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Chen JX, Shi XL, Liang CS, Ma XG, Xu L. Anesthesia management in a pediatric patient with complicatedly difficult airway: A case report. World J Clin Cases 2023; 11:2482-2488. [PMID: 37123316 PMCID: PMC10130984 DOI: 10.12998/wjcc.v11.i11.2482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/31/2023] [Accepted: 03/21/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce. In addition to relatively more difficulties in the technique of endotracheal intubation, the time for manipulation is restricted compared to adults. Securing the airways safely and avoiding the occurrence of hypoxemia in these patients are of significance.
CASE SUMMARY A 9-year-old boy with spastic cerebral palsy, severe malnutrition, thoracic scoliosis, thoracic and airway malformation, laryngomalacia, pneumonia, and epilepsy faced the risk of anesthesia during palliative surgery. After a thorough preoperative evaluation, a detailed scheme for anesthesia and a series of intubation tools were prepared by a team of anesthesiologists. Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways. Given the age and medical condition of the patient, we kept him sedated with spontaneous breathing during endotracheal intubation. The endotracheal intubation was completed on the second attempt after the failure of the first effort. Fortunately, the surgery was successful without postoperative complications.
CONCLUSION Dealing with difficult airways in the pediatric population, proper sedation allows time to intubate without interrupting spontaneous breathing. The appropriate endotracheal intubation method based on the patient’s unique characteristics is the key factor in successful management of these rare cases.
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Affiliation(s)
- Jia-Xiang Chen
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen 518038, Guangdong Province, China
- Department of Anesthesiology, Shenzhen Pediatrics Institute of Shantou University Medical College, Shenzhen 518038, Guangdong Province, China
| | - Xiao-Li Shi
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen 518038, Guangdong Province, China
| | - Chang-Sheng Liang
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen 518038, Guangdong Province, China
| | - Xing-Gang Ma
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen 518038, Guangdong Province, China
| | - Liang Xu
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen 518038, Guangdong Province, China
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Yang SZ, Huang SS, Yi WB, Lv WW, Li L, Qi F. Awake fiberoptic intubation and use of bronchial blockers in ankylosing spondylitis patients. World J Clin Cases 2021; 9:6705-6716. [PMID: 34447817 PMCID: PMC8362533 DOI: 10.12998/wjcc.v9.i23.6705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/21/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with ankylosing spondylitis (AS) combined with severe cervical fusion deformity have difficult airways. Awake fiberoptic intubation is the standard treatment for such patients. Alleviating anxiety and discomfort during intubation while maintaining airway patency and adequate ventilation is a major challenge for anesthesiologists. Bronchial blockers (BBs) have significant advantages over double-lumen tubes in these patients requiring one-lung ventilation.
AIM To evaluate effective drugs and their optimal dosage for awake fiberoptic nasotracheal intubation in patients with AS and to assess the pulmonary isolation effect of one-lung ventilation with a BB.
METHODS We studied 12 AS patients (11 men and one woman) with lung or esophageal cancer who underwent thoracotomy with a BB. Preoperative airway evaluation found that all patients had a difficult airway. All patients received an intramuscular injection of penehyclidine hydrochloride (0.01 mg/kg) before anesthesia. In the operating room, dexmedetomidine(0.5 μg/kg) was infused intravenously for 10 min, with 2% lidocaine for airway surface anesthesia, and a 3% ephedrine cotton swab was used to contract the nasal mucosa vessels. Before tracheal intubation, fentanyl (1 μg/kg) and midazolam (0.02 mg/kg) were administered intravenously. Awake fiberoptic nasotracheal intubation was performed in the semi-reclining position. Intravenous anesthesia was administered immediately after successful intubation, and a BB was inserted laterally. The pre-intubation preparation time, intubation time, facial grimace score, airway responsiveness score during the fiberoptic introduction, time of end tracheal catheter entry into the nostril, and lung collapse and surgical field score were measured. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded while entering the operation room (T1), before intubation (T2), immediately after intubation (T3), 2 min after intubation (T4), and 10 min after intubation (T5). After surgery, all patients were followed for adverse reactions such as epistaxis, sore throat, hoarseness, and dysphagia.
