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May
1997
Laryngeal
mask airway in severe cervical stenosis.
Defalque RJ, Hyder ML; Can J Anaesth 1997; 44: 305-7.
Accompanying Editorial:
Refusal of treatment and moral compromise.
McKnight DJ, Webster GC; Can J Anaesth 1997; 44: 239-42.
[ no abstract available ]
In the March issue of the Canadian Journal of Anaesthesiology, Defalque
and Hyder (1) report on the use of a laryngeal mask airway (LMA) to facilitate
ventilation of a 61 year-old man with severe ankylosing spondylitis requiring
intense muscle relaxation for a closed reduction of a dislocated femoral
head.
The patient's ankylosing spondylitis had left him with severe restrictive
lung disease, a fixed anterior cervical spine flexion deformity, and Temporomandibular
joint involvement that restricted his mouth opening to 35 mm. In addition
he had a history of lifelong heavy smoking and had severe emphysema with
airway obstruction; he was on bronchodilators as well as steroids (15
mg prednisolone a day) and potent analgesics (hydrocodone and propoxyphene).
Two months prior to the right femoral hip dislocation the patient had
undergone a revision of a previous total hip arthroplasty. His spondylitis
precluded regional anesthesia and an awake transnasal fiberoptic intubation
was performed to facilitate general anesthesia. The hip revision was difficult
and took four hours; at the end of the case the patient failed tracheal
extubation and spent the next 11 days in the intensive care unit on mechanical
ventilation.
His postoperative course was complicated by, among other things, pneumonia,
septicemia, edema and renal insufficiency. Ultimately he self-extubated
but was able to maintain adequate gas exchange and was transferred out
of the ICU on the 15th postoperative day.
The patient had very bad recollection of the awake intubation (despite
midazolam 2 mg IV) and especially of his ICU course (it is noteworthy
that little sedation was given in the ICU as early extubation and weaning
were desired--but this is another story). He adamantly refused to undergo
tracheal intubation for his hip reduction, to the extent that he stated
that he would refuse surgery if this approach were used.
The authors therefore elected to provide anesthetic induction with fentanyl
150 mcg in divided doses, thiopental 200 mg and succinylcholine 60 mg.
The patient was then easily mask ventilated with a nasopharyngeal airway;
however, the authors elected to pass a #4 LMA to facilitate positive pressure
ventilation because they anticipated that the reduction would be difficult.
Although the LMA was passed with difficulty there were no adverse effects
and the patient could be easily ventilated at low airway pressures. After
several attempts over five minutes, the hip was reduced and the patient
had a smooth and uneventful emergence. The LMA was removed without problem
and on awakening the patient expressed his appreciation that he had been
spared tracheal intubation.
Defalque and Hyder present this case to illustrate that because the patient's
objection to a tracheal tube "forced us to look for an alternative;" they
had an opportunity to show that the LMA can be used safely to manage patients
with severe ankylosing spondylitis. In the accompanying editorial, McKnight
and Webster do not comment on the authors' prowess with an LMA. Instead,
they address the moral and ethical dilemma that anesthesiologists (indeed,
all physicians) are faced with when a patient accepts some but not all
planned therapy. The archetypal conundrum is blood transfusion in a Jehovah's
Witness.
Although the editorial is replete with tidbits from the ethicist's lexicon
such as "dis-ease", "moral residue", and "integrity-preserving compromise",
the writers pinpoint the crux of the matter thoughtfully and incisively.
That is: what is the moral and legal responsibility of the physician if
complications arise from management modified to suit the patient's wishes?
They point out that ultimately the patient must be "...the primary decision
maker in matters of treatment and care. The patient bears the burdens
and consequences of these decisions..." At the same time, the anesthesiologist
cannot compromise his or her standards of care or participate in practices
which they might consider unsafe or unethical.
Thus, McKnight and Webster suggest that the physician and patient must
work toward a compromise which preserves the integrity of both. The anesthesiologist
must explain to the patient all options and the consequences of the treatment
restriction, and not reject an alternate--but safe--form of treatment
simply because he or she disagrees with it.
Ultimately, the therapeutic relationship between physician and patient
must be based upon mutual respect in which each party neither imposes
a decision on the other, nor sacrifices personal beliefs or values for
the sake of a desired outcome.
This case report and its accompanying editorial are timely and thought-provoking
examination of a problem we will all face sooner or later. It is worth
examination, contemplation and discussion. I would welcome comments from
readers on this topic.
Email questions or comments regarding this article to: editors@anesthesiaweb.com
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