Transtracheal lidocaine: An alternative to intraoperative propofol infusion when muscle relaxants are not used

Biomechanical Evaluation of Tracheal Needle Puncture Forces: Comparative Analysis of Annular Ligaments and Tracheal Cartilage

Percutaneous tracheotomies (PCT) are commonly performed minimally invasive procedures involving the creation of an airway opening through an incision or puncture of the tracheal wall. While the medical intervention is crucial for critical care and the management of acute respiratory failure, tracheostomy complications can lead to severe clinical symptoms due to the alterations of the airways biomechanical properties/structures. The causes and mechanisms underlaying the development of these post-tracheotomy complications remain largely unknown. In this study, we aimed to investigate the needle puncture process and its biomechanical characteristics by using a well establish porcine ex vivo trachea to simulate the forces involved in accessing airways during PCT at varying angular approaches. Given that many procedures involve inserting a needle into the trachea without direct visualization of the tracheal wall, concerns have been raised over the needle punctures through the cartilaginous rings as compared to the space between them may result in fractured cartilage and post-tracheostomy airway complications. We report a difference in puncture force between piercing the cartilage and the annular ligaments and observe that the angle of puncture does not significantly alter the puncture forces. The data collected in this study can guide the design of relevant biomechanical feedback system during airway access procedures and ultimately help refine and optimize PCT.

Airway anesthesia with lidocaine for general anesthesia without using neuromuscular blocking agents in a patient with a history of anaphylaxis to rocuronium: a case report

We experienced a case of induction of general anesthesia without using neuromuscular blocking agents (NMBAs) in a 40-year-old woman with a history of anaphylaxis immediately after the administration of anesthetics lidocaine, propofol, and rocuronium to perform endoscopic sinus surgery 2 years before. The skin test showed a positive reaction to rocuronium and cis-atracurium. We induced general anesthesia without using NMBAs after inducing airway anesthesia with lidocaine (transtracheal injection and superior laryngeal nerve block). Deep general anesthesia was maintained with end-tidal 4 vol% sevoflurane. Hypotension was treated with phenylephrine infusion. The operation condition was excellent, and patient recovered without complications after surgery. Airway anesthesia with local anesthetics may be helpful when we cannot use NMBAs for any reason, including hypersensitivity to NMBA and surgery that needs neuromuscular monitoring.

Safety and efficacy of dexmedetomidine versus propofol infusion as an adjunct to transtracheal block in ensuring patient immobility during general anesthesia without the use of muscle relaxants

Background:

In surgeries where nerve stimulation study is required intraoperatively, the use of long-acting muscle relaxants should be avoided.

Aim of Study:

This study aimed to assess the efficacy of dexmedetomidine versus propofol infusion as an adjunct to transtracheal block to ensure patient immobility during general anesthesia without the use of muscle relaxants and to compare hemodynamics in both the groups.

Settings and Design:

It was a prospective randomized controlled trial done at a tertiary care center.

Subjects and Methods:

Forty adult patients undergoing brachial plexus surgeries were included in the study and all patients received a transtracheal block just before the induction. After standardized induction and intubation, Group D received intravenous (i.v.) bolus of dexmedetomidine 0.5 μg.kg^-1 body weight followed by infusion at 0.5 μg/kg/h intraoperatively. In Group B, the infusion of propofol was started at 1 mg/kg/h after induction. In both the groups, if the patient moved, bucked on endotracheal tube, or if there were signs of inadequate depth of anesthesia, bolus of propofol 0.5 mg.kg^-1 i.v. was given and repeated as required.

Statistical Tests Used:

Mann–Whitney U-test and Fisher's exact test were used for the statistical analysis.

Results:

Number of times propofol bolus was required intraoperatively and hemodynamic parameters were comparable in both the groups at all-time points. Time to extubate was significantly higher in Group P compared to Group D (16.06 ± 5.78 vs. 9.61 ± 11.53 min).

Conclusion:

The use of dexmedetomidine infusion as an adjunct to transtracheal block is superior to propofol infusion in view of significantly shorter extubation time though both the agents provided comparable intraoperative hemodynamics and patient immobility.