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  Table of Contents 
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 104-105

Ureteral guidewire, an adjunct for the paediatric difficult airway management

1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, India
2 Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India

Date of Submission25-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_117_20

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How to cite this article:
Patnaik S, Setlur R, Dwivedi D, Sharma R. Ureteral guidewire, an adjunct for the paediatric difficult airway management. Indian Anaesth Forum 2021;22:104-5

How to cite this URL:
Patnaik S, Setlur R, Dwivedi D, Sharma R. Ureteral guidewire, an adjunct for the paediatric difficult airway management. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:104-5. Available from: http://www.theiaforum.org/text.asp?2021/22/1/104/309743


Incidence of difficult intubation in children varies between 0.24% and 4.7% in infants and 0.07% to 0.7% in older children.[1] Tongue flap surgery for palatal fistula is a two-staged surgery; in first stage, a tongue flap is attached anteriorly or posteriorly, and the flap division with inset is done in the second stage.[2]

We describe a 5-year-old, nonsyndromic, male child, weighing 13 kg, a case of an iatrogenic difficult airway due to the presence of an anterior tongue flap presenting as an anticipated difficult intubation situation during the second-stage surgery. Preoperative assessment and investigations were within normal limits. The parents were apprised of the anticipated difficult intubation, preoperative written informed consent and nil per oral status were confirmed. The plan was awake fiber optic intubation followed by general anesthesia (GA).

On the day of surgery, the child was nebulized with 1 ml of 2% lignocaine diluted in 3 ml of normal saline and Injection glycopyrrolate 0.1 mg was given. Standard monitoring ensued, and the child was sedated with intravenous ketamine 10 mg and 5μg of dexmedetomidine. Adequacy of mask ventilation was ascertained. The child was maintained on spontaneous respiration with a, 4.5mm ID, endotracheal tracheal tube (ETT) inserted in the left nostril and connected to the Jackson's Rees circuit at the flow rate of 6l/min of oxygen (100%) and sevoflurane 2%–4%. A pediatric Ambu® aScope™ 3.8/1.2 was inserted through the right nostril without an ETT as the scope could not negotiate the 4.5 mm ID ETT apt for his age and size. On visualizing the glottis, 3 ml of 2% lignocaine was sprayed over it and then, ETT of the left nostril was directed into glottis under the vision of the fiberoptic scope; however, the attempt was unsuccessful. An atraumatic, Roadrunner® hydrophilic PC guidewire (Cooks Medical) used for ureteral stenting was passed through the working channel of the Ambuscope into the glottic opening [Figure 1]a. Ambuscope was then removed, and a pediatric ventilating bougie was railroaded over the guidewire [Figure 1]b. This was followed by the railroading of the ETT over the bougie and its passage into glottis, which was confirmed by the capnography. After ascertaining bilateral equal air entry, the airway was secured and GA with muscle relaxant was administered. On no occasion, there were desaturations noted during the procedure. Intraoperative period was uneventful, and the child was successfully extubated and shifted awake in the ward.
Figure 1: Chest X-ray posterior-anterior view showing surgical emphysema

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Literature shows varied techniques of airway management by different authors, Sahoo et al. established the airway with retromolar approach, performed direct laryngoscopy with a straight miller blade in an adult patient.[3] So et al. in a 6-year-old child with a posterior tongue flap secured airway orally by using the flexible fiberoptic bronchoscope.[2] In our case, since it was an anterior flap, we avoided direct laryngoscopy to prevent damage to the vascularity and soft tissue of the tongue. Kuroiwa et al. have used remifentanil infusion along with local anesthesia for the awake division of the flap in sedation followed by orotracheal intubation.[4] We had an unsuccessful attempt of nasotracheal intubation with Ambuscope, as described by Sharma et al.[5] This case highlights and suggests the role of atraumatic Roadrunner® hydrophilic PC guidewire along with the pediatric ventilating bougie as a rescue device in securing an airway where one is not able to negotiate the Ambuscope with the desired size ETT.

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

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Conflicts of interest

There are no conflicts of interest.

  References Top

Pawar DK, Doctor JR, Raveendra US, Ramesh S, Shetty SR, Divatia JV, et al. All India difficult airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in paediatrics. Indian J Anaesth 2016;60:906-14.  Back to cited text no. 1
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So E, Yun HJ, Karm MH, Kim HJ, Seo KS, Ha H. Airway management in pediatric tongue flap division for oronasal fistula closure: A case report. J Dent Anesth Pain Med 2018;18:309-13.  Back to cited text no. 2
Sahoo NK, Desai AP, Roy ID, Kulkarni V. Oro-nasal communication. J Craniofac Surg 2016;27:e529-33.  Back to cited text no. 3
Kuroiwa KK, Nishizawa M, Kondo N, Nakazawa H, Hirabayashi T. Remifentanil for sedation and analgesia during awake division of tongue flap in children: A report of two cases. JA Clin Rep 2017;3:43.  Back to cited text no. 4
Sharma A, Dwivedi D, Sharma RM. Temporomandibular joint ankylosis: “A pediatric difficult airway management”. Anesth Essays Res 2018;12:282-4.  Back to cited text no. 5
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