Awake Endotracheal Intubation Research Articles

Anesthetic Management with Intubation in Awake Patient with Ludwig's Angina Using Dexmedetomidine and Ketamine: A Case Report

Introduction: Ludwig's Angina (LA) is a bacterial infection of the submandibular space that can cause airway obstruction. Prompt surgical treatment and antimicrobial therapy are crucial. Airway evaluation is important to identify risk factors for difficult intubation and anatomical distortion that may require awake endotracheal intubation. Case presentation: A 22-year-old female presented to the emergency department with left submandibular pain, edema, increased skin temperature, and erythema with a history of grade III caries of 6 months evolution without treatment. Physical examination revealed extension to the left lateral neck region and mild respiratory distress. Classified as ASA grade III, the patient underwent awake intubation using dexmedetomidine (DXM) and ketamine (KET), followed by balanced general anesthesia for the surgical procedure. Clinical discussion: The patient's condition predicted high difficult airway, therefore awake intubation was performed to maintain spontaneous ventilation and reduce cardiac arrest risk. In this case, DXM was used to avoid anxiety and respiratory depression, while KET was employed for its analgesic, bronchodilator, and tachycardic effects. Conclusion: Ketamine and dexmedetomidine allow adequate spontaneous ventilatory mechanics, without respiratory depressant effect. Further research is needed to find more anesthetic drugs that can be used for intubation without suppressing autonomic ventilation, and to develop guidelines to prevent respiratory depressant effects in patients with LA.

Comparison of modified anterior and traditional posterior accesses for ultrasound-guided superior laryngeal nerve block in awake endotracheal intubation: study protocol for a randomised non-inferiority clinical trial

IntroductionAwake tracheal intubation (ATI) involves placing a tracheal tube in an awake, spontaneously breathing patient. Superior laryngeal nerve block (SLNB) can effectively abolish the glottic closure reflex, and blunt the...

Case report: Nasal polyp exfoliated into the tracheal tube in a patient with a difficult airway during nasotracheal intubation

BackgroundDifficult airway has always been one of the greatest challenges for anesthesiologists. Patients with difficult airways and severe obstructive sleep apnea-hypopnea syndrome (OSAHS) often find themselves in life-threatening danger before their artificial airway is established and after their artificial airway is removed.Case presentationThe study reported a case of nasal polyps shedding into the tracheal tube when nasotracheal intubation in a patient diagnosed with a difficult airway and OSAHS; the patient was being prepared for a transoral tonsillectomy under general anesthesia. The uniqueness of this case was that nasal polyps were scraped off using the tracheal tube during nasotracheal intubation, and detected in real-time; this ultimately prevented an airway foreign body obstruction. Reviewing the literature on intubation methods for difficult airways, awake endotracheal intubation guided by fiberoptic bronchoscopy remains to be the gold standard for airway management. Additionally, nasotracheal intubation can provide more operating space for oral surgery. In this case, the unexpected nasal polyp fell off into the tracheal tube during intubation, as is visualized on the following pictures. This fortunate event prevented the nasal polyp from falling into the trachea and bronchus.ConclusionIt is necessary to rule out any nasal abnormalities in patients requiring nasotracheal intubation; otherwise, blind nasal intubation may be dangerous.

Ultrasound-Guided Superior Laryngeal Nerve Block Facilitates Anesthesia Management in Bariatric Surgery

BackgroundPatients with obesity usually have a narrow pharyngeal cavity. They are prone to exposure difficulties and intubation failure during endotracheal intubation, and even face mask oxygen supply difficulties and hypoxemia in severe cases. We described the successful completion of conscious endotracheal intubation with superior laryngeal nerve internal branch block (SLNi) in a patient with pathologic obesity. Case ReportA 29-year-old, nondiabetic man with severe obesity (weight 211 kg, height 186 cm, and body mass index [BMI] 60.99 kg/m2) was scheduled for a laparoscopic sleeve gastrectomy. The superior laryngeal nerve internal branch was blocked under ultrasound guidance to eliminate the cough induced by fiberscope during awake endotracheal intubation. Why Should an Emergency Physician Be Aware of This? The cough caused by fiberscope was completely suppressed and the awake endotracheal intubation was completed successfully.

