Achieving Successful Extubation and Cost-Effective Recovery Following Anesthetic Airway Management in Supracarinal Tracheal Reconstruction Surgeries: A Retrospective Analysis.

Introduction From an anesthesiologist's perspective, perioperative concerns related to supracarinal tracheal reconstruction surgery include having uninterrupted smooth ventilation without any laryngeal edema, glottic dysfunction, and airway leak. Surgical concerns comprise various kinds of anastomotic dissections, fistulas to innominate arteries, and the esophagus. The most serious complication following tracheal surgery is anastomotic separation, which might manifest modestly as stridor, respiratory distress, and extremis. To avoid dire repercussions, prompt management and securing the airway are necessary. Against this background, we wanted to highlight the importance of early extubation and discharge of supracarinal tracheal reconstruction patients from hospitals without any postoperative complications and with the least expenses possible, since most of these patients have already undergone postintubation tracheal stenosis and prolonged intensive care unit stay, and have experienced significant financial burden incurring from preceding events. Methodology Medical records of all patients admitted for tracheal reconstruction during the period from March 2019 to April 2022 (four years) were reviewed to collect patient demographic details, surgical descriptions, anesthesia data, records of pre-anesthetic evaluations, and postoperative details up until the hospital discharge. Results The most common reason for tracheal stenosis among our patients was post-intubation tracheal stenosis (PITS), which was seen in 8/13 patients (61.53%); 4/13 patients (30.76%) had stridor at rest and underwent emergency tracheostomy preoperatively immediately following admission to the hospital. The stenosis was situated at a median distance of 3 cm [interquartile range (IQR): 0.5-7] from the true vocal cords or 7 cm (IQR: 3-9) from the carina. The median length of tracheal resection was 2 cm (IQR: 1-4). We observed that the mode of induction for airway management was tracheostomy tube in four patients (with 90% tracheal stenosis), placement of laryngeal mask airway (LMA) with spontaneous ventilation in four patients (with 75% tracheal stenosis), and small-size (#5-7.5 sizes) endotracheal tube (ETT) placement in five patients (with less than 75% tracheal stenosis). The postoperative complication noted was bleeding from the operative site in 1/13 patients (7.6%); a 0% mortality rate was noted during the hospital stay and up until six months post-discharge. We noted that the median duration of postoperative hospitalization was five days (IQR: 2-15), and the total cost incurred by each patient was less than INR 85,000 (USD 1,000). Conclusion Our analysis revealed that all our patients were extubated in the operative room and shifted to the ward. In the "open airway phase", standard distal tracheal intubation and cross-field ventilation techniques, and tracheal suturing were facilitated by the apnoea-ventilation-apnoea technique. Both the techniques along with the emergency tracheostomies done in severe tracheal obstruction preoperatively and intraoperative anesthesia management with the insertion of LMA Supreme, maintained with spontaneous breathing techniques, offered potential advantages in the management of supracarinal tracheal reconstruction surgeries. The multidisciplinary teamwork along with close communication and good rapport with the surgical team was found to be the key factor in the fast-track extubation and recovery of these patients.

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Figures 2 and 4 are original drawings by Dr. Amuktamalyada M, who owns the copyright to the same.