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A 57-year-old man was admitted for a laparoscopic appendectomy for acute appendicitis. He was otherwise healthy apart from essential hypertension, for which he took hydrochlorothiazide. He had fasted for more than 12 hours.

On examination, he was lying on a stretcher in a moderate amount of pain. He was hemodynamically stable. His height was 183 cm and his weight was 80 kg. His airway examination demonstrated a Mallampati score of II, mouth opening of 4.5 cm, thyromental distance of 6 cm, and good jaw protrusion. He had a full set of teeth, was not obese, and was estimated to be easy to ventilate with a bag and a mask. His cardiac and respiratory examinations were normal.

The patient was premedicated with intravenous midazolam 1 mg and, fentanyl 200 mcg, and this was followed by denitrogenation with 100% oxygen by facemask. As he did not have any indicators of a difficult airway, a decision was made to induce anesthesia with propofol 200 mg and rocuronium 50 mg. Bag-mask-ventilation (BMV) was established with an oral airway. Initial evaluation with direct laryngoscopy using a Macintosh laryngoscope showed a Cormack/Lehane Grade 3 view. The first attempt with direct laryngoscopy employing a tracheal introducer (bougie) resulted in an esophageal intubation. BMV was reestablished and a Glidescope was prepared. When the Glidescope was inserted, only the posterior arytenoids could be visualized, and several attempts with a styleted endotracheal tube and a tracheal introducer were unsuccessful (and were associated with a small amount of bleeding in the oropharynx).

At this point, the decision was made to attempt flexible bronchoscopy. Unfortunately, BMV became more difficult, the patient's oxygen saturation dropped into the low 80s, and it became necessary to insert nasal and oral pharyngeal airways and begin a two-hand and two-person BMV technique. A #4 Laryngeal Mask Airway Classic was rapidly prepared and inserted without complication, at which point it became possible to easily ventilate the patient. Sevoflurane was selected to maintain anesthesia, and to manage escalating tachycardia and hypertension. A 6.0 mm ID Microlaryngeal tracheal tube (MLT, [Covidien-Nellcor, Boulder, CO]) was loaded onto a flexible bronchoscope, which was then inserted through the LMA and into the glottic opening. The MLT was advanced into the trachea over the bronchoscope. After confirmation of correct placement by auscultation and capnograph recording, the decision was made to leave both the endotracheal tube and LMA in place for the duration of the procedure.

The surgery was uneventful and the patient emerged from anesthesia fully awake, warm, with adequate analgesia, and with no residual neuromuscular blockade. The difficult airway cart was brought to the room. However, the patient was extubated without complication, although he did complain of a sore throat in the post-anesthetic care unit, which gradually improved. He was later informed of the difficulty and provided with a notice to inform any subsequent practitioner of his difficult airway.

12.2.1 What Are Extraglottic Devices? ...

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