Endotracheal intubation in an adult patient of Hallermann-Streiff syndrome-Case report and review of literature.

Dear Editor, Hallermann–Streiff syndrome (HSS), a rare genetic polymalformative dysostic syndrome with only 150 reported cases, was first described in 1893 and is characterized by bird-like facies, hypoplasia of nasal bridge, mandibular hypoplasia, hypertrichosis, ocular abnormalities, severe tracheomalacia, and dwarfism.[1] Because of facial features, airway management is considered difficult in them; however, reports are scarce with only two adult patients previously reported.[1] Paucity of literature on airway management in adult HSS patients prompted us to report the present patient as when syndromes are rare, case reports guide an anesthesiologist for management. A 20-year-old female patient of HSS, American Society of Anesthesiologists grade I, 55 kg, and 154 cm height, was posted for septo-rhinoplasty because of progressive nasal deformity since birth. She had history of snoring not associated with daytime somnolescence or night awakenings. Airway examination revealed microstomia, mouth opening of 2 cm, retrognathia, hyomental distance of 21/2 fingers, large tongue, crowding of teeth, high arched palate, small nares, and modified Mallampati Grade 3 [Figures 1 and 2]. Systemic examination and biochemical profile revealed no abnormality. As patient was anxious regarding awake fiberoptic intubation (FOI), plan was to first assess Cormack and Lehane (CL) grade on laryngoscopy in spontaneously breathing patient without muscle relaxants and in case of failure of endotracheal intubation (ETI) oral FOI under anesthesia was planned (nasal FOI was not possible due to small nares). Informed consent for emergency tracheostomy was taken. In the operation theater, routine monitors were attached. Following preoxygenation with 100% oxygen for 3 min, intravenous ketamine 50 mg with glycopyrrolate 0.2 mg was injected and sevoflurane 2–8% was gradually administered in 4–6 L/min 100% O2 preserving spontaneous respiration. Oropharyngeal airway was required for effective ventilation. Under deep anesthesia, check laryngoscopy with C Mac video laryngoscope size 3 blade revealed CL grade 1. Following this, injection atracurium 0.5 mg/kg was given and a cuffed endotracheal tube 6.5 was inserted successfully at first attempt. Intraoperative analgesia was supplemented with injection fentanyl 2 mcg/kg and paracetamol. Rest of the intraoperative period was uneventful. Surgery lasted for 3 h. At the end of surgery, neuromuscular blockade was reversed with neostigmine and glycopyrrolate and trachea extubated with no adverse sequelae. Patient was observed in recovery room for 2 h and was discharged from ward after 2 days.Figure 1: Frontal view of patient showing small and deformed naresFigure 2: Lateral view of patient showing retrognathia and decreased hyomental distanceThere are only eight reported cases of anesthesia management in HSS patients with two described in adults [Table 1][23456789] of which details of two non-English PubMed reported patients were not found.[46]Table 1: Reported cases of HSS patientsIn the reported adult patients, ETI was anticipated to be difficult; thus, awake ETI was performed in one and lighted stylet via the intubating laryngeal airway was used in the other. However in both patients, ETI was easily performed.[89] In the present patient also, airway management was anticipated to be difficult because of associated facial features like microstomia, <2 cm mouth opening, retrognathia, large tongue, crowding of teeth, and high arched palate. Contrarily ETI was easily established without any manipulations or adjuncts. This could be probably due to presence of small teeth, normal BMI, and adequate mouth opening. Through this case report, we want to highlight that even though adult HSS patients are considered to have difficult ETI, previous two reports including the present one have indicated that in an adult HSS patient, ETI might not be difficult; however, mask ventilation might be challenging. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Improving mucosal anesthesia for awake endotracheal intubation with a novel method: a prospective, assessor-blinded, randomized controlled trial

