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LETTER TO THE EDITOR Table of Contents   
Year : 2007  |  Volume : 10  |  Issue : 1  |  Page : 64
An unusual tracheal intubation in a patient with tracheo-oesophageal fistula


Department of Anaesthessiology and Cardiothoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi., India

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How to cite this article:
Mathur S K, Ahmad S, Singh R, Rao P B, Agarwal D. An unusual tracheal intubation in a patient with tracheo-oesophageal fistula. Ann Card Anaesth 2007;10:64

How to cite this URL:
Mathur S K, Ahmad S, Singh R, Rao P B, Agarwal D. An unusual tracheal intubation in a patient with tracheo-oesophageal fistula. Ann Card Anaesth [serial online] 2007 [cited 2019 Aug 23];10:64. Available from: http://www.annals.in/text.asp?2007/10/1/64/37930


To,

The Editor,

A13-year-old male was admitted for repair of tracheo-oesophageal fistula (TOF) following ingestion of one tablet of celphos (aluminium phosphide) for suicidal purposes in the past. Magnetic resonance imaging and panedoscopy revealed an oval shaped TOF approximately 2 cm size, about 2.5 cm proximal to the carina. Oropharyngeal examination showed mild fibrosis and crowding of laryngo-pharyngeal structures. After an informed consent and overnight fast, the patient was premedicated with 0.25 mg alprazolam through nasogastric tube. Inj. perinorm and inj. ranitidine were given 15 min prior to induction of anaesthesia. Continuous monitoring of the patient with noninvasive blood pressure, ECG, end-tidal carbon dioxide (EtCO 2 ), arterial oxygen saturation and temperature was done by using Datex­Ohmeda AS-5 monitor. Inj. glycopyrrolate 0.2 mg, and fentanyl 120 µg were given intravenously after institution of monitoring.

Following preoxygenation, anaesthesia was induced with inhalational technique using halothane and oxygen. After attaining deep plane of anaesthesia, laryngoscopy was performed. The epiglottis was seen displaced anteriorly and it was difficult to identify vocal cords due to crowding of structures. However, the endotracheal tube (ET) was inserted without difficulty and its position was checked by auscultation of chest and confirmed by EtCO 2 . Nasogastric tube was inserted and no air leak was seen from the proximal end when it was dipped in water, which suggested its placement beyond the fistula. After thoracotomy, when the TOF was being clamped, the surgeon noticed that the ET was passing through the TOF from the oesophagus into the trachea. A large portion of inflated cuff of ET was in the trachea and a part of it was in the TOF. The tip of the ET tube was just above the carina. To place the ET correctly, surgeon was asked to introduce retrogradely a nasogastric tube through the fistula into the trachea. As the nasogastric tube came out in the oral cavity, a se­cond endotracheal tube was rail-roaded over it and the nasogastric tube was removed. When this ET reached near TOF, the first ET was removed to help advancing it further into the trachea. After confirming its correct placement, anaesthesia was continued in the standard manner. The intraoperative and postoperative periods were uneventful and the patient was extubated and transferred to the postoperative ward.

Celphos (Aluminium phosphide) is a potentially fatal compound and its use has increased for suicidal attempts. Celphos poisoning may present with haemorrhage, acute renal failure, disseminated intravascular coagulation and arrythmias. [1] TOF is an unusual and a late complication. [2] When celphos comes in contact with a moist surface, phosphine gas, a systemic poison is liberated that causes a severe inflammatory response. [3],[4] Excessive corrosion at the site of contact of the tablet with gastrointestinal mucosa may lead to destruction of structures and development of TOF. [2] Keeping in mind the distortion of laryngopharyngeal structures due to fibrosis, the ideal intubation technique would have been with the help of flexible intubating fibrescope, but due to its non-availability, intubation with direct laryngoscopy with spontaneous respiration under inhalational induction was performed. The authors conclude that even though auscultatory and EtCO 2 findings confirm tracheal placement of the ET, it may not predict its correct pathway in a patient with TOF.

 
   References Top

1.Siwach SB, Yadav DR, Arora B, Dalal S. Acute aluminium phosphide poisoning, an epidemiological, clinical, and histopathological study. J Assoc Phys Ind 1988; 36: 594-96.  Back to cited text no. 1    
2.Tiwari J, Lahoti B, Dubey K, Mishra P, Verma S. Tracheo­ oesophageal fistula - An unusual complication following celphos poisoning. Ind J Surg 2003; 65: 442-44.  Back to cited text no. 2    
3.Koley TF. Aluminium phosphide poisoning. Ind J Clin Pract 1988; 9: 14-22.  Back to cited text no. 3    
4.Chung SN, Arora BB, Melhotra GC. Incidence and outcome of aluminium phosphide poisoning in a hospital study. Ind J Med Res 1991; 94: 232-35.  Back to cited text no. 4    

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Correspondence Address:
S K Mathur
Department of Anaesthessiology and Cardiothoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.37930

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