Broken safety pin in bronchus - Anaesthetic considerations
A 1-year-old, 9-kg female infant was brought in emergency with alleged history of inhaled FB. There was history of coughing and dyspnoea immediately following aspiration. Child had tachycardia and tachypnoea with mild respiratory distress on presentation. X-ray chest revealed the presence of a broken safety pin in right main bronchus []. Bronchoscopic removal of FB was planned immediately with written informed parental consent. Monitoring was established with pulse oximetry (SpO2), electrocardiogram (ECG) and noninvasive blood pressure (NIBP).\nChild was premedicated with glycopyrrolate (0.1 mg), and induced with i.v. propofol (25 mg) and succinyl choline (15 mg). The airway was handed over to surgeon for rigid bronchoscopy after ventilating with 100% O2. During the procedure, ventilation was accomplished via manually operated pressure-regulated jet from the side port of the bronchoscope. Repeated attempts at removal failed. Anticipating the delay in procedure, Propofol infusion was started to maintain the depth of anaesthesia. The surgeon had to withdraw from prolonged attempts repetitively to maintain saturation. Finally, unsuccessful with bronchoscopic removal, considering possible complications, decision for its open surgical removal via right thoracotomy was taken. The airway was secured with a single-lumen uncuffed endotracheal (ET) tube which was passed via cords into the left main bronchus using the traditional tilting of the head to right side method, as facilities for paediatric double lumen tube/fibreoptic/bronchial blockers were not available. The ET tube was then fixed at 13 cm at mouth. Left-sided endobronchial tube position was confirmed by auscultation. The child was taken on controlled ventilation maintaining anaesthesia with sevoflurane in oxygen and atracurium, and i.v. fentanyl administered for added analgesia. SpO2, ECG, NIBP and temperature were monitored. The EtCO2 could not be monitored due to non-functioning of the module. While intubating, the child had an episode of bradycardia (HR 45/min) which responded to i.v. atropine.\nDuring the initial period, till right bronchial incision was closed after procuring the broken safety pin, 100% oxygen was required to maintain oxygen saturation of more than 98%. After the closure of bronchial incision, the tracheal tube was withdrawn up to the carina and ventilation of both the lungs started. Nitrous oxide (60%) in oxygen was then started. Patient was administered 3rd–7th intercostal nerve blocks for post operative analgesia before extubation. The infant recovered well from anaesthesia and was discharged from hospital on the 7th postoperative day.