BackgroundTopical anesthesia is a crucial step in awake endotracheal intubation for providing favorable intubation conditions. The standard of care technique for awake intubation at our institution, which consists of oropharyngeal tetracaine spray, can result in inadequate mucosal anesthesia. Therefore, we sought to compare the effectiveness of dyclonine hydrochloride mucilage to the standard of care tetracaine in achieving anesthesia of the upper airways for awake endotracheal intubation.MethodsThis is a randomized, assessor-blinded, prospective study. From Jun. 1st, 2019 to Aug. 1st, 2019, patients scheduled for either endoscopic submucosal dissection or peroral endoscopic myotomy were enrolled and randomly allocated into two groups after obtaining written informed consent: patients allocated to novel awake intubation care (Group N-AIC) received a single administration of oral dyclonine hydrochloride mucilage, whereas patients allocated to standard awake intubation care (Group S-AIC) received three oropharyngeal tetracaine sprays before transcricoid tetracaine injection before awake intubation. Mean arterial pressure (MAP), which was the primary outcome of this study, as well as heart rate (HR) were recorded throughout the procedure and compared between the two groups. Feeling of numbness, nausea, and intubation conditions after topical anesthesia were also assessed.ResultsSixty patients were enrolled and completed the study. Baseline MAP and HR were similar between the two groups. However, hemodynamic responses to intubation and gastrointestinal endoscopy, especially MAP, were significantly less elevated in Group N-AIC. The degree of numbness of the oropharyngeal mucosa after topical anesthesia did not differ between the two groups, neither did the feeling of nausea during laryngoscopy. The amount of pharyngeal secretions before intubation was less in Group N-AIC. Total intubation time was significantly shorter in Group N-AIC when compared to Group S-AIC (18.4 ± 2.86 vs. 22.3 ± 6.47, P < 0.05). Extubation bucking was significantly less frequent in Group N-AIC (13.3% vs. 76.7%). Patients received in Group N-AIC had a lower rate of post-extubation sore throat compared to Group S-AIC (6.7% vs. 43.3%). No adverse side effects attributable to either tetracaine or dyclonine were observed in this study.ConclusionsIn awake endotracheal intubation, novel care using oral dyclonine hydrochloride mucilage can provide more favorable mucosal anesthesia and better intubation conditions compared to standard of care practice using oropharyngeal tetracaine spray.Trial registrationChiCTR1900023151. Date of registration: May 14th, 2019.

Comparison of Hemodynamic Response and Complications in Patients with Difficult Airway Using Two Techniques-Retrograde and Fibreoptic Intubation

Objective: The Aim of this study was to identify the hemodynamic response and success rate to awake retrograde endotracheal intubation (REI) and fiberoptic bronchoscope (FOB) assisted endotracheal intubation in difficult airway situation and to validate whether the REI can attenuate the hemodynamic response to tracheal intubation compared with the FOB assisted intubation. Design: Randomized Prospective Study. Methods: 64 adults, ASA I-II scheduled for elective surgery requiring endotracheal intubation were randomly allocated to either the awake REI group (n=32) or the FOB group (n=32). Non-invasive blood pressure (NIBP), heart rate (HR) and Spo2 were recorded. Time taken for intubation and success rate of intubation during the observation was also recorded. Results: During awake intubation, the magnitude of change of both NIBP and HR was greatest in Group REI as compare to Group FOB. Time taken for intubation and success rate were better in FOB group, while complication like airway trauma was higher in awake retrograde intubation group (REI). Conclusions: Awake Endotracheal intubation using FOB and REI in adult may cause increases in MAP and HR. However we observed maximum increase in heart rate and MAP occurred at the end of intubation in REI group than FOB, while time taken for intubation were lesser and success rate of intubation were superior in FOB as compare to REI group.

