Successfully anticipated difficult airway management of a “can ventilate, but cannot intubate” situation for urgent laparoscopic appendectomy in a patient with Duchenne muscular dystrophy

Successfully anticipated difficult airway management of a “can ventilate, but cannot intubate” situation for urgent laparoscopic appendectomy in a patient with Duchenne muscular dystrophy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successfully anticipated difficult airway management of a “can ventilate, but cannot intubate” situation for urgent laparoscopic appendectomy in a patient with Duchenne muscular dystrophy Fabian Peter Brunner, Philippe Neth, Alexander Kaserer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3837368/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jun, 2024 Read the published version in Reports → Version 1 posted You are reading this latest preprint version Abstract Background: Airway management in Duchenne patients can be challenging. We present a case of an anticipated difficult airway in a Duchenne patient that was managed by planning different suitable strategies based on the unanticipated difficult airway algorithm of the Difficult Airway Society (DAS). Case presentation: The patient initially presented with appendicitis, requiring laparoscopic appendectomy within 6 hours. Due to the underlying condition and a known difficult airway, we anticipated potential airway problems and successfully managed the "can ventilate but cannot intubate" situation using the algorithm. The difficult airway was attributed to reduced mandibular mobility, limited inclination or reclination, a large tongue, prominent incisors, and a posteriorly positioned epiglottis. Despite thorough preparation and team briefing, we experienced three failed intubation attempts. Considering limited nighttime resources, the urgency of surgery, the need for a tube for laparoscopy, and the risk of exacerbating airway issues, we made the decision to awaken the patient and wait for a second attempt after the epiglottis swelling had subsided. We used reversible, short-acting agents for induction, enabling us to continue with the algorithm within the allotted timeframe. In a second stage, we successfully performed fiberoptic-guided intubation via a supraglottic airway device using the Aintree intubation catheter, utilizing more favorable resources. Conclusion: For a patient with Duchenne Muscular Dystrophy and a difficult airway, advanced expertise is critical. Detailed anesthesia planning, clear team communication, and the use of reversible, short-acting agents are crucial. Adherence to the Difficult Airway Society guidelines is essential for safe airway management. Difficult Airway Duchenne difficult intubation reversal of anesthesia advanced airway management wake-up Aintree Background Airway management in Duchenne patients can be challenging due to the muscular contractions ( 1 – 3 ). This case highlights the need to assess a potentially difficult airway while pre anesthesia assessment particularly in patients with muscular dystrophy and therefore the careful preparation and evaluation of the difficult airway algorithm in the context of the patient’s medical needs in addition to human and clinical resources ( 4 ). The DAS-difficult airway algorithm ( 5 ) gives clear guidance for an unanticipated difficult airway but was used in this context to anticipate and manage the induction of a pre-assessed potentially difficult airway in a Duchenne patient. The described exit strategy by “waking-up” the patient ( 5 ) is a considerable option in a “can ventilate but cannot intubate” situation if set in context to available resources and patient`s condition and urge for medical treatment. This option enables to continue the algorithm within the given time frame by clinical indication in a setting with more favorable resources ( 4 ). To enable a potential exit strategy reversible agent such as rocuronium ( 6 ) and potent ultra-short-acting selective µ-opioid agonist such as remifentanil ( 7 ) were used. Case presentation We present a challenging ASA IV case involving a 24-year-old Duchenne patient with a BMI of 18.7 kg/m2 who arrived at our Emergency Department (ED) with lower right abdominal pain that had begun 24 hours earlier. The patient had no fever but exhibited elevated infection parameters indicative of acute appendicitis, a diagnosis confirmed by a CT scan that showed no signs of perforation. This patient's condition was complicated by the deletion of exon 12 in the dystrophin gene, leading to cognitive impairment, cardiomyopathy, contractions in all flexor muscles, scoliosis, and progressive weakening of the respiratory muscles. Consequently, the patient had previously undergone thoracic spondylodesis and required continuous BIPAP (room air, PEEP 4 mbar, Psupp 14 mbar) with their own device. When the surgeon determined that surgery was necessary within 6 hours, the limited night crew was already occupied with surgeries of higher priority. Airway assessment according to current guidelines( 5 , 6 ) revealed several concerning findings: reduced mouth opening (1–2 cm) indicating limited mandibular mobility, inability to incline or recline, Mallampati Class 3, a large tongue, prominent incisors (teeth 7–10), and the absence of nasopharyngeal imaging examination. The patient provided a hand-written anesthesia protocol from six years earlier, reporting a Cormack & Lehane (CL) Grade 3 with failed direct laryngoscopy, but successful fiberoptic oral intubation and adequate mask ventilation. The decision to proceed with surgery involved interdisciplinary discussions, considering various options such as awake fiberoptic guided intubation, while also taking into account