Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH)

Patient gave a written informed consent that we can use all his real-time digitally recorded data. Dotarem 3D-contrast medium enhanced magnetic resonance angiography revealed a 47 mm aortic aneurism 5 cm cranial to aortic valve and a 16 mm coarctation of descending aorta at left subclavian artery outlet. Left diaphragmatic crus habitus (comprising left kidney and left colon flexure, Fig. 1) was 67 mm higher than the right diaphragmatic crus [2]. Left ureter was 9 cm elongated. Left renal artery was also 9 cm retro-aortic elongated with a double renal vein. Echocardiography showed 17 mm hypertrophy of the left ventricle.

Fig. 1figure 1

Magnetic resonance angiography. Left diaphragmatic crus habitus (comprising left kidney and left colon flexure Bochdalek congenital-diaphragmatic-hernia) is 67 mm displaced higher than the right diaphragmatic crus. The left ureter is 9 cm elongated and the left renal artery is also 9 cm retro-aortic elongated with two renal veins. Ascending aortic aneurism 47 mm

Because our patient’s aortic aneurism was 4.7 cm, and the American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines recommend replacement of the ascending aorta when it reaches > 4.5 cm in a patient undergoing AVR; [3] different strategies for AVR, ascending aorta repair and contingency plans for failed OLV or oxygenation were all presented, planned and discussed.

Preoperative laryngeal examination revealed Mallampati Class IV anatomical condition of exceedingly ventrally displaced trachea, a condition that was not clearly visible in preoperative magnetic resonance imaging. The first major problem encountered was Cormack-Lehane grade IV extremely difficult endotracheal intubation. Following fentanyl 1–2 µg kg− 1, propofol 2–3 mg kg− 1 and rocuronium 100 mg for tracheal intubation, anesthesiologists documented in patient’s chart “limited laryngeal space because the epiglottis was extremely ventrally displaced”. Neither glottis nor epiglottis was visible on laryngoscopy resulting in failed placement of the double-lumen endotracheal tube (DLT) following numerous attempts. The DLT was eventually inserted via a GlideScope videolaryngoscopy. The endobroncheal right lung block for left OLV was successfully placed in the “extremely ventrally displaced trachea” using a fiberopticscope. The numerous intubation attempts resulted in laryngeal edema that required antihistaminic administration, but no apparent laryngeal injury or trauma.

The crus habitus encroached on OLV tidal volume by the cranially displaced ascending colon and left kidney. Skilled anesthesiologists successfully maintained acceptable arterial blood gases levels, adequate tidal volume ventilation and oxygenation (pressure control with volume guarantee 6–7 cmH2O PEEP, 50–100% FiO2, 140–279 mmHg PaO2, 98.9–99.9% SpO2 lung protection strategy).

A clear surgical strategy was devised based upon right anterior minimal invasive mini-thoracotomy approach [4] and a Perceval self-anchoring, self-expanding valve, designed for quick sutureless deployment allowing quick valve placement under direct vision [2]. The surgical strategy aim was maximal reduction of blood loss, surgical trauma, operative procedure time and intensive care unit (ICU) stay [4]. Multiple studies have demonstrated adverse effects of prolonged operative time; as Ranucci et al. [5] demonstrated 1.4% increase in severe cardiovascular morbidity for each additional minute of aortic cross clamping (ACC) time [5].

Remifentanil /sevoflurane anesthesia was adjusted throughout the whole procedure to maintain bispectral index (BIS) at 60 − 40. Placement of vascular cannulae for transfemoral femoro-femoral cardiopulmonary bypass (CPB) was uneventful and a lateral right mini-thoracotomy incision successfully gained access to the desired surgical field. The annulus of the massively calcified 0.5 cm² aortic valve area (AVA) congenital bicuspid aortic valve was decalcification, and a sutureless self-expandable Perceval valve was placed. During the entire anesthesia, the digitally recorded BIS was 38–62 except when BIS precipitously sustained a decline to 38 − 14 (SR, suppression ratio < 10) for 25 min after the termination of the CPB when mean arterial pressure (MAP) dropped to 39 − 35 mm Hg under noradrenaline (0.06 mg ml− 1) 8–13 ml h− 1 continuous infusion (Fig. 2a, b, c and d).

Fig. 2figure 2

a, b, c and d Digitally recorded Bispectral index (BIS) during the entire anesthesia was between 38 and 62 except when BIS precipitously sustained a 25 min decline between 14 and 38 after the termination of cardiopulmonary bypass

Despite the laryngeal edema resulting from numerous intubation attempts; extubation was uneventful. Piritramide 30 mg was administered for postoperative analgesia. Patient spent one day in the ICU, one day in the Intermediate Care, was then transferred to the ward and had an uneventful post-operative course with a well-positioned aortic valve prosthesis.

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