The application of the ultrasonic atomization surface anesthesia with lidocaine for an awake endotracheal intubation during autonomous position-display

Objective To explore the feasibility of the ultrasonic atomization surface anesthesia with lidocaine for awake fiberoptic endotracheal intubation in patients' autonomous position-display before general anesthesia and to evaluate its advantages. Methods 68 adult patients who needed prone position for elective surgery under general anesthesia were selected and randomly divided into two groups, the control group and the treatment group, each group in 34 cases.In control group patients were received surface anesthesia of cricothyroid membrane puncture.In treatment group, nebulized 2% lidocaine with ultrasonic nebulizer was used for topical anesthesia.Patients lied in the prone position according to their own comfort with the guide of the medical staff in the waking state after an awake fiberoptic endotracheal intubation.The statistics of mean arterial pressure (MAP) and heart rate (HR) were recorded respectively in the basal state(T0), in the time instantly after intubations(T1), in the 3 minute after intubations(T2) and in the time instantly after the body turning(T3). Choking cough response were recorded during endotracheal intubation.Patients were asked the efficacy of surface anesthesia and the tolerance for awake intubation after operation. Results Patients in both two groups completed the whole process smoothly.MAP and HR had no significant differences between the two groups in the same time point (all P>0.05). There were no statistical significance between the two groups in choking cough response, the time of surface anesthesia and intubation, neither (all P>0.05). Conclusion The surface anesthesia with lidocaine by continuous ultrasonic atomizing inhalation is a good and simple method deserving generalization with plenty merits and is practicable for patients to display position autonomously.This method have the advantages of small operation, it will and can replace cricothyroid membrane puncture. Key words: Lidocaine; Ultrasonic atomization; Cricothyroid membrane puncture; Awake endotracheal intubation; Posture

Cardiac arrest from tramadol and fentanyl combination.

Sir, Tramadol is a centrally acting atypical opioid analgesic commonly used in the treatment of moderate to severe pain. It has a low affinity to μ opioid receptors and also inhibits the reuptake of serotonin and norepinephrine. Fentanyl is a potent, synthetic opioid with a rapid onset of action and strong affinity to μ receptor. Both the drugs are considered to have a high safety profile and used widely in anaesthesia. Fentanyl and tramadol impair presynaptic reuptake of serotonin and in combination with other serotonergic medications can cause serotonin syndrome. We report a case where premedication with the two drugs in therapeutic doses led to serotonin syndrome with severe life-threatening cardiac arrhythmia. A 43-year-old male American Society of Anaesthesiologists physical status1 patient, with radicular pain was scheduled for C5–6 anterior cervical discectomy. He was on gabapentin 150 mg tid and ibuprofen 200 mg bid for pain relief since 1 month. Preanaesthetic evaluation had been insignificant, and and so was the examination prior to shifting into the theatre. After connecting standard monitors and preoxygenation, intravenous (i.v.) fentanyl 50 μg (0.83 μg/kg, in dilution of 1 ml = 50 μg) was administered. Patient was agitating, and pain was thought to be the cause of his agitation. For the fear of developing chest wall, rigidity another agent was considered instead of higher doses of fentanyl. I.v. tramadol 75 mg (1.25 mg/kg, in dilution of 1 ml = 20 mg) was administered