Use of Video Laryngoscope in Sedated Spontaneously Breathing Patients with Predicted Difficult Tracheal Intubation and Impossibility of Using Fibreoptic Bronchoscopy

Intubation with a flexible fibrobronchoscope in an awake patient is frequently considered the technique of choice in patients with predicted difficult intubation. There are, however, situations in which the use of the fibrobronchoscope is not applicable, particularly due to problems attributable to the patient or to limited use of the instrument. In such situations, the video laryngoscope can be a useful alternative, as long as it is associated with adequate sedation of the patient. In fact, it ensures excellent viewing of the glottis, allowing for successful orotracheal intubation to be performed even in case of difficult airways, while keeping the patient spontaneously breathing throughout the procedure. From the data present in the literature, this technique seems to ensure a success rate and a safety profile similar to those obtained with the fibrobronchoscope, moreover, with greater ease of use by the anaesthesiologist. The main purpose of this work is to provide a valid and safe alternative to intubation with a fibrobronchoscope while awake in those patients with anticipated difficult airway management and in whom, for different reasons, fibrobronchoscope cannot be used.

Management of Brain Tumors in Eloquent Areas with Awake Patient

This chapter aims to provide an overview of the transdisciplinary work of the Neurosurgeon, Neuroanesthesiologist and Neuropsychologist before, during and after the resection of a neoplasm in eloquent areas with the patient conscious under the 3A anesthesia modality (asleep, awake, asleep). The diagnostic approach and the logistics to carry out this procedure and achieve better results will be shown. At present there is growing evidence regarding the benefits of surgery in awake patients, with application in the treatment of epilepsy, abnormal movements and oncological surgery. The benefits of awake craniotomy are increased lesion removal, with improved survival benefit, whilst minimizing damage to eloquent cortex and resulting postoperative neurological dysfunction. Other advantages include a shorter hospitalization time, hence reduced cost of care, and a decreased incidence of postoperative complications. This approach has allowed to achieve a higher degree of resection with less morbidity and a higher quality of life.

Down a wrong path – A nasogastric tube in lung

Nasogastric tube insertion is a common bedside procedure. In an awake patient, unexpected passage into airway is easily noticeable due to the gag reflex; however, in the case of ventilated patients false cannulation is liable to be missed, unless insertion is carried out under direct visualization. We present a case of passage of nasogastric tube into peripheral bronchiole of the right lung, which was initially missed on chest radiography. This case report highlights the fallacy of relying on a chest radiograph.

Surgical anesthesia for proximal arm surgery in the awake patient

This education article discusses a combination of brachial plexus and peripheral nerve blocks aimed at providing complete surgical anesthesia to the proximal arm, while consistently avoiding diaphragmatic paresis. This type of approach may be warranted in patients with respiratory compromise of any etiology. In these settings awake surgery is recommended to preserve respiratory function and at the same time minimize the risk of infection of the healthcare team by avoiding the aerosol-generating medical procedures associated with general anesthesia.

Neuromonitoring

Neuromonitoring is used during surgery to assess the functional integrity of the brain, brain stem, spinal cord, or peripheral nerves. The aim of monitoring is to prevent permanent damage by early intervention when changes are detected in the monitor. Neuromonitoring is also used to map areas of the nervous system in order to guide management in some cases. The best neuromonitor remains the awake patient. In the conscious state, the function of individual parts of the nervous system and the complex interactions of its different parts can be assessed more accurately. However, most surgical procedures involving the nervous system require general anaesthesia. Procedures that require neuromonitoring can have changes in their monitored parameters corrected by modifying the surgical approach or by having the anaesthesiologist manipulate the parameters under their control. An ideal neuromonitor would be one that is specific for the parameter of interest, and gives reliable, reproducible, or continuous results.