G Chopra, P Jindal, R Makker
G Chopra, P Jindal, R Makker. Letter to the Editor. The Internet Journal of Anesthesiology. 2006 Volume 12 Number 1.
An 18 months old male baby weighing 8 kg was posted for cleft lip surgery. After taking informed consent and clearance from the pre anaesthetic check up the child was kept fasting for six hours prior to surgery and premedicated with syrup phenargan 1 tsf.
After securing intravenous access the patient was induced with Inj thiopentone sodium 5 mg/kg, inj fentanyl 2µg/kg and inj vecuronium 0.08 mg/kg was given to facilitate endotracheal intubation and intermittent positive pressure ventilation (IPPV) was started. The child was monitored with a pulse oximeter, non invasive blood pressure, electrocardiogram and precordial stethoscope. About 20 seconds after giving the intubating dose of muscle relaxant we observed resistance in the bag during IPPV. The spo2 dropped from 100% to 88% and the heart rate increase from 112/min to 164 bpm.The resistance increased during the next few seconds and the SpO2 decreased to 77% and the heart rate was now 120bpm. Attempts at relieving the airway obstruction by triple maneuvers and insertion of an oropharyngeal airway and to relieve probable laryngospasm with IPPV proved unsuccessful with progressive fall in oxygen saturation. Immediately direct laryngoscopy was done for endotracheal intubation, which revealed a red coloured object at the laryngeal inlet. The object visualized was taken out by Magill's forceps and endotracheal intubation was done with uncuffed endotracheal tube (ID 4mm). The object removed from the larynx was found to be a red thread i.e. MOULIE (sacred thread tied on wrist).
Immediately after removal, the spasm was relieved and oxygen saturation increased from 81% to 100% on 100% oxygen. The surgery was continued and the child was reversed at the end of surgery. Retrospectively on asking the parents it was found that the child was wearing the thread over the wrist just prior to surgery and due to hunger he was chewing on the thread. We anticipate that the child might have been chewing the broken thread when he was taken to the OT and unfortunately nobody noticed it. On giving the muscle relaxant and intermittent positive pressure ventilation the thread was pushed into the laryngeal inlet and the child must have gone into laryngospasm and consequently the resistance in the bag was observed.
From this incidence we wish to bring to the notice that along with the nursing staff the attending anesthesiologist should be careful that pediatric patients should not be wearing any accessories because even a benign looking thread can lead to serious consequences and strict vigilance is required to notice such freak incidents.