the patient's emotional distress and respiratory challenges. Based on our archive records, successful mask ventilation and asleep fiberoptic intubation were achievable, but video laryngoscopy, especially with a D-Blade, had not been attempted yet. We decided to adhere to the DAS difficult airway protocol, initiating a modified rapid sequence induction (RSI) as Plan A, with the use of potentially reversible agents and video laryngoscopy employing a MAC #4 Blade. The choice for a modified RSI was made to confirm the effectiveness of mask ventilation before proceeding further, considering the patient's Duchenne dystrophy, respiratory status, and the need for swift intubation. Plan B involved switching to the D-Blade with the potential use of a bougie. Plan C, following the DAS algorithm, consisted of a combination of laryngoscopy to lift the tongue and fiberoptic-guided oral intubation. Given the high success rate and routine use of video laryngoscopy, we regarded it as a more favorable option than fiberoptic intubation, designating it as Plan C. In the event that ventilation remained possible, "waking-up" the patient was determined to be Plan D. Several considerations influenced this decision, including limited human resources during the night shift, the urgency of surgery, the need for a tube for laparoscopy, the absence of ENT specialists at that hour, and the likelihood of further airway complications with additional manipulations, such as fiberoptic-guided intubation through a supraglottic airway device using an Aintree intubation catheter ( 10 ). This scenario constituted Plan E, which we wished to reserve as the last resort before resorting to a more suitable setting with greater manpower, broader expertise, a refreshed team, and a patient who had time to recover from Plans A to D, provided the surgical urgency allowed for this timeframe. For induction, we administered reversible agents at typical RSI doses. Fentanyl served as the primary opioid, supplemented with fast-acting remifentanil. Propofol, following Schnider's TCI model, served as the hypnotic agent of choice. To adhere to Duchenne contraindications, we avoided succinylcholine and selected Rocuronium as the muscle relaxant, with ready-to-use Sugammadex for reversal. In anticipation of hemodynamic depression, particularly given Duchenne-related cardiomyopathy, we prepared a noradrenaline perfusor in advance. Preoxygenation was performed using the patient's BIPAP device set to 100% FiO2. We initiated a modified RSI, minimally supported by noradrenaline for hemodynamic stability, which we continuously monitored via an arterial catheter. Neuromuscular blockade was confirmed through relaxometry. Despite challenges in head positioning due to muscular dystrophy, we successfully achieved two-handed mask ventilation. However, Plan A failed as video laryngoscopy revealed a Cormack-Lehane grade 3b view with no glottic visibility, a posteriorly positioned larynx, hindered by prominent incisors and limited mouth opening. Recognizing that we were in a "can ventilate but cannot intubate" situation, we requested ENT assistance and prepared for Plan B while maintaining oxygenation above 90% to prevent desaturation. Utilizing a D-Blade, we obtained a partial view of the arytenoid cartilage, but the vocal cords remained obscured. Multiple intubation attempts, including direct tube insertion and the use of a bougie, were unsuccessful, with the tube unintentionally entering the esophagus. For the third attempt, we once again utilized the D-Blade to create space for fiberoptic guided intubation. Unfortunately, swelling obscured the epiglottis, leading the scope into the esophagus. ENT confirmed epiglottal swelling the following day. We decided to awaken the patient, considering surgery urgency, airway risks, and limited resources overnight. During this process, the patient maintained stable hemodynamics without experiencing desaturation or hypercapnia. We discontinued the administration of Propofol and Remifentanil, reversed the effects of Rocuronium using Sugammadex, and administered Nalbuphine to counteract the effects of Fentanyl. Additionally, Methylprednisolone was administered to prevent further swelling. The patient awakened without any incidents and was subsequently transferred to the intensive care unit with BIPAP support. This delay allowed for additional evaluations, including an airway CT scan and an assessment by ENT specialists, which confirmed the previously identified anatomical challenges. Plans were put in place for a subsequent attempt with Plan E, to be carried out by an ENT anesthesia team during the morning shift. The second induction used the same agents and dosages to facilitate the placement of a size #3 supraglottic device, one size smaller than ideal due to the patient's limited mouth opening. Although ventilation had a significant leak, fiberoptic-guided intubation through the device was performed using an Aintree intubation catheter. The Aintree's correct placement was verified via fiberoptic view of the carina. After removing the supraglottic device while maintaining the Aintree's position, the tube was inserted over it into the trachea, confirmed by capnography and bronchoscopy. The laparoscopic appendectomy was initially attempted but converted to laparotomy owing to the patient's challenging anatomy. Post-operatively, the patient was assessed by ENT, anesthesia, and intensive care teams due to increased glottic swelling. Extubation, conducted 48 hours after intubation, revealed left-sided recurrent nerve palsy. Within the first three days at the hospital, he developed pneumonia caused by Klebsiella, worsening his respiratory condition. This led to emergency re-intubation 