slowly over 2–3 min. Immediately a supraventricular rhythm (SVT) with a rate of 180/min and ventricular ectopics were noted on the monitor. It soon deteriorated to ventricular tachycardia (VT) and then into ventricular fibrillation (VF). Cardiopulmonary resuscitation (CPR) was initiated, and airway was secured with endotracheal intubation. Defibrillation with biphasic mode (200 J) was administered thrice during the CPR cycle without sustained sinus rhythm. Injection amiodarone 300 mg bolus was administered after 3rd shock after which sustained sinus rhythm was achieved. After initiating maintenance amiodarone infusion (0.5 mg/kg/h for 24 h) and vasoactive support (noradrenaline and adrenaline infusion at 20 mcg/min) patient was shifted to the intensive care unit (ICU). In the ICU, ventilation was continued for a day with midazolam and morphine for sedation and analgesia. A bedside echocardiogram revealed a good cardiac contractility and output. Induced hypothermia at 34°C was maintained for the day. The next day vasoactive drugs were weaned off, and the patient was awake and successfully extubated. Amiodarone was changed to oral mode of administration and patient was discharged to the ward on 2nd day. The combination of tramadol and fentanyl for premedication is seldom used. The combination has improved tolerance for awake endotracheal intubation[1] and has reduced the incidence of supraventricular arrhythmia in patients undergoing pulmonary resection.[2] Fentanyl associated fatalities have been primarily due to respiratory depression as even low concentrations lead to it.[3] Life-threatening central nervous system (CNS) and cardiac complications are generally found after tramadol ingestion at high doses with unintentional or intentional suicidal attempts. Ahmadi et al., after analysing the cases of tramadol intoxication found mortality rate of 0.97%. Most of the cases have been reported in conjunction with other drugs such as CNS depressants.[4] However, Shadnia et al., reported two fatalities with tramadol intoxication without any co-ingestions.[5] In therapeutic doses, both tramadol and fentanyl have been implicated in serotonin toxicity though tramadol is more notorious for severe toxicity.[6] Serotonin toxicity is marked by the triad of neuromuscular excitation, autonomic stimulation and changes in mental state. Based on the clinical profile we suspected serotonin syndrome to be causative for the complication in our patient. The features of toxicity from drug combination develop rapidly after onset of effective blood levels of the second drug. The autonomic features such as tachycardia and tachypnea are not usually severe.[6] In our patient, the administration of i.v. fentanyl initiated the toxicity features (agitation) which became more pronounced with tramadol dose. However, the cardiac signs erstwhile considered not to be of serious consequence, in our patient caused near fatal arrhythmia. The rhythm quickly transformed from SVT to VT and then to VF [Figure 1]. No role of use of gabapentin preoperatively in this peroperative drug interaction between fentanyl and tramadol could be explained. Figure 1 Electrocardiogram tracing of the rhythm during cardiopulmonary resuscitation To our knowledge and belief, this is the first report of serotonin toxicity with tramadol and fentanyl combination, in therapeutic doses without any other serotonergic medication. The inability to monitor serum drug level has been a limitation, but the absence of any other drug administered prior to fentanyl and tramadol effectively establishes the aetiology. This case report highlights the dangers of combining two drugs with potential of serotonin toxicity and the severity of cardiac complication that can even be near fatal.

