Hybrid Spinal-General Anesthesia With a Supraglottic Airway in Severe Rheumatoid Arthritis: A Case Report

Rheumatoid arthritis (RA) can present significant challenges during airway management because of cervical spine involvement, restricted neck mobility, temporomandibular joint disease, and limited mouth opening.We report the perioperative anesthetic management of a patient with severe deforming RA and multiple predictors of an anticipated difficult airway undergoing laparoscopic cholecystectomy.A 54-year-old woman with long-standing RA had a Mallampati grade IV airway, approximately 1.5 cm mouth opening, a short neck, and markedly restricted cervical spine movement.A comprehensive difficult airway strategy was formulated with immediate availability of videolaryngoscopy, fiberoptic bronchoscopy, supraglottic airway devices, and emergency front-of-neck airway equipment.Following spinal anesthesia with 3.2 mL of 0.5% hyperbaric bupivacaine and 15 μg of fentanyl, light general anesthesia was induced while preserving spontaneous ventilation.Neuromuscular blockade was avoided, and a size 3 i-gel second-generation supraglottic airway was successfully inserted on the first attempt.Anesthesia was maintained with sevoflurane while spontaneous ventilation was preserved throughout laparoscopic surgery.Pneumoperitoneum was established gradually with intra-abdominal pressure maintained below 12 mmHg.The procedure was completed uneventfully without desaturation, airway obstruction, or significant hemodynamic instability.The i-gel was removed after recovery of consciousness and adequate airway reflexes.Postoperative recovery was uncomplicated, with satisfactory analgesia and no respiratory, neurological, or airway-related complications.This case illustrates that hybrid spinal-general anesthesia using a second-generation supraglottic airway while preserving spontaneous ventilation may be a useful alternative in carefully selected patients with an anticipated difficult airway.Such an approach requires meticulous preoperative airway assessment, experienced anesthetic management, and immediate availability of appropriate rescue airway equipment.