A comparison of two doses of ketamine with dexmedetomidine for fiberoptic nasotracheal intubation

Epiglottic injury and airway management - a challenging and unexpected diagnosis

Patients with facial trauma are complex; difficult airway management is often anticipated and challenging for the anaesthetist. Awake tracheal intubation is the gold standard in the management of predicted difficult airway because of its high success rate and safety profile. We present the case of a patient with facial trauma who underwent orotracheal intubation with combined videolaryngoscopy and flexible bronchoscopy, under conscious sedation with intermittent boluses of ketamine and dexmedetomidine. Videolaryngoscopy showed significant oedema and epiglottic laceration, not diagnosed by the computed tomography scan, with visualisation of a false passage that could have led to a failed intubation and further trauma. Airway management in patients with facial trauma is challenging and should be planned and discussed by a multidisciplinary team. A technique combining videolaryngoscopy and flexible bronchoscopy during awake intubation has previously been described and, when used in this case, was successful.

A Randomized Comparison of Intravenous Versus Nebulized Routes for Administering Dexmedetomidine and Ketamine Combination to Facilitate Awake Fibreoptic Intubation

Introduction Awake fibreoptic intubation is a technique used to secure the airway of patients who are having predicted difficult intubation. We compared two routes, intravenous and nebulized, for administering a combination of ketamine and dexmedetomidine to patients requiring sedation for fibreoptic intubation. Methods and materials After approval of the institutional ethics committee, 64 patients between 18 and 60 years belonging to the American Society of Anesthesiologists physical status I or II and having predicted difficult airway were randomized to receive study medications through either intravenous (group I, n = 32) or nebulized (group N, n = 32) routes. Group I patients were given a combination of ketamine and dexmedetomidine through intravenous route. Group N patients were nebulized with a combination of ketamine and dexmedetomidine. The time required for awake fiberoptic intubation was the primary outcome variable. In addition, sedation score, cough severity, patient tolerance, intubating condition, hemodynamic changes, recall of events and discomfort during intubation, and any adverse events in the perioperative period were also compared. Results Compared to group N, the time needed to intubate the patients was significantly less in group I (75.69 ± 10.83 versus 49.19 ± 3.60 seconds, p < 0.001). Observer assessment sedation/alertness score (p < 0.001), cough severity (p < 0.001), patient tolerance (p < 0.001), and intubating condition (p = 0.001) were statistically significant, all conditions being better in group I. Patient discomfort and recall of the procedure were statistically similar between the groups. Conclusions The efficacy of a combination of dexmedetomidine and ketamine through the intravenous route is better than the nebulized route for patients undergoing awake fibreoptic intubation.