected via pilot balloon did adequately inflate the balloon with no “actual” air reaching the distal cuff, which continued to remain deflated in this situation albeit giving a “false” impression of a functional pilot balloon-cuff system [Figure 1a and b].Figure 1: (a) Deflated endotracheal tube with deflated pilot balloon; (b) deflated endotracheal tube cuff despite inflated pilot balloonMalfunctioning of the device is not unusual, wherein it becomes prudent to ensure a comprehensive pre-specified equipment checklist.[3] There have been reports of ETT-cuff failing to deflate due to kinking of inflation tubing or non-functional valve, resulting in difficult extubation.[4,5] In the present case, however, a cuff-inflation test was “likely” not satisfactorily performed, which posed further challenges in a difficult airway situation in a setting of a planned intraoral surgery where there was additionally a high risk of aspiration without a functional cuffed ETT. In hindsight, a potential contributing factor to the above-stated apparent “human error” was constituted by the ETT pre-procedurally being in its’ “sterile” packing when checking the cuff while inflating the proximal pilot balloon, thereby missing the possibility of any foreign body in a pilot balloon which latter got dislodged into narrow inflation tube. Ahead of the pivotal role of a meticulous pre-use check of all instruments in ensuring patient safety,[3] the propensity to catastrophic events escalates further in a clinical scenario as presented above. It would not be overstated to mention that the most well-planned strategic approach can go unimaginably wrong when the equipment-devices-gadgets are not probed well before proceeding ahead, as a small miss in anesthesia can be as good (or as bad) as being miles away… Author contribution JG and NC conceptualized the manuscript. did the relevant research and reviewed the final draft. RM was lead in writing the manuscript. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.