RESULTS All patients had a history of AS (20.4 ± 9.6 years). They had a Willson's score of 5 or above, grade III or IV Mallampati tests, an inter-incisor distance of 2.9 ± 0.3 cm, and a thyromental (T-M) distance of 4.8 ± 0.7 cm. The average pre-intubation preparation time was 20.4 ± 3.4 min, intubation time was 2.6 ± 0.4 min, facial grimace score was 1.7 ± 0.7, airway responsiveness score was 1.1 ± 0.7, and pulmonary collapse and surgical exposure score was 1.2 ± 0.4. The SBP, DBP, and HR at T5 were significantly lower than those at T1-T4 (P < 0.05). While the values at T1 were not significantly different from those at T2-T4 (P > 0.05), they were significantly different from those at T5 (P < 0.05). Seven patients had minor epistaxis during endotracheal intubation, two were followed 24 h after surgery with a mild sore throat, and two had hoarseness without dysphagia.
CONCLUSION Patients with AS combined with severe cervical and thoracic kyphosis should be intubated using fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Proper doses of penehyclidine hydrochloride, dexmedetomidine, fentanyl, and midazolam, combined with 2% lidocaine, administered prior to intubation, can provide satisfactory conditions for tracheal intubation while maintaining the comfort and safety of patients. BBs are safe and effective for one-lung ventilation in such patients during thoracotomy.
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Affiliation(s)
- Shao-Zhong Yang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Shan-Shan Huang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Wen-Bo Yi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Wei-Wei Lv
- Department of Radiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Liang Li
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Feng Qi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Goswami D, Singh A, Yadav P, Roychoudhury A. Challenges during bilateral total temporomandibular joint replacement for ankylosis in ankylosing spondylitis patient-a case report. J Oral Biol Craniofac Res 2021; 11:544-546. [PMID: 34386341 DOI: 10.1016/j.jobcr.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/28/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022] Open
Abstract
Alloplastic replacement of temporomandibular joint is the preferred treatment for temporomandibular joint ankylosis (TMJA) in ankylosing spondylitis (AS) patients. These patients exhibit neck rigidity due to fixed flexion deformity or fusion of vertebrae that make the intubation and surgical positioning of patients difficult and challenging. Chin on the chest makes tracheostomy almost impossible. Fiberoptic-assisted intubation is recommended. It is mandatory that no neck flexion or rotation is performed during intubation or surgical positioning. The use of an operating table that permits lateral tilt is recommended for surgical positioning. 15-20-degrees tilt of table or a lateral positioning of the patient, can provide sufficient neck support and reduce the chances of lateral neck rotation or neck flexion. Improper positioning may result in readjusting the patient's neck repeatedly during operative procedure. This may cause serious neurological injury. Minimal documentation exists for proper and secure positioning of the patient for bilateral alloplastic joint replacement in AS patients. The authors present a case of bilateral TMJA in AS patient who was managed successfully by awake fiberoptic intubation and lateral positioning for alloplastic total joint replacement (TJR).
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Affiliation(s)
- Devalina Goswami
- Department of Anaesthesia Pain Medicine and Critical Care Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Apoorva Singh
- Department of Oral & Maxillofacial Surgery, CDER, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Yadav
- Department of Oral & Maxillofacial Surgery, CDER, All India Institute of Medical Sciences, New Delhi, India
| | - Ajoy Roychoudhury
- Department of Oral & Maxillofacial Surgery, CDER, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Objective To assess the feasibility of an awake fiberoptic intubation (AFOI)
protocol. Methods We enrolled 40 patients with simulated difficult intubation. The protocol
consisted of conscious sedation (midazolam, 0.03 mg/kg and sufentanil, 0.1
µg/kg), regional anesthesia, and intubation. The time, first-attempt
intubation success rate, hemodynamic parameters, blood oxygen saturation
(SpO2), intubation amnesia rate, patient satisfaction, and
relative complications were recorded. Results AFOI was completed in all patients. The average total AFOI time was
14.17 ± 1.47 minutes, and the time to placing the landmark-guided bilateral
superior laryngeal nerve block was 1.24 ± 0.42 minutes. The first-attempt
intubation success rate was 97.5%, and patient satisfaction was 90%. Blood
pressure changed (<20%) briefly after administering conscious sedation.
Heart rates did not change significantly, and SpO2 remained
stable and ≥95%. Three patients had a sore throat, which resolved on
postoperative day 1 without other complications. On postoperative day 1,
82.5% (33/40) of the patients had no recall of AFOI, and 17.5% (7/40) had
only an indistinct memory. Conclusions The protocol was feasible with a high first-attempt intubation success rate
and low complications rate. Hemodynamic parameters and respiration remained
stable, with high patient satisfaction and effective amnesia.