48 hours post-extubation, where the same anesthesia team successfully implemented Plan E for airway management. A dilatative tracheotomy was performed 13 days into the hospital stay. After a 30-day hospitalization, the patient was discharged for rehabilitation and to learn tracheostoma management. Discussion Several key points emerge from this case. First, preoperative airway evaluation, both clinical and from prior anesthetic experiences, is crucial for anticipating and managing potential risks ( 8 , 10 ). Adhering to established guidelines ( 5 , 9 ), maintaining clear communication ( 4 ), and being flexible in decision-making are essential for effectively handling such situations ( 11 ). Ideally the team knows each other well and is trained to work together. The selection of a modified Rapid Sequence Induction (RSI) approach in the context of a potentially challenging airway ( 12 ), utilizing short-acting Remifentanil ( 7 ) and Rocuronium, with the option of reversal using Sugammadex ( 6 ), aligns with established practices documented in the literature. Notably, Succinylcholine is contraindicated in individuals with Duchenne muscular dystrophy ( 13 ) due to the associated risks. Additionally, it's worth mentioning that Nalbuphine is a well-established agent for counteracting ventilatory depression induced by fentanyl ( 14 ), further underscoring the importance of judicious drug selection and the need for tailored pharmacological strategies in patients with Duchenne muscular dystrophy and potential airway challenges ( 1 – 3 , 15 ). A point of contention revolves around the decision to opt for video laryngoscopy, despite previous difficulties encountered with direct laryngoscopy in this patient, as opposed to initially considering fiberoptic intubation during sleep. However, recent studies provide compelling evidence supporting the effectiveness of video laryngoscopy in similar scenarios ( 16 , 17 ), especially when augmented with a D-Blade ( 18 ) and a bougie ( 19 ). This approach finds further validation in a case report detailing the successful use of video laryngoscopy and a bougie in a Duchenne muscular dystrophy patient ( 2 ). Conversely, fiberoptic nasal intubation was not attempted due to the associated risks of hemodynamic changes and prolonged intubation times ( 20 ), compounded by the risk of bleeding in the context of the patient's challenging anatomy. The decision to reserve oral fiberoptic intubation as our Plan C can be open to discussion, considering that the manipulation involved induced swelling, making the attempt more challenging. Notably, studies comparing video laryngoscopy to the gold standard in awake intubations have demonstrated comparable or even faster intubation times and success rates ( 21 ), lending support to our decision to employ video laryngoscopy in managing a sleeping patient with a difficult airway. Interdisciplinary discussion is essential to assess the appropriateness of the chosen exit strategy and to consider whether alternative actions, such as implementing Plan E during the initial induction, should have been contemplated earlier. The clinical presentation of the epiglottis being situated entirely on the posterior side of the pharynx led us to believe that using a supraglottic device might exacerbate trauma to the epiglottis by pushing it downward, potentially obstructing the glottis completely. Consequently, we regarded front-of-neck access as the last resort. The initial unsuccessful intubation attempts likely played a role in the development of recurrent nerve palsy; a complication consistent with literature documenting glottic edema as a common occurrence ( 22 ). Additionally, the broader challenges associated with airway management in patients with muscular dystrophy, such as the heightened risks of anesthesiologic complications like rhabdomyolysis and potentially life-threatening hyperkalemia when using succinylcholine, have been well-documented ( 2 , 15 ). Conclusion In conclusion, managing a patient with Duchenne muscular dystrophy who presents with a challenging airway requires the expertise of senior medical professionals. Thorough anesthetic planning and effective interdisciplinary communication are essential prerequisites before proceeding with intubation. The use of reversible and short-acting agents is crucial for maintaining flexibility in the exit strategy. Furthermore, the DAS (Difficult Airway Society) algorithm, designed for unanticipated difficult airways, not only proves invaluable for responding to unexpected airway challenges but also serves as a valuable tool for anticipating and preparing for difficult airway scenarios in such patients. Declarations Ethics approval and consent to participate : Ethics approval not required. Written permission for participation in this case report was obtained from the legal guardian (father) of the patient. Consent for publication: Written permission for publication of potentially identifying information/images in an online open-access publication was obtained from the legal guardian (father) of the patient. Availability of data and materials: The clinical records analyzed during this case report are not publicly available due to duty of confidentiality but are available from the corresponding author on reasonable request. Our clinical record was collected in the clinical information system of the University Hospital Zurich. Competing interests: AK received lecture honoraria from Bayer AG (Switzerland), CSL Behring GmbH (Switzerland) and advisory honoraria from AstraZeneca AG (Switzerland). Funding: None. Authors' contributions: FB managed the case personally with PN as background and initiated the idea to publish this case, and therefore wrote this paper on its own. PN was the coordinating consultant in charge of the shift during which the case occurred. AK provided academic and research background for realizing this case report and reviewed the manuscript. All authors gave their final approval to the manuscript. Acknowledgements: None. References Larsen UT, Juhl B, Hein-Sörensen O, de Fine Olivarius B. Complications during anaesthesia in patients with Duchenne’s muscular dystrophy (a retrospective study). Can J Anaesth. 