Airway management of a huge thyroid swelling with retrosternal extension by awake intubation using loco-sedative technique

To the Editor, The anesthesiologist approaching the patient with a difficult airway has got many techniques and instruments that can be applied for securing and maintaining oxygenation and ventilation.[1234] We report here the airway management of a patient with massive thyroid swelling accompanied by tracheal narrowing, deviation and retrosternal extension. The patient was posted for total thyroidectomy. A 43-year-old female patient presented with a history of the diffuse neck swelling since 5 years with recent onset of dyspnea. There was no suggestive history of hyper or hypothyroidism. On examination, her vital parameters were normal, and she was neither in distress nor sweating. Neck examination showed a huge swelling of around 8 cm × 4 cm on the right side and 6 cm × 4 cm on the left side. It was moving with swallowing, firm in consistency but not tender. Getting below the swelling was not possible. Cardiovascular system examination revealed no added sounds or murmurs. Chest examination showed bilateral good air entry. Laboratory investigation including thyroid function tests were within normal ranges. Radiological examination including Chest X-ray and magnetic resonance imaging (MRI) revealed diffusely enlarged thyroid gland with left lobe measuring 11.2 × 7.5 × 5.5 cms in size with retrosternal extension and right lobe measuring 8.5 × 6.2 × 4.5 cms in size with inferior margin of right lobe just above sternum associated with superior mediastinal widening, significant compression and displacement of trachea to right side. Carotid artery and jugular vein were displaced laterally on both sides of neck. There was no tracheal erosion or infiltration [Figure 1]. On IDL, larynx was not seen and with 70 degree scope, larynx was pushed to right with normal and mobile bilateral vocal cords. Fine-needle aspiration cytology showed possibility of benign follicular lesion. Airway assessment revealed adequate mouth opening with Mallampati Grade II, but limited neck movement. The plan was to perform awake endotracheal intubation through direct laryngoscopy.Figure 1: Magnetic resonance imaging plate showing huge swelling with retrosternal extensionPremedication was achieved with injection glycopyrrolate 0.2 mg intramuscular and injection midazolam 1 mg intravenous (iv) followed by nebulization with lignocaine (2%) solution and lignocaine (2%) viscus gargles. In the operation theater, the difficult airway cart was arranged and noninvasive blood pressure cuff, SpO2 and electrocardiogram were attached to the patient. Injection dexmedetomidine bolus was started at 1 mcg/kg over 10 min, followed by infusion at 0.6 mcg/kg/h along with which preoxygenation was done with 100% oxygen. When the sedation score was Ramsay score 3, direct laryngoscopy was performed and lignocaine (5%) spray was puffed and after 5 min trachea was intubated successfully with 7.5 mm size armored tube with external manipulation of larynx. Intubation was confirmed by attaching EtCO2 monitor, which was followed by IV injection of propofol and injection vecuronium. Anesthesia was maintained with incremental doses of vecuronium and sevoflurane. Total thyroidectomy was uneventful. On completion of surgery, neuromuscular blockade was reversed and trachea was extubated after performing leak test to rule out any possibility of tracheomalacia. The problems anticipated during induction were difficult mask ventilation after induction of general anesthesia and muscle relaxation secondary to partial or complete airway collapse by huge thyroid swelling, which can cause severe hypoxia and warrants urgent tracheal intubation which may be difficult and time consuming due to distorted anatomy.[234] In this situation, it was prudent to secure the airway before induction of anesthesia. Awake fiberoptic intubation is ideal gold standard technique in such situation where intubation is done under direct visualization of the glottis.[1] Fiberoptic bronchoscope was not available in our institute so awake oral intubation with direct laryngoscopy was planned. Dexmedetomidine is selective ά2 agonist with pharmacological actions like analgesia, anxiolysis, sedation, reduction in the secretion, sympatholytic action, minimal respiratory depression, decreased stress response to intubation and attenuation of airway reflexes making it promising agent in this situation.[5] Hence dexmedetomidine in bolus and infusion was used during induction to enhance patient comfort and cooperation, which is essential for the success of awake intubation using direct laryngoscopy. In conclusion, awake intubation using topical anesthesia and sedation with dexmedetomidine infusion is a viable option in case of huge thyroid swelling. Acknowledgments A deep regards and my profound gratitude to Department of Otorhinolaryngology, New Civil Hospital, Surat for providing all help with patient's details and MRI picture of the patient.

Tramadol combined with fentanyl in awake endotracheal intubation.

To explore the feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation. Using Dixon's up-and-down sequential design, the study enrolled patients from each of the 20-49, 50-60 and 70-and-above age groups scheduled for elective surgery under general anesthesia. The feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation, guided by fiberoptic bronchoscopy, were verified. After intravenous injection with fentanyl 2.2 μg/kg and tramadol 2.0 mg/kg in the 20-49 age group, fentanyl 1.6 μg/kg and tramadol 1.9 mg/kg in the 50-69 age group and fentanyl 1 μg/kg and tramadol 1.8 mg/kg in those at the age of 70 or above, the patients achieved conscious sedation without obvious respiratory depression. Meanwhile, under these dosages, the patients could easily tolerate the thyrocricocentesis airway surface anesthesia and fiberoptic bronchoscope guided tracheal intubation. Postoperative follow-up showed that most patients had memory of the intubation process but without significant discomfort. No awake endotracheal intubation-related side effect was noted. Fiberoptic bronchoscope guided nasotracheal intubation can be successfully completed with background administration of fentanyl and tramadol. However, the specific dosages need to be tailored in different age of patients.

