Case Report DOI: 10.18231/2394-4994.2017.0107 Indian Journal of Clinical Anaesthesia, 2017;4(4): 536-538 536 C-MAC D-blade laryngoscope: A saviour for difficult intubation in lateral position Mamta Dubey 1,* , Nitesh Goel 2 , Itee Choudhary 3 , Lalit Gupta 4 1,3 Senior Consultant, 2 Consultant, RGCI, 4 Assistant Professor, Dept. of Anaesthesia, MAMC *Corresponding Author: Email: ek_mamta@yahoo.co.in Abstract Video laryngoscopes are the latest addition in an anaesthesiologist’s armamentarium. They are comparable to fiberoptic bronchoscope in terms of ease of visualization of vocal cords especially in awake intubation and in those with difficult airway. They have an added advantage of having an easier learning curve than fiberoptic bronchoscope guided intubation. There are several studies where video-laryngoscopes have been used in manikins and normal patients for intubation in both supine and lateral position successfully. Of these C-Mac D-Blade laryngoscope has an added advantage of having a blade like Macintosh with camera at the tip which gives good results. In our case report we describe an emergent scenario of successful awake nasal intubation in lateral position using C-Mac D-blade laryngoscope in a patient with documented difficult intubation. Keywords: Video laryngoscope, C-Mac, D-blade, Nasal intubation, Difficult intubation Introduction Flexible fiberoptic intubation is the gold standard in the management of the expected difficult airway. But in an emergent scenario or when faced with an unanticipated difficult intubation, we still resort to using a conventional Macintosh laryngoscope (1) aided by bougie or Magill forceps. This is probably due to the ease of availability. Many anatomical and pathological factors can make direct visualization of the airway difficult. In the last decade, multiple video laryngoscopes have been introduced into clinical practice and have become more common during emergency intubations. (2) C-Mac is recently introduced video laryngoscope that has the advantage of having a Macintosh type of laryngoscope blade with a camera at the tip. Though this device is useful for intubating in difficult airway in supine position, various studies are available which shows better results while intubating in lateral position. (3) We report the use of C-Mac D blade laryngoscope for emergency awake intubation in a patient with established difficult airway, where the difficulty was compounded by unusual positioning of the patient. Case Report Patient has reviewed the case report and gave written permission for the authors to publish the report. A 60 year old, 60 kg male, tobacco chewer, diagnosed case of squamous cell carcinoma left middle ear, treated with radiotherapy and chemotherapy, was scheduled for a temporal bone resection (Fisch type B) with pectoralis major flap reconstruction. His Mallampatti grading was II and other airway indices were within normal limits. During intubation he was found to have a Cormack- Lehane (CL) grading III even after applying BURP, with a Macintosh laryngoscope. Intubation was then performed in second attempt using a C -Mac D blade video laryngoscope with a POGO of 60%. On the third postoperative day, he had a secondary hemorrhage and was shifted to the operating room in right lateral position with a surgical resident applying compression to the bleeding site. Due to sudden rapid blood loss, the patient was in hypotension and the pulse was feeble (blood pressure 80/54 mm Hg with pulse rate of 120/min). In view of previous difficult intubation, a fiberoptic bronchoscope was asked for as we had to perform awake intubation. But the patient was deteriorating rapidly and there was no time to wait till the bronchoscope could be set up. Thus, an awake C - Mac guided oral intubation was attempted, but was not successful as negotiating the tube in limited mouth opening was difficult. The airway was finally secured by an awake nasotracheal intubation aided by the boedeker forceps (curved forceps). All this while the patient was lying in the lateral position with the compression to bleeding point continuing. Once the airway was secured, anaesthesia was administered with fentanyl, oxygen and air and surgery was allowed to proceed. The bleeding vessel was identified and ligated and haemostasis achieved. Meanwhile hemodynamic parameters were stabilised with fluid, blood transfusion and inotropes. Post operatively the patient was shifted to PACU for elective ventilation. Discussion Awake fiberoptic intubation remains the gold standard in the expected difficult airway. The use of video laryngoscopes such as the C Mac have increased over the past few years leading to a significant decrease in the number of awake fiberoptic intubations. Certain circumstances require an anaesthesiologist to perform endotracheal intubation in positions other than supine like lateral. These situations like trauma, accidental airway loss during surgery, neoplastic conditions of the occiput, back, or the sacral region make it either impossible or very difficult to place the patient in the