1989;36(4):418–22. Breucking E, Reimnitz P, Schara U, Mortier W. [Anesthetic complications. The incidence of severe anesthetic complications in patients and families with progressive muscular dystrophy of the Duchenne and Becker types]. Anaesthesist. 2000;49(3):187–95. Mota S, Germanova L, Cortesão J, Paiva T. Anaesthetic Management in a Duchennne Muscle Dystrophy Patient for Treatment of Recurrent Pneumothorax. Rev Port Cir Cardiotorac Vasc. 2017;24(3–4):200. Gleeson S, Groom P, Mercer S. Human factors in complex airway management. BJA Educ [Internet]. 2016;16(6):191–7. https://doi.org/10.1093/bjaed/mkv045 . Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults†. BJA: British Journal of Anaesthesia [Internet]. 2015;115(6):827–48. https://doi.org/10.1093/bja/aev371 . Curtis R, Lomax S, Patel B. Use of sugammadex in a ‘can’t intubate, can’t ventilate’ situation. Br J Anaesth [Internet]. 2012;108(4):612–4. Available from: https://www.sciencedirect.com/science/article/pii/S0007091217322675 . Scott LJ, Perry CM. Remifentanil: a review of its use during the induction and maintenance of general anaesthesia. Drugs. 2005;65(13):1793–823. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC. The Physiologically Difficult Airway. West J Emerg Med. 2015;16(7):1109–17. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway*. Anesthesiology [Internet]. 2022;136(1):31–81. https://doi.org/10.1097/ALN.0000000000004002 . Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32(4):429–34. Rall M, Dieckmann P. Safety culture and crisis resource management in airway management: general principles to enhance patient safety in critical airway situations. Best Pract Res Clin Anaesthesiol. 2005;19(4):539–57. Allene MD, Melekie TB, Ashagrie HE. Evidence based use of modified rapid sequence induction at a low income country: A systematic review. International Journal of Surgery Open [Internet]. 2020;25:17–23. Available from: https://www.sciencedirect.com/science/article/pii/S2405857220300474 . Stephens ID. Succinylcholine and Duchenne’s muscular dystrophy. Can J Anaesth. 1990;37(2):274. Jaffe RS, Moldenhauer CC, Hug CCJ, Finlayson DC, Tobia V, Kopel ME. Nalbuphine antagonism of fentanyl-induced ventilatory depression: a randomized trial. Anesthesiology. 1988;68(2):254–60. Segura LG, Lorenz JD, Weingarten TN, Scavonetto F, Bojanić K, Selcen D, et al. Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth. 2013;23(9):855–64. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022;4(4):CD011136. Wong J, Lee JSE, Wong TGL, Iqbal R, Wong P. Fibreoptic intubation in airway management: a review article. Singap Med J. 2019;60(3):110–8. Kılıçaslan A, Topal A, Erol A, Uzun ST. Comparison of the C-MAC D-Blade, Conventional C-MAC, and Macintosh Laryngoscopes in Simulated Easy and Difficult Airways. Turk J Anaesthesiol Reanim. 2014;42(4):182–9. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–89. Chahar JS, Das PK, Dubey RK, Malviya D, Harjai M, Rastogi S. Comparison of Orotracheal versus Nasotracheal Fiberoptic Intubation Using Hemodynamic Parameters in Patients with Anticipated Difficult Airway. Anesth Essays Res. 2020;14(1):81–6. Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia. 2018;73(9):1151–61. Wallace S, McGrath BA. Laryngeal complications after tracheal intubation and tracheostomy. BJA Educ [Internet]. 2021;21(7):250–7. https://doi.org/10.1016/j.bjae.2021.02.005 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Jun, 2024 Read the published version in Reports → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3837368","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":266995719,"identity":"ac73dd35-7a4b-4e97-9969-e145af81fe88","order_by":0,"name":"Fabian Peter Brunner","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYBAC9gYehgMwDjOUZnwApiSwa+E5ANXCg6SF2YCQFgZ0LWwSeLWwnz144OeOO3L27L0PmAv3HM4zZ+99Vs3zp46Bf3YDdi08eQkHe888M+bhOW7APOPZ4WLLnuNmt3nb2Bgk7hzAqsWeIcfgAG/b4cQeiTQGZp4DhxM33Ehju80LDBUDiQTstvC/MTj4t+1wfY/8M6iW+8/Yinn+SODWIpFjcBhoSwKPBBvMFjY2Zh42Azxa3iUclm17ZthzJo3h8IwD6YkbzqQxS85tA5pxA5fDcg9/fNt2R569/Rjj44ID1okbjh9j/PDmT50c/wzsWqDgABIJMwyfenTFo2AUjIJRMApQAQCjhl5xtSlYxwAAAABJRU5ErkJggg==","orcid":"","institution":"University and University Hospital Zurich","correspondingAuthor":true,"prefix":"","firstName":"Fabian","middleName":"Peter","lastName":"Brunner","suffix":""},{"id":266995720,"identity":"456b1607-d2d3-4d15-9663-e7378e68088a","order_by":1,"name":"Philippe Neth","email":"","orcid":"","institution":"University and University Hospital Zurich","correspondingAuthor":false,"prefix":"","firstName":"Philippe","middleName":"","lastName":"Neth","suffix":""},{"id":266995721,"identity":"a148182f-98de-461d-b623-abad8055a146","order_by":2,"name":"Alexander Kaserer","email":"","orcid":"","institution":"University and University Hospital Zurich","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Kaserer","suffix":""}],"badges":[],"createdAt":"2024-01-05 13:35:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3837368/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3837368/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3390/reports7020047","type":"published","date":"2024-06-14T16:17:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58824347,"identity":"3d2f6f30-c581-43fd-b6a5-14632f33c820","added_by":"auto","created_at":"2024-06-21 17:19:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":248273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3837368/v1/7c190d4f-ff84-47fd-84dc-5b5de6a8e853.