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Affiliation(s)
- Yuanyuan Ma
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xue Cao
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Zhang
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengjin Ge
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, China
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Alessandri F, Bellucci R, Tellan G, Pinchera P, Buonopane C, Ralli M, Greco A, de Vincentiis M, Pugliese F, Bilotta F. Awake fiberoptic intubation in patients with stenosis of the upper airways: Utility of the laryngeal nerve block. Clin Ter 2020; 171:e335-e339. [PMID: 32614368 DOI: 10.7417/ct.2020.2236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Awake fiberoptic intubation (AFOI) is mandatory to manage difficult airways. Superior laryngeal nerve block (SLNB) could reduce risks and improve patient comfort. The aim of this study is to assess the procedural comfort of SLNB during AFOI in a population of patients undergoing upper airway oncological surgery. Forty patients were randomized into two groups and were treated with continuous infusion of remifentanil, topic anesthesia and intercricoid block. In the study group (=20), SLNB was performed with lidocaine (L-SLNB); in the control group (n=20) SLNB was performed using saline (S-SLNB). AFOI was more comfortable in the L-SLNB group compared to S-SLNB patients [FOICS ≤ 1 in 18 patients (90%) L-SLNB; 2 (10%) S-SLNB (P <0.001)]. Intubation was faster in L-SLNB (47.45 ±15.38 sec) than S-SLNB (80.15 ±37.91 sec) (p <0.001). The SLNB procedure during AFOI is a safe and comfortable procedure in a population of patients undergoing upper airways surgery. Time to intubation was shorter in L-SLNB than in S-SLNB.
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Affiliation(s)
- F Alessandri
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - R Bellucci
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - G Tellan
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - P Pinchera
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - C Buonopane
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - M Ralli
- Department of Sense Organs, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - A Greco
- Department of Sense Organs, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - M de Vincentiis
- Department of oral and maxillofacial sciences, University of Rome "Sapienza", Rome, Italy
| | - F Pugliese
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
| | - F Bilotta
- Department of Anesthesia and Critical Care Medicine, University of Rome "Sapienza", Policlinico Umberto I, Rome
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Chao TN, Atkins JH, Qasim Z, Kearney JJ, Mirza N, Rassekh CH. Airway management of angioedema patients during the COVID-19 pandemic. World J Otorhinolaryngol Head Neck Surg 2020; 6:S36-S39. [PMID: 32837761 PMCID: PMC7274586 DOI: 10.1016/j.wjorl.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/14/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
Importance The COVID-19 pandemic is characterized by high transmissibility from patients with prolonged minimally- or asymptomatic periods, with a particularly increased risk of spread during aerosol-generating procedures, including endotracheal intubation. Observations All patients presenting with upper airway obstruction due to angioedema during this time should be carefully managed in a way that is safest for both patient and provider. Conclusions For patients requiring emergent airway management during the COVID-19 pandemic, minimization of aerosols while taking the necessary precautions to protect healthcare workers should are critical principles for their management.
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Affiliation(s)
- Tiffany N Chao
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, United States
| | - Joshua H Atkins
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, United States
| | - Zaffer Qasim
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, United States
| | - James J Kearney
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, United States
| | - Natasha Mirza
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, United States
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, United States
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Bano N, Singh P, Singh D, Prabhakar T. A Comparative Study of Midazolam Alone or in Combination with Dexmedetomidine or Clonidine for Awake Fiberoptic Intubation. Anesth Essays Res 2019; 13:539-546. [PMID: 31602075 PMCID: PMC6775834 DOI: 10.4103/aer.aer_64_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Awake fiberoptic intubation (AFOI) is the gold standard technique for managing patients with anticipated difficult airway. Conscious sedation is desirable, not only to make the procedure more tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Ideal sedation regime for AFOI should provide comfort, cooperation, hemodynamic stability, and amnesia along with maintenance of spontaneous respiration. Several sedative agents have been assessed over the past two decades for this purpose but α2 agonists appear to be the favorable choice owing to its sedative, analgesic, amnestic, and sympatholytic properties along with good hemodynamic profile. Aims: The present study has been aimed to recognize the characteristics of dexmedetomidine, clonidine, and midazolam and to compare their efficacy in providing optimal intubating conditions as well as hemodynamic stability during AFOI. Settings and Design: A prospective double-blind randomized study done in tertiary care hospital. Materials and Methods: Sixty patients of American Society of Anesthesiologists physical status Classes I and II aged 18–60 years with anticipated difficult airway were randomly allocated into three groups. All the patients received injection midazolam bolus followed by sedation infusion of midazolam, dexmedetomidine, and clonidine according to the allocated group. Primary