Successful Tracheal Intubation Using the Airtraq in Thoraco-omphalopagus Twins

Abstract

To the Editor Tracheal intubation in conjoined twins, especially thoraco-omphalopagus twins, represents a unique challenge because of the varying extent of anatomical development and awkward positioning.1 We successfully intubated the tracheas of thoraco-omphalopagus twins using the Airtraq® (Prodol Meditec S.A., Vizcaya, Spain) (Fig. 1).Figure 1: Thoraco-omphalopagus twins after intubation (identified as A, on the right, and B, on the left).Female thoraco-omphalopagus conjoined twins, 40 days old, weighing 6.5 kg, were scheduled for surgical separation. The use of Airtraq optical laryngoscope in children was approved by the Human Ethics Committee of West China Hospital, and the parents provided informed consent. Preoperative studies showed a large cross-abdominal liver and separate hearts in a single pericardial sac combined with a left-sided superior vena cava of twin A draining into the coronary sinus of twin B. Both twins presented with micrognathism, high-vaulted arch, and short neck, and therefore difficult airway management was anticipated. After they were placed on the operating table with their necks slightly hyperextended, routine monitoring was established. Anesthesia was induced with sevoflurane, midozalam, and low-dose fentanyl with the intention to intubate the tracheas under deep sedation while maintaining spontaneous respiration. After the disappearance of eyelash reflex, tracheal intubation in twin B using a Macintosh laryngoscope blade size 1 was attempted by an experienced pediatric anesthesiologist with the twins in the lateral position to avoid significant hemodynamic compromise. Only the tip of the epiglottis was viewed and Cormack and Lehane grade III difficulty of intubation confirmed. Withdrawing the laryngoscope resulted in laryngospasm similar to that described by Shank1 and was resolved by administration of propofol. According to our preoperative protocol, we planned that the trachea of the second twin should be intubated. Therefore, while twin B underwent mask ventilation, the trachea of twin A was intubated without difficulty using an Airtraq optical laryngoscope (AOL; Prodol, Vizcaya, Spain), directly after which twin B was given succinylcholine 3 mg IV and tracheal intubation performed for twin B in a similar fashion. Although thoraco-omphalopagus twins usually present with an inflexible position, tracheal intubation can be achieved with the twins in the lateral and partly rotated position in most cases, rather than holding one baby above the other.2,3 We prefer deep sedation, maintaining spontaneous breathing in the management of anticipated difficult intubation. Transient laryngospasm occurring in our case was probably due to inadequate depth of anesthesia. Had our attempt using video-laryngscopy not been successful, we were prepared to use fiberoptic and rigid Seldinger-assisted video-telescopic intubation, as successfully applied in other similar cases.4–6 Jing Lin, MD Bin Liu, MD Ling Tan, MD Yun-Xia Zuo, MD, PhD Department of Anesthesiology West China Hospital Sichuan University Chengdu, Sichuan People's Republic of China [email protected]