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successfully anticipated difficult airway management of a “can ventilate, but cannot intubate” situation for urgent laparoscopic appendectomy in a patient with Duchenne muscular dystrophy","fulltext":[{"header":"Background","content":"\u003cp\u003eAirway management in Duchenne patients can be challenging due to the muscular contractions (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This case highlights the need to assess a potentially difficult airway while pre anesthesia assessment particularly in patients with muscular dystrophy and therefore the careful preparation and evaluation of the difficult airway algorithm in the context of the patient\u0026rsquo;s medical needs in addition to human and clinical resources (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The DAS-difficult airway algorithm (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) gives clear guidance for an unanticipated difficult airway but was used in this context to anticipate and manage the induction of a pre-assessed potentially difficult airway in a Duchenne patient. The described exit strategy by \u0026ldquo;waking-up\u0026rdquo; the patient (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) is a considerable option in a \u0026ldquo;can ventilate but cannot intubate\u0026rdquo; situation if set in context to available resources and patient`s condition and urge for medical treatment. This option enables to continue the algorithm within the given time frame by clinical indication in a setting with more favorable resources (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). To enable a potential exit strategy reversible agent such as rocuronium (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and potent ultra-short-acting selective \u0026micro;-opioid agonist such as remifentanil (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) were used.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eWe present a challenging ASA IV case involving a 24-year-old Duchenne patient with a BMI of 18.7 kg/m2 who arrived at our Emergency Department (ED) with lower right abdominal pain that had begun 24 hours earlier. The patient had no fever but exhibited elevated infection parameters indicative of acute appendicitis, a diagnosis confirmed by a CT scan that showed no signs of perforation. This patient's condition was complicated by the deletion of exon 12 in the dystrophin gene, leading to cognitive impairment, cardiomyopathy, contractions in all flexor muscles, scoliosis, and progressive weakening of the respiratory muscles. Consequently, the patient had previously undergone thoracic spondylodesis and required continuous BIPAP (room air, PEEP 4 mbar, Psupp 14 mbar) with their own device. When the surgeon determined that surgery was necessary within 6 hours, the limited night crew was already occupied with surgeries of higher priority.\u003c/p\u003e \u003cp\u003eAirway assessment according to current guidelines(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) revealed several concerning findings: reduced mouth opening (1\u0026ndash;2 cm) indicating limited mandibular mobility, inability to incline or recline, Mallampati Class 3, a large tongue, prominent incisors (teeth 7\u0026ndash;10), and the absence of nasopharyngeal imaging examination. The patient provided a hand-written anesthesia protocol from six years earlier, reporting a Cormack \u0026amp; Lehane (CL) Grade 3 with failed direct laryngoscopy, but successful fiberoptic oral intubation and adequate mask ventilation.\u003c/p\u003e \u003cp\u003eThe decision to proceed with surgery involved interdisciplinary discussions, considering various options such as awake fiberoptic guided intubation, while also taking into account the patient's emotional distress and respiratory challenges. Based on our archive records, successful mask ventilation and asleep fiberoptic intubation were achievable, but video laryngoscopy, especially with a D-Blade, had not been attempted yet. We decided to adhere to the DAS difficult airway protocol, initiating a modified rapid sequence induction (RSI) as Plan A, with the use of potentially reversible agents and video laryngoscopy employing a MAC #4 Blade. The choice for a modified RSI was made to confirm the effectiveness of mask ventilation before proceeding further, considering the patient's Duchenne dystrophy, respiratory status, and the need for swift intubation. Plan B involved switching to the D-Blade with the potential use of a bougie. Plan C, following the DAS algorithm, consisted of a combination of laryngoscopy to lift the tongue and fiberoptic-guided oral intubation. Given the high success rate and routine use of video laryngoscopy, we regarded it as a more favorable option than fiberoptic intubation, designating it as Plan C. In the event that ventilation remained possible, \"waking-up\" the patient was determined to be Plan D. Several considerations influenced this decision, including limited human resources during the night shift, the urgency of surgery, the need for a tube for laparoscopy, the absence of ENT specialists at that hour, and the likelihood of further airway complications with additional manipulations, such as fiberoptic-guided intubation through a supraglottic airway device using an Aintree intubation catheter (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This scenario constituted Plan E, which we wished to reserve as the last resort before resorting to a more suitable setting with greater manpower, broader expertise, a refreshed team, and a patient who had time to recover from Plans A to D, provided the surgical urgency allowed for this timeframe.