outcome includes the time to achieve Ramsay Sedation Score (RSS) ≥2, time taken in intubation, intubation score, comfort score for fiberoptic insertion and intubation, and patient tolerance after intubation. The secondary outcome was hemodynamic, and respiratory variables include changes in heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and respiratory rate during the procedure. Statistical Analysis: All data were recorded, summarized, tabulated, and statistically analyzed using SPSS 16.0 version (Chicago, Inc., USA). The data were presented in mean ± standard deviation. P < 0.05 was considered as statistically significant. Results: All the three groups were comparable in terms of demographic profile. Time to achieve RSS ≥2 and mean intubation time was significantly less in Groups D and C as compared to Group M (P < 0.001). Among groups, Group D took least time to achieve RSS ≥2 (5.53 ± 0.74) and mean intubation time (4.53 ± 0.91). Similarly, overall intubation score, comfort, and patient tolerance score were significantly more in Group M as compared to Groups D and C (P < 0.001). Among the groups, Group D achieved least intubation score (3.80 ± 0.67) and comfort score (2.53 ± 0.74). Although Groups D and C have a lower mean HR and MAP during the procedure and intubation compared to Group M, the incidence of SpO2 is most frequent with clonidine. Conclusions: Patients who received α2 agonist were calmer and cooperative with less pain and discomfort than the patients who received midazolam. Dexmedetomidine allows better endurance, stable hemodynamics, and patent airway as compared to clonidine.
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Affiliation(s)
- Noor Bano
- Department of Anesthesiology and Critical Care, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
| | - Pooja Singh
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Dheer Singh
- Department of Anesthesiology and Critical Care, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
| | - Tallamraju Prabhakar
- Department of Anesthesiology and Critical Care, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
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Jarzebowski M, Rajagopal A, Austell B, Moric M, Buvanendran A. Change in management of predicted difficult airways following introduction of video laryngoscopes. World J Anesthesiol 2018; 7:1-9. [DOI: 10.5313/wja.v7.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/24/2017] [Accepted: 01/16/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine if video laryngoscopy (VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation (FOI).
METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009 (“pre-VL” group) and over the same 2-mo period after the introduction of VLs in 2012 (“post-VL” group). Patient records with predicted difficult airways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.
RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually (P = 0.1768), it showed a trend toward significance when covariates were accounted for (P = 0.0910). Several factors predicting a higher likelihood of awake FOI were found to be statistically significant: Morbid obesity (larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender (P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score (P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.
CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.
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Affiliation(s)
- Mary Jarzebowski
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612, United States
| | - Arvind Rajagopal
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612, United States
| | - Bryce Austell
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612, United States
| | - Mario Moric
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612, United States
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612, United States
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Knudsen K, Nilsson U, Högman M, Pöder U. Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study. BMC Anesthesiol 2016; 16:71. [PMID: 27576876 PMCID: PMC5006435 DOI: 10.1186/s12871-016-0240-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 08/23/2016] [Indexed: 11/21/2022] Open
Abstract
Background Awake fiberoptic intubation is an alternative procedure for securing the airway and is a recommended option when a difficult airway is expected. The aim of the present study was to describe patient experiences with this procedure. Methods A qualitative, descriptive design was used and patients were recruited from three county hospitals and one university hospital in Sweden. Data was collected by semi-structured interviews with 13 patients who underwent awake fiberoptic intubation. A qualitative content analysis extracted theme, categories, and subcategories. Results From the patient statements, one main theme emerged, feelings of being in a vulnerable situation but cared for in safe hands, which were described in five categories with 15 subcategories. The categories were: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff’s competence, professional caring and support, and no hesitation about new awake intubation. The patients felt they lacked information about what to expect and relied on the professionals’ expertise. Some patients felt overwhelmed by the information they were given and wanted less specific information about the equipment used but more information about how they would be cared for in the operating room. Undergoing awake intubation was an acceptable experience for most patients, whereas others experienced it as being painful and terrifying because they felt they could not breathe or communicate during the procedure itself. Conclusions Tailored information about what to expect, ensuring eye contact and breathing instruction during the procedure seems to reduce patient distress when undergoing awake fiberoptic intubation. Most of the patients would not hesitate to undergo awake intubation again in the future if needed.
