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Clinical Journal: Freeman OR

Noah M. Carpenter

Department of Nursing, Missouri Southern State University

NURS 333: Adult Health II

Professor Jessica Cooper MSN, RN

February 12th, 2023

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Clinical Journal: Clinical Location

My patient was a 50 year-old female, who for the sake of clarity in this journal we will call

“Patricia Patient” as a fake name. Patricia was in the operating room for a partial left foot resection of a

wound caused by her type 2 diabetes in order to prevent further complications. The problem I found while

observing was an issue with the intubation of the patient due to swelling of the esophagus most likely

from laryngeal edema.

Noticing

The CRNA initiated the anesthesia and the patient went under quite smoothly from my

knowledge and from what the previous times had looked like that day so there seemed to be no issue

there, but once they began to place the intubation tube into Patricia’s throat an issue arose. In previous

patients if they encountered any trouble with the insertion of the tube the CRNA used a device that had a

camera on the end and was shaped to hold open the airway to allow for easy access to the desired

location. This technique is called “videolaryngoscopy” and it worked well for the two previous patients I

had seen intubated, but when used on Patricia it seemed to not work. I noticed on the monitor that showed

the camera’s view that there was a lot of swelling, making the opening seem nonexistent and a lot

narrower than the previous ones I had seen that day. The CRNA seemed concerned at the amount of saliva

and blood that was pooling up around the opening of the trachea. I noticed the mentioned fluid on the

camera and was very concerned myself since throughout this time the oxygen saturation monitor had been

beeping increasingly rapidly and made for a stressful environment. Upon looking at the screen it was

showing that Patricia’s oxygen levels were alternating between around fifty percent and “APN” which

upon asking a scrub tech after meant a state of apnea-no breathing. I also noticed the people in the room

seemed to be in an increased state of urgency, which led to me ensuring I was completely out of the way

so as to not interrupt at a critical time. After a bit of time the CRNA removed the tube and put Patricia

back on the oxygen mask and requested a specialist’s assistance from a couple rooms over. They came in
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and noticed the same issues that presumably everyone had by looking at the monitor but ended up being

able to properly insert the tube which allowed for the surgery to continue as planned.

Interpreting

There were many cues that led back to the problem of laryngeal edema from what I

noticed. The first and foremost was the cue that they couldn’t get the intubation tube down

Patricia’s throat because of swelling. The swelling most likely is caused by laryngeal edema due

to previous intubations from Patricia’s admittance into the hospital as well as potential allergic

reactions to food or medication or complications with her type 2 diabetes. In their article

discussing the correlation between intubated and non-intubated patients, Matsushita and Shirozu

state, “[intubation] tube usage was significantly associated with higher incidence of severe PLE

[postoperative laryngeal edema]” (Matsushita et al. 2021). Since Patricia had been previously

intubated on admission, she was at a higher likelihood of having laryngeal edema prior to the

surgery which led to the complication of inserting the intubation tube. The videolaryngoscopy also

helped to confirm that it was indeed edema that was causing the issue with intubation because of how

much fluid, both blood and saliva, that there was. The apnea and low oxygen saturation also led to the

problem of a narrowed esophagus and closing larynx with less room for air to flow, especially with a tube

being inserted and abundant fluid.

Responding

There were many interventions that were being implemented as well as many that I would have

implemented myself if given the chance but I will focus on a few major ones. The first and probably most

important intervention was the administration of an intravenous corticosteroid by the CRNA. This

allowed for the swelling of the larynx to be addressed and helped for the airway to open up for Patricia to

breathe and be able to have the tube inserted for the operation to proceed. The CRNA also used clinical
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judgment to intervene by applying an oxygen mask when Patricia was apneic. This helped for her to

receive supplemental oxygen when she was unable to provide it for herself. A similar intervention I would

have done was to raise the head of the bed and apply a footboard to prevent Patricia from falling while

also allowing her easier access to breathe deeper and proper breaths. Another important intervention was

the CRNA finding a different intubation tube that was the proper size as well as asking for assistance

from a specialist instead of risking further injury to Patricia’s larynx since, as further stated by Matsushita

and Shirozu, important risk factors for laryngeal edema and intubation complications are, “female sex,

longer duration of intubation, [and] use of large tube size” (Matsushita et al. 2021). With Patricia being a

female and having been intubated for a moderate long duration previously with presumably a large size

tube, she most likely already has laryngeal edema and is at a higher risk for complications with further

intubation arising from that. The CRNA doing this allowed for less of a risk of worsening the issue and

allowed for the best possible outcome for Patricia.

Reflecting

Thankfully Patrticia’s issue of being unable to be intubated was solved relatively quickly as

evidenced by her oxygen saturation returning to her baseline and the CRNA being able to administer

anesthesia into her since the tube was in proper position. Another indication of the problem being

resolved was the tension in the room dissipating and the patient breathing at a normal rate and depth, as

assisted by the CRNA. After the surgery was completed, Patricia arose from anesthesia and while she did

mention a little soreness in her throat, she was able to breathe normally and no major damage was done

because of the interventions that were applied.

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References

Matsushita, H., Shirozu, K., Umehara, K., Uehara, K., Takatori, M., & Yamaura, K. (2021). Association

of an electromyographic tube for severe postoperative laryngeal edema and reintubation in

neurosurgery: a retrospective study. Journal of Anesthesia, 35(5),

611–616.https://doi.org/10.1007/s00540-021-02953-5