\u003c/p\u003e \u003cp\u003eFor induction, we administered reversible agents at typical RSI doses. Fentanyl served as the primary opioid, supplemented with fast-acting remifentanil. Propofol, following Schnider's TCI model, served as the hypnotic agent of choice. To adhere to Duchenne contraindications, we avoided succinylcholine and selected Rocuronium as the muscle relaxant, with ready-to-use Sugammadex for reversal. In anticipation of hemodynamic depression, particularly given Duchenne-related cardiomyopathy, we prepared a noradrenaline perfusor in advance.\u003c/p\u003e \u003cp\u003ePreoxygenation was performed using the patient's BIPAP device set to 100% FiO2. We initiated a modified RSI, minimally supported by noradrenaline for hemodynamic stability, which we continuously monitored via an arterial catheter. Neuromuscular blockade was confirmed through relaxometry. Despite challenges in head positioning due to muscular dystrophy, we successfully achieved two-handed mask ventilation. However, Plan A failed as video laryngoscopy revealed a Cormack-Lehane grade 3b view with no glottic visibility, a posteriorly positioned larynx, hindered by prominent incisors and limited mouth opening. Recognizing that we were in a \"can ventilate but cannot intubate\" situation, we requested ENT assistance and prepared for Plan B while maintaining oxygenation above 90% to prevent desaturation. Utilizing a D-Blade, we obtained a partial view of the arytenoid cartilage, but the vocal cords remained obscured. Multiple intubation attempts, including direct tube insertion and the use of a bougie, were unsuccessful, with the tube unintentionally entering the esophagus.\u003c/p\u003e \u003cp\u003eFor the third attempt, we once again utilized the D-Blade to create space for fiberoptic guided intubation. Unfortunately, swelling obscured the epiglottis, leading the scope into the esophagus. ENT confirmed epiglottal swelling the following day. We decided to awaken the patient, considering surgery urgency, airway risks, and limited resources overnight. During this process, the patient maintained stable hemodynamics without experiencing desaturation or hypercapnia.\u003c/p\u003e \u003cp\u003eWe discontinued the administration of Propofol and Remifentanil, reversed the effects of Rocuronium using Sugammadex, and administered Nalbuphine to counteract the effects of Fentanyl. Additionally, Methylprednisolone was administered to prevent further swelling. The patient awakened without any incidents and was subsequently transferred to the intensive care unit with BIPAP support. This delay allowed for additional evaluations, including an airway CT scan and an assessment by ENT specialists, which confirmed the previously identified anatomical challenges. Plans were put in place for a subsequent attempt with Plan E, to be carried out by an ENT anesthesia team during the morning shift.\u003c/p\u003e \u003cp\u003eThe second induction used the same agents and dosages to facilitate the placement of a size #3 supraglottic device, one size smaller than ideal due to the patient's limited mouth opening. Although ventilation had a significant leak, fiberoptic-guided intubation through the device was performed using an Aintree intubation catheter. The Aintree's correct placement was verified via fiberoptic view of the carina. After removing the supraglottic device while maintaining the Aintree's position, the tube was inserted over it into the trachea, confirmed by capnography and bronchoscopy. The laparoscopic appendectomy was initially attempted but converted to laparotomy owing to the patient's challenging anatomy.\u003c/p\u003e \u003cp\u003ePost-operatively, the patient was assessed by ENT, anesthesia, and intensive care teams due to increased glottic swelling. Extubation, conducted 48 hours after intubation, revealed left-sided recurrent nerve palsy. Within the first three days at the hospital, he developed pneumonia caused by Klebsiella, worsening his respiratory condition. This led to emergency re-intubation 48 hours post-extubation, where the same anesthesia team successfully implemented Plan E for airway management. A dilatative tracheotomy was performed 13 days into the hospital stay. After a 30-day hospitalization, the patient was discharged for rehabilitation and to learn tracheostoma management.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSeveral key points emerge from this case. First, preoperative airway evaluation, both clinical and from prior anesthetic experiences, is crucial for anticipating and managing potential risks (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Adhering to established guidelines (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), maintaining clear communication (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and being flexible in decision-making are essential for effectively handling such situations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Ideally the team knows each other well and is trained to work together.\u003c/p\u003e \u003cp\u003eThe selection of a modified Rapid Sequence Induction (RSI) approach in the context of a potentially challenging airway (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), utilizing short-acting Remifentanil (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and Rocuronium, with the option of reversal using Sugammadex (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), aligns with established practices documented in the literature. Notably, Succinylcholine is contraindicated in individuals with Duchenne muscular dystrophy (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) due to the associated risks.