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Affiliation(s)
- Kati Knudsen
- Department of Public Health and Caring Sciences, Uppsala University, SE 751 22, Uppsala, Sweden. .,Department of Health and Caring Sciences, University of Gävle, Kungsbäcksvägen 47, SE 801 76, Gävle, Sweden. .,Centre for Research & Development, Uppsala University/Region Gävleborg, SE 801 88, Gävle, Sweden.
| | - Ulrica Nilsson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, SE 701 82, Örebro, Sweden
| | - Marieann Högman
- Centre for Research & Development, Uppsala University/Region Gävleborg, SE 801 88, Gävle, Sweden.,Department of Medical Sciences, Uppsala University, SE 751 22, Uppsala, Sweden
| | - Ulrika Pöder
- Department of Public Health and Caring Sciences, Uppsala University, SE 751 22, Uppsala, Sweden
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Chopra P, Dixit MB, Dang A, Gupta V. Dexmedetomidine provides optimum conditions during awake fiberoptic intubation in simulated cervical spine injury patients. J Anaesthesiol Clin Pharmacol 2016; 32:54-8. [PMID: 27006542 PMCID: PMC4784215 DOI: 10.4103/0970-9185.175666] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and Aims: We undertook this study to assess if a small-dose of dexmedetomidine (DEX) for conscious sedation during awake fiberoptic intubation (AFOI) in simulated cervical spine injury (CSI) patients provides optimum conditions and fulfills the need of postintubation neurological examination required in such patients. The aim was to assess the efficacy of DEX on arousability and patient's comfort during AFOI in simulated CSI patients. Material and Methods: In this prospective, randomized double-blind study, 100 American Society of Anesthesiologists Grade I-II patients aged between 18 and 65 years scheduled for elective surgery under general anesthesia underwent AFOI under conscious sedation with DEX. After locally anesthetizing the airway and applying a cervical collar, patients either received DEX 1 μg/kg over 10 min followed by 0.7 μg/kg/h maintenance infusion or normal saline in the same dose and rate during AFOI. Targeted sedation (Ramsay sedation score [RSS] ≥2) during AFOI was maintained with midazolam [MDZ] in both groups. Statistical Analysis was performed using unpaired Student's t-test, Chi-square test, Mann-Whitney test and Wilcoxon-w test. Results: The total number of patients requiring MDZ and the mean dose of MDZ required to achieve targeted sedation (RSS ≥2) was significantly less in DEX group compared to the placebo group (P < 0.001). Similarly, patient satisfaction score, heart rate, systolic, diastolic and mean arterial pressure and respiratory parameters were significantly better in DEX group (P < 0.001). Postintubation arousability in the two groups was comparable (P = 0.29). Conclusions: Dexmedetomidine provides optimum sedation without compromising airway or hemodynamic instability with better patient tolerance and satisfaction for AFOI. It also preserves patient arousability for the postintubation neurological assessment.
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Affiliation(s)
- Pooja Chopra
- Department of Anesthesia and Intensive Care, Hindu Rao Hospital, New Delhi, India
| | - Madhu Bala Dixit
- Department of Anesthesia and Intensive Care, Hindu Rao Hospital, New Delhi, India
| | - Aashish Dang
- Department of Anesthesia and Intensive Care, Hindu Rao Hospital, New Delhi, India
| | - Vibhuti Gupta
- Department of Anesthesia and Intensive Care, Hindu Rao Hospital, New Delhi, India
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11
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Leung Y, Vacanti FX. Awake without complaints: maximizing comfort during awake fiberoptic intubation. J Clin Anesth 2015; 27:517-9. [PMID: 26093943 DOI: 10.1016/j.jclinane.2015.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 04/27/2015] [Accepted: 05/13/2015] [Indexed: 11/21/2022]
Abstract
In obese patients with unfavorable airways, awake fiberoptic intubations are sometimes performed to maintain spontaneous respiration and airway reflexes, until a secure airway is attained. Obese patients may be sensitive to the effects of sedation. Rapid oxygen desaturation may occur as a result of brief moments of apnea from even minimal amounts of sedating medications, due to poor baseline functional reserve as well as common comorbid conditions such as obstructive sleep apnea and obesity hypoventilation syndrome. To maximize the chance of success when performing an awake fiberoptic intubation in a minimally sedated patient, the upper airway should be sufficiently anesthetized. Adequate topical anesthesia minimizes airway stimulation, optimizes patient comfort and facilitates patient compliance. We report two cases of awake fiberoptic intubation in two morbidly obese patients, where a simple apparatus, made of an atomizer embedded in an oral airway, was used to effectively topicalize the airway and achieve excellent intubating condition with minimal sedation.