Comparative study of awake endotracheal intubation with Glidescope video laryngoscope versus flexible fiber optic bronchoscope in patients with traumatic cervical spine injury

BackgroundThe Gldiescope video laryngoscope (GVL) as a recent intubating device has gained much popularity in difficult intubation over the last decade. It can be used as a substitute to flexible fiber optic bronchoscope (FOB) in intubating challenges. The object of this study is to compare the utility of GVL and FOB for intubating time, attempts, effects on hemodynamics, adverse effects, patient satisfaction and post intubation neurological outcome during awake intubation in traumatic cervical spine injury.MethodsFifty patients undergoing post traumatic cervical spine fixation under general anesthesia were randomly allocated to two groups in a prospective, controlled non-blinded study. All patients were premedicated with glycopyrrolate 0.2 mg iv and midazolam 1 mg iv that be repeated up to 0.05 mg/kg followed with a bolus dose of remifentanil 1.5 μg/kg then a continuous remifentanil infusion of 0.15 μg/kg/min for 3 min before procedure. Each patient underwent a wake endotracheal intubation with either GVL (G group) or FOB (F group) with manual in line stabilization (MILS). Intubating time, intubating attempts, hear rate (HR), mean arterial pressure (MAP), oxygen desaturation (SO2 < 90%), sore throat, patient satisfaction and postintubation neurological outcome were recorded.ResultsIntubating time was significantly lower in G group compared with F group (26 ± 5 versus 72 ± 11 respectively), while the percentage of the first successful intubating attempt was insignificantly higher in G group (88%) than in F group (72%). Both HR and MAP were significantly increased only in F group during intubation in comparison with the basal line values. Both devices were safe for post neurological outcome. No significant differences of adverse effects or patient satisfaction were recorded between groups.ConclusionThe GVL is a safe surrogate for FOB during awake intubation for post traumatic cervical spine fixation.

Regional Anesthesia Considerations for Awake Endotracheal Intubation and Prevention and Management of Dental Injuries

Regional Anesthesia Considerations for Awake Endotracheal Intubation and Prevention and Management of Dental Injuries

Ultrasound-Guided Bilateral Superior Laryngeal Nerve Block to Aid Awake Endotracheal Intubation in a Patient with Cervical Spine Disease for Emergency Surgery

Ultrasound has been widely used to locate nerves for various nerve blocks. The potential advantages of using ultrasound imaging for nerve blocks include reduction in the amount of local anaesthetic required, improved success rate, reduced time to perform the block and reduced complication rate. We describe the successful performance of ultrasound-guided bilateral superior laryngeal nerve block to facilitate awake fibreoptic intubation in a patient presenting for emergency surgery on the cervical spine.

Comparison of awake endotracheal intubation with GlideScope videolaryngoscope and fibreoptic bronchoscope in patients with difficult airway

Comparison of awake endotracheal intubation with GlideScope videolaryngoscope and fibreoptic bronchoscope in patients with difficult airway

The use of the McGrath videolaryngoscope for awake endotracheal intubation in a patient with severe ankylosing spondylitis

The use of the McGrath videolaryngoscope for awake endotracheal intubation in a patient with severe ankylosing spondylitis

Awake Endotracheal Intubation and Prone Patient Self-Positioning: Anesthetic and Positioning Considerations During Percutaneous Nephrolithotomy in Obese Patients

Obesity is associated with adverse outcomes with certain urologic procedures and may make patient positioning more difficult. We describe our technique of awake intubation and prone patient self-positioning before percutaneous nephrolithotomy (PCNL), and review the literature regarding prone positioning in obese patients and the impact of obesity on PCNL. Patient preparation begins with detailed preoperative counseling regarding the procedure. Premedication with a sedative and antisialagogue is followed by airway topicalization to suppress gag reflex and pain. Fiberoptic bronchoscope intubation is then carried out. The patient then positions himself/herself comfortably before induction of general anesthesia. We have successfully performed awake intubation and patient prone self-positioning followed by PCNL, most recently in a 58-year-old (body mass index 51.3 kg/m(2)) man with a history of gastric bypass, diabetes mellitus, and hypertension, without added morbidity. Adverse effect on patient cardiopulmonary dynamics can be minimized in the prone position. The technique of awake intubation with prone patient self-positioning can be helpful for positioning morbidly obese patients before PCNL and has been safe and effective in properly selected patients. Efficacy of PCNL should not be impacted by obesity or prone positioning and morbidity minimized provided that surgical and anesthesia teams understand and safeguard against potential complications.

