Nasotracheal intubation-extubation-intubation and asleep-awake-asleep anesthesia technique for deep brain stimulation

The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility

Among all the proposed predictors of difficult intubation defined by the intubation difficulty scale, head and neck movement (motility) stands out and plays as a crucial factor in determining the success rate and the degree of ease on endotracheal intubation. Aside from other airway tools (e.g., supraglottic airway devices), optical devices have been developed and applied for more than two decades and have shown their superiority to conventional direct laryngoscopes in many clinical scenarios and settings. Although awake/asleep flexible fiberoptic bronchoscopy is still the gold standard in patients with unstable cervical spines immobilized with a rigid cervical collar or a halo neck brace, videolaryngoscopy has been repeatedly demonstrated to be advantageous. In this brief report, for the first time, we present our clinical experience on the routine use of the Shikani video-assisted intubating stylet technique in patients with traumatic cervical spine injuries immobilized with a cervical stabilizer and in a patient with a stereotactic headframe for neurosurgery. Some trouble-shooting strategies for this technique are discussed. This paper demonstrates that the video-assisted intubating stylet technique is an acceptable alternative airway management method in patients with restricted or confined neck motility.

Anesthesia for deep brain stimulation system implantation: adapted protocol for awake and asleep surgery using microelectrode recordings

Purpose

Deep brain stimulation (DBS), an effective treatment for movement disorders, usually involves lead implantation while the patient is awake and sedated. Recently, there has been interest in performing the procedure under general anesthesia (asleep). This report of a consecutive cohort of DBS patients describes anesthesia protocols for both awake and asleep procedures.

Methods

Consecutive patients with Parkinson’s disease received subthalamic nucleus (STN) implants either moderately sedated or while intubated, using propofol and remifentanil. Microelectrode recordings were performed with up to five trajectories after discontinuing sedation in the awake group, or reducing sedation in the asleep group. Clinical outcome was compared between groups with the UPDRS III.

Results

The awake group (n = 17) received 3.5 mg/kg/h propofol and 11.6 μg/kg/h remifentanil. During recording, all anesthesia was stopped. The asleep group (n = 63) initially received 6.9 mg/kg/h propofol and 31.3 μg/kg/h remifentanil. During recording, this was reduced to 3.1 mg/kg/h propofol and 10.8 μg/kg/h remifentanil. Without parkinsonian medications or stimulation, 3-month UPDRS III ratings (ns = 16 and 52) were 40.8 in the awake group and 41.4 in the asleep group. Without medications but with stimulation turned on, ratings improved to 26.5 in the awake group and 26.3 in the asleep group. With both medications and stimulation, ratings improved further to 17.6 in the awake group and 15.3 in the asleep group. All within-group improvements from the off/off condition were statistically significant (all ps < 0.01). The degree of improvement with stimulation, with or without medications, was not significantly different in the awake vs. asleep groups (ps > 0.05).

Conclusion

The above anesthesia protocols make possible an asleep implant procedure that can incorporate sufficient microelectrode recording. Together, this may increase patient comfort and improve clinical outcomes.