\u003c/p\u003e \u003cp\u003eAdditionally, it's worth mentioning that Nalbuphine is a well-established agent for counteracting ventilatory depression induced by fentanyl (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), further underscoring the importance of judicious drug selection and the need for tailored pharmacological strategies in patients with Duchenne muscular dystrophy and potential airway challenges (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA point of contention revolves around the decision to opt for video laryngoscopy, despite previous difficulties encountered with direct laryngoscopy in this patient, as opposed to initially considering fiberoptic intubation during sleep. However, recent studies provide compelling evidence supporting the effectiveness of video laryngoscopy in similar scenarios (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), especially when augmented with a D-Blade (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and a bougie (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This approach finds further validation in a case report detailing the successful use of video laryngoscopy and a bougie in a Duchenne muscular dystrophy patient (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConversely, fiberoptic nasal intubation was not attempted due to the associated risks of hemodynamic changes and prolonged intubation times (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), compounded by the risk of bleeding in the context of the patient's challenging anatomy. The decision to reserve oral fiberoptic intubation as our Plan C can be open to discussion, considering that the manipulation involved induced swelling, making the attempt more challenging. Notably, studies comparing video laryngoscopy to the gold standard in awake intubations have demonstrated comparable or even faster intubation times and success rates (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), lending support to our decision to employ video laryngoscopy in managing a sleeping patient with a difficult airway.\u003c/p\u003e \u003cp\u003eInterdisciplinary discussion is essential to assess the appropriateness of the chosen exit strategy and to consider whether alternative actions, such as implementing Plan E during the initial induction, should have been contemplated earlier. The clinical presentation of the epiglottis being situated entirely on the posterior side of the pharynx led us to believe that using a supraglottic device might exacerbate trauma to the epiglottis by pushing it downward, potentially obstructing the glottis completely. Consequently, we regarded front-of-neck access as the last resort.\u003c/p\u003e \u003cp\u003eThe initial unsuccessful intubation attempts likely played a role in the development of recurrent nerve palsy; a complication consistent with literature documenting glottic edema as a common occurrence (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Additionally, the broader challenges associated with airway management in patients with muscular dystrophy, such as the heightened risks of anesthesiologic complications like rhabdomyolysis and potentially life-threatening hyperkalemia when using succinylcholine, have been well-documented (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, managing a patient with Duchenne muscular dystrophy who presents with a challenging airway requires the expertise of senior medical professionals. Thorough anesthetic planning and effective interdisciplinary communication are essential prerequisites before proceeding with intubation. The use of reversible and short-acting agents is crucial for maintaining flexibility in the exit strategy. Furthermore, the DAS (Difficult Airway Society) algorithm, designed for unanticipated difficult airways, not only proves invaluable for responding to unexpected airway challenges but also serves as a valuable tool for anticipating and preparing for difficult airway scenarios in such patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e: Ethics approval not required. Written permission for participation in this case report was obtained from the legal guardian (father) of the patient.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003eWritten permission for publication of potentially identifying information/images in an online open-access publication was obtained from the legal guardian (father) of the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u0026nbsp;\u003c/em\u003eThe clinical records analyzed during this case report are not publicly available due to duty of confidentiality but are available from the corresponding author on reasonable request. Our clinical record was collected in the clinical information system of the University Hospital Zurich.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests:\u0026nbsp;\u003c/em\u003eAK received lecture honoraria from Bayer AG (Switzerland), CSL Behring GmbH (Switzerland) and advisory honoraria from AstraZeneca AG (Switzerland).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/em\u003eFB managed the case personally with PN as background and initiated the idea to publish this case, and therefore wrote this paper on its own. PN was the coordinating consultant in charge of the shift during which the case occurred. AK provided academic and research background for realizing this case report and reviewed the manuscript. All authors gave their final approval to the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLarsen UT, Juhl B, Hein-S\u0026ouml;rensen O, de Fine Olivarius B. Complications during anaesthesia in patients with Duchenne\u0026rsquo;s muscular dystrophy (a retrospective study). Can J Anaesth. 