Jinekolojik onkoloji hastalarında öngörülen ve öngörülemeyen zor havayolu olgularının karşılaştırılması

Öz

Amaç: Anesteziye bağlı morbidite ve mortalite nedenlerinden bir tanesi zor ve/veya başarısız entübasyondur. Havayolu muayenesinin zor havayolu (ZH) varlığını öngörmedeki rolü bilinmekle birlikte, ameliyat öncesi dönemde bu amaçla kullanılan testlerin özgüllüğü yüksek, ancak özgünlüğü düşüktür. Bu çalışmada, genel anestezi altında cerrahi tedavi uygulanacak komorbiditesi yüksek bir hasta popülasyonunda, preoperatif havayolu değerlendirmesi ile öngörülen ve öngörülemeyen zor havayolu olgularını belirlemek, karşılaştırmak ve zor entübasyon için olası risk faktörlerini ortaya koymak amaçlanmıştır. Gereç ve Yöntemler: Jinekolojik onkoloji cerrahisi için genel anestezi uygulanan, 18 yaş ve üzeri, toplam 162 hasta prospektif olarak çalışmaya dahil edildi. Preoperatif havayolu incelemeleri sonrasında; Basitleştirilmiş Havayolu Risk İndeksi (Simplified Airway Risk Index: SARI)’ne göre, ZH öngörülen ve öngörülemeyen olgular belirlendi. Endotrakeal entübasyon sonrasında Entübasyon Zorluk Skalası (Intubation Difficulty Scale: IRS)’na göre entübasyonu zor olan ve olmayan olgular gruplandırıldı, ZH’na neden olan etmenler ortaya konuldu Bulgular: SARI’ya göre toplam 162 hastanın 32’si (%19,75) ZH öngörülen, 130’u (%80,25) ise ZH öngörülemeyen olarak değerlendirildi. Entübasyon sonrasında IRS’ye göre 59 (%36,4) olguda zor entübasyon varlığı kayıt edildi. Boyun uzunluk ölçümü (p<0.003), vücut kitle indeksi (p=0.01), uzun üst ön kesici dişler (p=0.046), Mallampati Skoru (p=0.002), tiromental mesafe (p=0.003), yüksek damak varlığı (p=0.016) ZH varlığını etkileyen faktörler olarak bulundu. Ayrıca bu hasta grubunda, ileri yaş (>60 yaş; p=0.006) ve kronik hastalık varlığında (p=0.032) ZH ile karşılaşılma ihtimalinin arttığı da izlendi. Sonuç: Bu çalışma ile preoperatif hasta değerlendirmesinde kullanılan Mallampati skoru, boyun uzunluk ölçümü, tiromental mesafe ve ön kesici dişlerin uzun olmasının ZH varlığını etkileyen en önemli etmenler olduğu gösterilmiştir. Ameliyat öncesi dönemde yapılacak özenli havayolu muayenesinin ZH yönetimi için planlama yapılmasına olanak sağladığı düşünülmektedir.

Anahtar Kelimeler

• Genel anestezi
• entübasyon
• prediktif testler
• zor havayolu

Comparison of Predictable and Unpredictable Difficult Airway Cases in Gynecologic-Oncology Surgery Patients

Öz

Aim: One of the factors contributing to anesthesia-related morbidity and mortality is difficult intubation. Although it is well established that airway examination plays a crucial role in predicting the presence of a difficult airway (DA) during preoperative assessment, the predictive tests currently being utilized have a high specificity but a poor sensitivity. In this study, we sought to identify and compare the predictable and unpredictable DA cases with preoperative airway examination in a patient population with high comorbidity who underwent surgical intervention under general anesthesia. We also determine the possible risk factors for difficult intubation. Material and Methods: Between January and April 2022, a total of 162 patients who underwent general anesthesia for gynecological-oncology surgery and were at least 18 years old were evaluated prospectively. Following preoperative airway assessments, predictable and unpredictable DA were identified using the Simplified Airway Risk Index (SARI). In order to determine the factors that contributed to DA, patients were divided into groups with and without difficult intubation after endotracheal intubation using the "Intubation Difficulty Scale" (IRS). Results: In the study, 32 patients (19.75%) were found to have predicted DA, and 130 individuals (80.25%) were found to have unpredicted DA. According to the IRS, DA was detected in 59 (36.4%) patients after intubation. A high palate (p = 0.016), long anterior incisors (LAI) (p = 0.046), Mallampati Score (MS) (p = 0.002), Thyromental distance (TD) (p = 0.003), and neck length measurement (NLM) were shown to be the factors determining the existence of DA. Furthermore, advanced age (>60 years, p=0.006) and the presence of chronic diseases (p=0.032) increased the probability of encountering DA. Conclusion: The findings of the study demonstrated that preoperative MS, NLM, TD, LAI are found to be the most significant factors affecting the occurrence of DA. Attentive preoperative airway evaluation is critical while planning the DA and its management.