Severe Methemoglobinemia Detected by Pulse Oximetry

An elderly surgical patient acquired a life-threatening methemoglobinemia as a result of topical benzocaine spray to the oropharynx in preparation for awake endotracheal intubation. A new multiwavelength pulse oximeter, the Masimo Rad-57, detected this methemoglobinemia an hour before it was confirmed by laboratory CO-oximetry. The Rad-57 monitored the patient's methemoglobin levels during diagnosis and treatment with methylene blue, and the values it provided (as high as 33%) were very close to those of the laboratory CO-oximeter. The new pulse oximeter gave continuous readings of methemoglobin level at the bedside, whereas the laboratory values were delayed by up to an hour. This case demonstrates the clinical application of a multiwavelength pulse oximeter in the diagnosis and treatment of a life-threatening dyshemoglobinemia.

Clinical assessment of awake endotracheal intubation using the lightwand technique alone in patients with difficult airways

Background There is few study to determine whether the use of the lightwand technique alone could achieve effective, safe and successful awake endotracheal intubation (ETI), therefore we designed a prospective clinical study to systematically evaluate the feasibility, safety and efficacy of awake ETI using the lightwand alone in patients with difficult airways. Methods Seventy adult patients with difficult airways were enrolled in this study. After the desired sedation with fentanyl and midazolam, airway topical anesthesia was performed with 9 ml of 2% lidocaine, which were in order sprayed in three aliquots at 5 minutes intervals into the supraglottic (two doses) and laryngotracheal areas (one dose) using a combined unit of the lightwand and MADgic® atomizer. After airway topical anesthesia, awake ETI was performed using a Lightwand. Subjective assessments by patients and operators using the visual analogue scores (VAS), and objective assessments by an independent investigator using patients' tolerance and reaction scores, coughing severity, intubating conditions and cardiovascular variables were taken as the observed parameters. Results Of 210 airway sprays, 197 (93.8%) were successfully completed on the first attempt. The total time for airway spray was (14.6±1.5) minutes. During airway topical anesthesia, the average patients' tolerance scores were 1.7–2.3. After airway topical anesthesia, the mean VAS for discomfort levels that the patients reported was 6.5. Also airway topical anesthesia procedure was rated as acceptable and no discomfort by 94.3% of patients. The lightwand-guided awake ETI was successfully completed on first attempt within 29 seconds in all patients. During awake ETI, patients' reaction and coughing scores were 1.9 and 1.6, respectively. All patients exhibited excellent or acceptable intubating conditions. Cardiovascular monitoring revealed that changes of systolic blood pressure and heart rate at each stage of airway manipulations were less than 20% of baseline values. The postoperative follow-up showed that 95.7% of patients had no recall or slight memories of all airway instrumentation. The incidence of postoperative mild airway complications was 38.6%. Conclusion Alone use of the lightwand technique can achieve effective, safe and successful awake ETI in patients with difficult airways.

Comparison of the lightwand technique with direct laryngoscopy for awake endotracheal intubation in emergency cases

Study Objective: To clarify the efficacy of the lightwand technique compared with that of the conventional laryngoscopic technique for awake endotracheal intubation in patients requiring emergency surgery. Design: Prospective clinical study. Setting: Anesthesia department of a teaching hospital. Patients: 60 ASA physical status IE patients undergoing emergency surgery. Interventions: Awake intubations using the lightwand technique (LW group) and a laryngoscope (LS group) were performed with conscious sedation with midazolam and fentanyl. Measurements and Main Results: Time to intubation and number of intubation attempts in the LW group were significantly shorter and smaller, respectively, than those in the LS group (p < 0.01). Fewer LW group patients complained of a sore throat than in the LS group. ΔP [changes from “before intubation” to “immediately after intubation” in mean arterial pressure (MAP)] in the LS group was significantly larger than that in the LW group ( p < 0.05), although doses of sedatives in the two groups were not different. No hypoxemia or apnea associated with sedation was found in either of the groups. Conclusions: The lightwand technique produces less magnitude of stress following tracheal intubation than does the conventional laryngoscopic technique for awake intubation. Lightwand-assisted awake intubation is thought to be a useful means for induction of anesthesia in cases of emergency surgery.