1989;36(4):418\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBreucking E, Reimnitz P, Schara U, Mortier W. [Anesthetic complications. The incidence of severe anesthetic complications in patients and families with progressive muscular dystrophy of the Duchenne and Becker types]. Anaesthesist. 2000;49(3):187\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMota S, Germanova L, Cortes\u0026atilde;o J, Paiva T. 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Safety culture and crisis resource management in airway management: general principles to enhance patient safety in critical airway situations. Best Pract Res Clin Anaesthesiol. 2005;19(4):539\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllene MD, Melekie TB, Ashagrie HE. Evidence based use of modified rapid sequence induction at a low income country: A systematic review. International Journal of Surgery Open [Internet]. 2020;25:17\u0026ndash;23. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S2405857220300474\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S2405857220300474\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStephens ID. Succinylcholine and Duchenne\u0026rsquo;s muscular dystrophy. 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Singap Med J. 2019;60(3):110\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKılı\u0026ccedil;aslan A, Topal A, Erol A, Uzun ST. Comparison of the C-MAC D-Blade, Conventional C-MAC, and Macintosh Laryngoscopes in Simulated Easy and Difficult Airways. Turk J Anaesthesiol Reanim. 2014;42(4):182\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDriver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChahar JS, Das PK, Dubey RK, Malviya D, Harjai M, Rastogi S. Comparison of Orotracheal versus Nasotracheal Fiberoptic Intubation Using Hemodynamic Parameters in Patients with Anticipated Difficult Airway. Anesth Essays Res. 2020;14(1):81\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia. 2018;73(9):1151\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallace S, McGrath BA. Laryngeal complications after tracheal intubation and tracheostomy. BJA Educ [Internet]. 2021;21(7):250\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bjae.2021.02.005\u003c/span\u003e\u003cspan address=\"10.1016/j.bjae.2021.02.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Difficult Airway, Duchenne, difficult intubation, reversal of anesthesia, advanced airway management, wake-up, Aintree","lastPublishedDoi":"10.21203/rs.3.rs-3837368/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3837368/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground: \u003c/strong\u003e\u003c/em\u003eAirway management in Duchenne patients can be challenging. We present a case of an anticipated difficult airway in a Duchenne patient that was managed by planning different suitable strategies based on the unanticipated difficult airway algorithm of the Difficult Airway Society (DAS).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/em\u003e The patient initially presented with appendicitis, requiring laparoscopic appendectomy within 6 hours. Due to the underlying condition and a known difficult airway, we anticipated potential airway problems and successfully managed the \"can ventilate but cannot intubate\" situation using the algorithm. The difficult airway was attributed to reduced mandibular mobility, limited inclination or reclination, a large tongue, prominent incisors, and a posteriorly positioned epiglottis. Despite thorough preparation and team briefing, we experienced three failed intubation attempts. Considering limited nighttime resources, the urgency of surgery, the need for a tube for laparoscopy, and the risk of exacerbating airway issues, we made the decision to awaken the patient and wait for a second attempt after the epiglottis swelling had subsided. We used reversible, short-acting agents for induction, enabling us to continue with the algorithm within the allotted timeframe. In a second stage, we successfully performed fiberoptic-guided intubation via a supraglottic airway device using the Aintree intubation catheter, utilizing more favorable resources.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/em\u003e For a patient with Duchenne Muscular Dystrophy and a difficult airway, advanced expertise is critical. Detailed anesthesia planning, clear team communication, and the use of reversible, short-acting agents are crucial. Adherence to the Difficult Airway Society guidelines is essential for safe airway management.\u003c/p\u003e","manuscriptTitle":"Successfully anticipated difficult airway management of a “can ventilate, but cannot intubate” situation for urgent laparoscopic appendectomy in a patient with Duchenne muscular dystrophy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-15 08:50:11","doi":"10.21203/rs.3.rs-3837368/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67220dec-1d5c-4edd-a380-d6e995191ab5","owner":[],"postedDate":"January 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T16:17:59+00:00","versionOfRecord":{"articleIdentity":"rs-3837368","link":"https://doi.org/10.3390/reports7020047","journal":{"identity":"reports","isVorOnly":true,"title":"Reports"},"publishedOn":"2024-06-14 16:17:59","publishedOnDateReadable":"June 14th, 2024"},"versionCreatedAt":"2024-01-15 08:50:11","video":"","vorDoi":"10.3390/reports7020047","vorDoiUrl":"https://doi.org/10.3390/reports7020047","workflowStages":[]},"version":"v1","identity":"rs-3837368","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3837368","identity":"rs-3837368","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}