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Park CD, Lee HK, Yim JY, Kang IH. Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-. Korean J Anesthesiol 2013; 64:61-4. [PMID: 23372888 PMCID: PMC3558652 DOI: 10.4097/kjae.2013.64.1.61] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/09/2012] [Accepted: 04/20/2012] [Indexed: 11/25/2022] Open
Abstract
There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope® Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.
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Affiliation(s)
- Chong-Doo Park
- Department of Anesthesiology and Pain Medicine, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
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Dhasmana SC. Nasotracheal fiberoptic intubation: patient comfort, intubating conditions and hemodynamic stability during conscious sedation with different doses of dexmedetomidine. J Maxillofac Oral Surg 2013; 13:53-8. [PMID: 24644397 PMCID: PMC3955476 DOI: 10.1007/s12663-012-0469-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 12/20/2012] [Indexed: 11/14/2022] Open
Abstract
The study aims to evaluate the efficacy of two doses of dexmedetomidine for sedation during awake fiberoptic intubation (AFOI). The study was designed in a prospective, randomized, double-blinded manner and carried out in an academic medical university. Forty young co-operative patients aged 15–45 years of either sex belonging to ASA class I-II, planned for elective maxillo-facial surgery formed the study group. All patients received midazolam 0.05 mg/kg, glycopyrrolate 0.2 mg, ondansetron 4 mg, and ranitidine 50 mg IV 15 min before as premedication, oxygen by nasal cannula, and topical local anesthetics to the airway. Patients were randomly assigned to one of the groups; dexmedetomedine 1 μg/kg IV (Group L), or dexmedetomidine 1.5 μg/kg IV (Group H). Observer’s Assessment of Alertness/Sedation (OAA/S) was assessed. Primary outcome measurements were: HR, MAP, SpO2 and EtCO2 and secondary outcome measurements were: intubation scores by vocal cord movement, coughing and limb movement, fiberoptic intubation comfort score, nasotracheal intubation score and airway obstruction score. On the first post-operative day, recall, level of discomfort during fiberoptic intubation, adverse events and satisfaction score were also assessed. There were no significant hemodynamic differences between the two groups. OAA/S was significantly better with dexmedetomidine 1.5 μg/kg (p < 0.05) and patients were significantly calmer, more cooperative and satisfied during awake fiberoptic intubation with dexmedetomidine 1.5 μg/kg with fewer transient adverse effects. Dexmedetomidine 1.5 μg/kg proved to be more effective for sedation for awake fiberoptic intubation.
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Tan PCS, Esa N. Anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing: the challenges imposed -A case report-. Korean J Anesthesiol 2012; 62:474-8. [PMID: 22679546 PMCID: PMC3366316 DOI: 10.4097/kjae.2012.62.5.474] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 05/08/2011] [Accepted: 05/09/2011] [Indexed: 11/10/2022] Open
Abstract
Anesthetic management of patients with mediastinal masses remains challenging as acute cardiorespiratory decompensation may follow induction of anesthesia. We describe a 57 year old lady with massive retrosternal goiter and severe intrathoracic tracheal compression who had a total thyroidectomy. Comprehensive contingency plans were an essential prerequisite for successful management of difficult airway, including multidisciplinary involvement of otorhinolaryngologic and cardiothoracic surgeons preparing for rigid bronchoscopy and cardiopulmonary bypass. Awake oral fiberoptic intubation was performed under dexmedetomidine sedation. Severe tracheal narrowing necessitated usage of a 5.0 mm uncuffed flexometallic endotracheal tube. Anesthesia was maintained with sevoflurane and dexmedetomidine infusion with target controlled infusion of remifentanil as analgesia. No muscle relaxant was given. Surgical manipulation led to intermittent total tracheal compression and inadequate ventilation. The tumor was successfully removed via the cervical approach. A close working relationship between anesthesiologists and surgeons was the key to the safe use of anesthesia and uneventful recovery of this patient.
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Affiliation(s)
- Peter Chee Seong Tan
- Department of Anesthesiology and Intensive Care, Sarawak General Hospital, Kuching, Sarawak, Malaysia
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