Anahtar Kelimeler

• general anesthesia
• intubation
• predictive tests
• difficult airway

Kaynakça

1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice Guidelines for Management of the Difficult Airway. An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98(5):1269-1277.
2. Frerk C, Mitchell VS, McNarry AF et al. Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
3. Yavas G, Guler OC, Gultekin M, et al. Multi-institutional study on the role of post-operative radiotherapy in elderly patients with endometrial cancer International Journal of Gynecologic Cancer 2023;33:719-726.
4. Wang T, Sun S, Huang S. The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis. BMC Anesthesiology 2018 June;18:79.
5. Lee A, Fan LT, Gin T, Karmakar MK et al. A Systematic Review (Meta-Analysis) of the Accuracy of the Mallampati Tests to Predict the Difficult Airway. Anesthesia and Analgesia 2006 June;102(6):1867-78
6. Savva D. Prediction of difficult tracheal intubation. Br J Anaesth. 1994 Aug; 73(2): 149-53.
7. Brodsky JB, Lemmens HJM, Brock-Utne JG, Vierra M, Saidman LJ. Morbid Obesity and Tracheal Intubation. Anesthesia & Analgesia 2002 March; 94(3):732-736.
8. Rao KVN, Dhatchinamoorthi D, Nandhakumar A, Selvarajan N, Akula HR, Thiruvenkatarajan V. Validity of thyromental height test as a predictor of difficult laryngoscopy: A prospective evaluation comparing modified Mallampati score, interincisor gap, thyromental distance, neck circumference, and neck extension. Indian J Anaesth. 2018 Aug;62(8):603-608.

9. Khan ZH, Kashfi A, Ebrahimkhani E. A Comparison of the Upper Lip Bite Test (a Simple New Technique) with Modified Mallampati Classification in Predicting Difficulty in Endotracheal Intubation: A Prospective Blinded Study. Anesthesia Analgesia. 2003 Feb; 96(2):595-599.
10. Crawley SM, Dalton AJ. Predicting the difficult airway. BJA Educ. 2015;15(5):253-258.
11. Norskov AK, Wetterslev J, Rosenstock CV et al. Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation- a cluster randomized trial with 64,273 participants. Br J Anaesth. 2016 May;116(5):680-9.
12. Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, Lapandry C. The Intubation Difficulty Scale (IDS). Proposal and Evaluation of a New Score Characterizing the Complexity of Endotracheal Intubation. Anesthesiology. 1997; 87(6):1290-1297.
13. Crosby ET, Cooper RM, Douglas MJ, et al.The unanticipated difficult airway with recommendations for management. Can J Anaesth. 1998;45:757-76.
14. Ezri T, Warters RD, Szmuk P, Saad-Eddin H, Geva D, Katz J, Hagberg C. The Incidence of Class “Zero” Airway and the Impact of Mallampati Score, Age, Sex, and Body Mass Index on Prediction of Laryngoscopy Grade. Anesthesia & Analgesia. 2001 October; 93(4):1073-1075.
15. Ayhan A, Kaplan S, Kayhan Z, Arslan G. Evaluation and Management of Difficult Airway in Obesity: A Single Center Retrospective Study. Acta clinica Croatica. 2016; 55: 27-32.
16. Alıç M, Birbiçer H, Kurku Ö. Obez gebelerde entübasyon güçlüğünün belirlenmesinde prediktif testlerin önemi. Türk Anest Rean Der Dergisi. 2011; 39(3):126-133.
17. Wilson ME, Spiegelhalter D, Robertson JA, Leeser P. Predicting Difficult Intubation. BJA. 1988; 61:211-216.
18. Koirala S, Shakya BM, Marhatta MN. Comparison of Upper Lip Bite Test with Modified Mallampati Test and Thyromental Distance for Prediction of Difficult Intubation. Nepal Journal of Medical Sciences. 2020; 5(1), 2–9.
19. Riad W, Ansari T, Shetty N. Does neck circumference help to predict difficult intubation in obstetric patients? A prospective observational study. Saudi J Anaesth. 2018; 12:77‐81.
20. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022; 136:31–81.
21. Riad W, Vaez MN, Raveendran R, Tam AD, Quereshy FA, Chung F, Wong DT. Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: A prospective observational study. European Journal of Anaesthesiology. 2016 April; 33(4):244-249.
22. Acer N, Akkaya A, Tuğay BU, Öztürk A. Zor Entübasyonu Tahmin Etmek İçin Cormeck-Lehane ve Mallampati Testleri İle Mandibula ve Boyun Ölçümlerinin Karşılaştırılması. Balkan Medical Journal. 2011; 28(2):157-163.
23. Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018 May 15;5(5):CD008874.