Background
Patients with achondroplasia have a myriad of associated abnormalities which much be considered prior to administration of anesthesia. These patients often have difficult IV access, greater incidence of obesity, obstructive and central sleep apnea, and a tendency towards hyper-salivation. They also often show neurological abnormalities, and suffer from chronic pain secondary to skeletal changes.
Furthermore, these patients are often considered “difficult airways”, which makes a thorough preoperative airway examination, and proper preparation for airway management imperative. Several factors contribute to intubation difficulties in achondrolastic patient including: megalocephaly, macroglossia, pronounced adenoids, cervical instability with risk of medullary compression which makes hyperextension of cervical spine during intubation potentially life-threatening.
Our Case 60 year old 4’1 52 kg female with past medical history of achondroplasia, cervical myelopathy, and obesity, presenting for C3-4 and C4-5 anterior cervical discectomy and fusion. Patient presented with baseline left upper extremity weakness and sensory deficits. Outpatient workup included Cervical MRI which showed severe central canal stenosis with cord signal abnormalities at C3-C4, as well as a broad disc bulge at C4-C5.
Given cervical cord abnormalities, as evidenced by baseline neurological deficits as well as findings on imaging, which were compounded by the well documented airway challenges associated with achondroplasia, the decision was made for an awake intubation prior to induction of anesthesia.
Methods: In preparation of airway manipulation, 0.2 mg of glycopyrrolate was given intra-muscularly thirty minutes prior to intubation. The patient was also given one mg of versed in the pre-operative area immediately before being taken to the operating room. After the patient was comfortably positioned on operative table, two doses of 10 mg IV ketamine were administered. The patient was then asked to gargle 3 mL of 4% viscous lidocaine; this gargle was repeated one additional time. Next, an LMA MADgic mucosal atomization device used to deliver another 2 mL of 2% lidocaine to the posterior pharynx. Then, a trans-tracheal block was placed using 2mL 4% lidocaine, followed by the insertion of an Ovassapian airway coated with 5% lidocaine ointment. Finally, fiberoptic intubation endoscope inserted with “spray as you go” mucosal anesthetization of 4% lidocaine for a total of 2 mL. After the endotracheal tube position was confirmed with fiberoptic scope, the patient underwent successful induction with IV propofol.
