Extubation and Changing Endotracheal Tubes

Bilateral Tongue Necrosis in a Young Patient as a Complication of Prolonged Oral Endotracheal Intubation: A Case Report

We present a unique case of complete tongue necrosis caused by a compression of an endotracheal tube (ETT). A 39-year-old female underwent endotracheal intubation secondary to respiratory failure following sudden altered mental status. Tongue swallowing developed and worsened with obvious pallor on examination. Extensive ischemic changes with tongue necrosis developed dramatically due to the compression during her prolonged intubation. This case of tongue necrosis highlights the importance of proper ETT sizing and positioning during prolonged intubation in ICU patients.

Spontaneous sublingual hematoma secondary to warfarin therapy-A rare complication

Warfarin is the most commonly prescribed oral anticoagulant in Nepal. It is commonly used for chronic anticoagulation in patients with atrial fibrillation, venous thromboembolism, and artificial heart valves. The major side effect of warfarin is bleeding. Though extremely rare, a sublingual hematoma can lead to life-threatening complications as it can cause severe airway obstruction. We present a case of a 55-year-old female patient who had sublingual hematoma secondary to the use of Warfarin therapy. In addition to the discontinuation of warfarin, she was managed conservatively without any surgical intervention. Early diagnosis, timely discontinuation of the drug, and application of appropriate medical treatment are of utmost importance for reducing morbidity and mortality due to bleeding and airway compromise.

Extubation of the difficult airway

Managing the airway in the intensive care unit (ICU) is complicated by a wide array of physiologic factors. Difficult airway may be a consequence of patient’s anatomy or airway edema developed during the ICU stay and mechanical ventilation. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. In this article, we will provide a framework for identifying a difficult airway, criteria for safe extubation, as well as review the devices that are available for airway management in the ICU. Proficiency in identifying a potentially difficult airway and thorough familiarity with strategies and techniques of securing the airway are necessary for safe practice of critical care medicine

Equipment to manage a difficult airway during anaesthesia

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

[Extraglottic airway devices in the intensive care unit]

Extraglottic airway devices (EGA) are not only used in routine anaesthesia practice, they also have a distinct value for in-hospital and out-of-hospital difficult airway management. In the environment of the intensive care unit (ICU) EGA are not used on a regular basis. However, expertise and knowledge regarding EGA coming from the operating theatre or the out-of-hospital setting may also be of value for the ICU setting. This review presents the potential indications for EGA on the ICU for the management of difficult airway situations as well as during percutaneous tracheotomy. Furthermore, the possible advantages of EGA during postoperative recovery from anaesthesia as well as termination of controlled ventilation for intensive care patients are discussed.