Blood

The unanticipated bleeding airway is quite rare. Most times, when we encounter blood, we expect it - a trauma victim with a smashed face, a bleeding tonsil, a patient with a tongue mass. So unexpectedly encountering blood on intubation can be a little alarming. A patient having a routine gallbladder surgery goes off to sleep. When I look with a laryngoscope to intubate her, I notice a frondy pedunculated mass in the back of her throat. It's bleeding. It can't get my laryngoscope around it without touching it, and the slightest pressure causes it to bleed. I react instinctively: I don't think I can intubate her easily so I go back to mask ventilating her and call for help. Another anesthesiologist comes in with a video laryngoscope and we take a look at the mass together. The surgeon also peers at the screen and notes that it looks very much like a lesion from HPV (human papillomavirus). With the video laryngoscope, I manage to intubate the patient, but the experience is a little stressful. Even as I suction blood from the back of the mouth, touching the mass inadvertently causes more bleeding. The blood pools continuously so it is challenging to do anything for more than a few seconds. Time feels strange; even though just a few minutes go by, it feels like so much longer. I also have to multitask; I remain cognizant of the patient's vital signs and depth of anesthesia. I draw up and give additional medications as needed. There is a conscious effort to suppress panic, but also an awareness to assess risk. On the one hand, I can wake the patient up, cancel the surgery, and have her assessed by our ear-nose-throat surgeons. On the other hand, I can "just intubate her" through the blood, risking failure and getting blood into the lungs. Fortunately, well-trained instincts lead me to the best option: to call for help, reassess the situation, formulate a plan, and proceed cautiously. After intubation, we checked her coagulation panel and platelets to make sure we weren't missing anything. In the end, the patient did fine. After the surgery, we gave our ENT consultants a quick phone call, rechecked the airway before extubation, and watched her in recovery a bit longer than usual. When I talked to her in the recovery room, I was not surprised to hear that she actually does have some bleeding when she brushes her teeth, and was planning to see her dentist. We managed to set her up with an appointment with an ENT surgeon as well.