Emergent intubation induced iatrogenic tracheoesophageal fistula

Abstract

We report a case of a rare complication of emergent entubation in a trauma patient; symptomatic tracheoesophageal fistula. A 53 years old, obese, female patient with a history of falling down from a hieght was evaluated at the emergency department. Patient was immidiately entubated in an outer medical center by her severely detoriorated neurological status. A cardiopulmonary resusitation was also reported to be successfully at the same center. In our clinic, cranial computerised tomography scans revaled deep inracranial hemorrhage and parenchymal edema of occipital lobe. We observed an excessive amount of liquid drainage from tracheal aspiration at the sixth day of treatment. This liquid aspiration material also warned us for a suspicion of gastric juice/gastric feeding ingredients. Thus, we performed an endoscopic examination of trachea to clearify a possible fistula existance. This evaluation proved a proximally located TEF which we belived to be creating a passage from gastric content to tracheal/pulmonary side. Thoracic surgery consultation resulted with a decision of conservative medical treatment because of her severe neurological status. After a tracheostomy cannula insertion, TEF complications reduced by a possible direct closure effect of a compression from the cannula. Patients neurological and clinical status healed gradually by a month of treatment. Patient was transferred to thoracic surgery department with her tracheostomy cannula by the end of this period for elective surgery. We believe that, especially for trauma patients, intubation difficulties and several attempts may always carry a risk of TEF creation. Clinical suspicion of TEF must be clearifed in every case by endoscopic direct evaluation or other appropriate radiological methods such as multislice CT and magnetic resonance imaging. Existance of TEF indicates early definitive surgical repair. Thus, a multidisciplinary approach with participations of thoracic surgery, pulmonology, radiology and gastroenterology is essential during intensive unit treatment.

Özet

Özet: Görüntüleme tekniklerinin ve teknolojinin ilerlemesi, bir zamanlar açık cerrahi gerektiren bazı yaralanmaların ve tıbbi durumların tedavisinde girişimsel radyoloji işlemlerinin gelişmesine yol açmıştır. Girişimsel nöroradyoloji, endovasküler veya perkütan erişim yoluyla terapötik ilaçlar ve cihazlar yerleştirerek nörovasküler ve bazı nöroşirürjik hastalıkların yönetiminde önemli role sahiptir. Girişimsel nöroradyoloji işlemlerinin karmaşıklığı ve çoğunlukla uzun sürmesi ve sıklıkla önemli komorbiditeleri olan hastaların bu tür işlemlere alınması girişimsel nöroradyoloji alanında anestezi bakımına olan ihtiyacı giderek artırmaktadır. Bu alan aynı zamanda, özel hazırlıklar gerektiren ve ana ameliyathane bölümüne uzakta olan “saha dışı” konumu nedeniyle anestezi bakımında fazladan zorluklar yaratmaktadır. Bu derlemede girişimsel nöroradyolojide anestezi yönetimine değinilmek istenmiştir.Anahtar kelimeler: Anestezi yönetimi, girişimsel nöroradyoloji,monitörizasyon. Abstract: The advancement of imaging techniques and technology has led to the development of interventional radiology procedures in the treatment of certain injuries and medical conditions that once required open surgery. Interventional neuroradiology has an important role in the management of neurovascular and certain neurosurgical diseases by placing therapeutic drugs and devices through endovascular or percutaneous access. The complexity and often prolonged duration of interventional neuroradiology procedures, and the inclusion of patients with often significant comorbidities, increase the need for anesthesia care in the field of interventional neuroradiology. This area also contributes additional difficulties in anesthesia care due to its ‘’off-site” location, which requires special preparations and its distance from the main operating room. In this review, it is aimed to discuss anesthesia management in interventional neuroradiology.Key words: Anesthesia management, interventional neuroradiology, monitorisation.