Department of Anaesthesia, Royal Surrey County Hospital, Guildford GU2 7XX, UK.
Br J Anaesth. 2012 Apr;108(4):612-4. doi: 10.1093/bja/aer494. Epub 2012 Jan 26.
A 78-yr-old woman presented for a panendoscopy to investigate dysphonia and dysphagia. Intubation was anticipated to be difficult but possible, and mask ventilation was anticipated to be possible. After induction of anaesthesia and after three attempts at intubation, a 'can't intubate, can ventilate' situation deteriorated to a 'can't intubate, can't ventilate' (CICV) situation. Rocuronium-induced neuromuscular block was successfully reversed with sugammadex, as evidenced by the restoration of diaphragmatic movement, the ability of the patient to move her limbs, and the presence of a train-of-four nerve stimulation with no fade; however, ventilation was still not possible. A cricothyroid puncture using a Ravussin needle was performed successfully to provide emergency oxygenation. A tracheostomy was performed to allow the panendoscopy. CICV situations are rare anaesthetic emergencies. While sugammadex can be relied upon to reverse rocuronium-induced neuromuscular block, it should not be relied upon to rescue all CICV events, especially where airway instrumentation has led to airway swelling. The availability of sugammadex does not obviate the need for emergency tracheal access in the event of failed oxygenation. The presence of head and neck pathology should lead to the consideration of securing the airway awake.
一位 78 岁的女性因声音嘶哑和吞咽困难接受全内镜检查。预计插管困难但可行，预计面罩通气可行。麻醉诱导后，经过三次插管尝试，出现“无法插管，可通气”的情况恶化至“无法插管，无法通气”（CICV）的情况。罗库溴铵诱导的神经肌肉阻滞成功地被 sugammadex 逆转，这表现为膈肌运动的恢复、患者移动四肢的能力以及存在无衰减的四串神经刺激；然而，通气仍然不可能。使用 Ravussin 针进行环甲膜穿刺成功提供了紧急氧合。进行气管切开术以允许进行全内镜检查。CICV 情况是罕见的麻醉急症。虽然 sugammadex 可以依赖于逆转罗库溴铵诱导的神经肌肉阻滞，但它不应依赖于抢救所有 CICV 事件，尤其是在气道仪器操作导致气道肿胀的情况下。在出现通气失败的情况下，sugammadex 的可用性并不能排除紧急气管进入的需要。头颈部病理的存在应促使考虑在清醒时固定气道。
