Can Ultrasound-Guided Regional Anesthesia Techniques For Tracheostomy Be An Alternative To General Anesthesia?

Introduction The cervical plexus block (CPB) has been used for a long time for both analgesia and anesthesia in carotid endarterectomy and thyroid operations. To be unfamiliar with the technique and its perceived difficulty, potential risks, and possible adverse effects such as intravascular injection has limited broader use before the practical use of ultrasound. We hypothesize that the cervical plexus block can provide adequate anesthesia in tracheostomy cases and provide excellent anesthesia comfort when combined with a translaryngeal block. Methods This double-blinded, randomized 29 patients undergoing primary tracheostomy operation to receive either CPB (Group S) or CPB with translaryngeal block (Group ST). The primary outcome was cumulated analgesic consumption during the first 24 postoperative hours. Secondary outcomes were as follows: pain related to incision, patient tolerance as assessed by tracheostomy cannula comfort score, cough and gag, pain at rest, nausea and vomiting, and time to first analgesic demand. Results The patient tolerance for tracheostomy was higher in Group ST than Group S. The median tracheostomy cannula comfort score was 4.0 in Group S. In contrast, the median score was significantly lower in group ST (P<.001). The cough and gag reflex scores were significantly lower in Group ST than Group S (1.0 vs 4.0, P<.001). Conclusion This trial supported the hypothesis that the CPB combined with the translaryngeal block yields excellent anesthesia for tracheostomies. The technique we briefly described, in a way, is the equivalent of awake fiberoptic intubation to awake tracheostomy with minimal sedation adjusted according to airway patency.

Comparison of Cricothyroid Membrane Puncture Anesthesia and Topical Anesthesia for Awake Fiberoptic Intubation: A Double-Blinded Randomized Controlled Trial

Background: Awake fiberoptic intubation (AFOI) is commonly used for patients with a difficult airway. The purpose of this study was to evaluate the efficacy of cricothyroid membrane puncture anesthesia and topical anesthesia during AFOI.Methods: A total of 70 patients (the American Society of Anesthesiologists score I-III) with anticipated difficult airways scheduled for nonemergency surgery with AFOI were randomly slated to receive cricothyroid membrane puncture anesthesia (n = 35) or topical anesthesia (n = 35). Each group received dexmedetomidine at a dose of 1.0 μg/kg and sufentanil at a dose of 0.2 μg/kg over 10 min for conscious sedation before intubation. The endoscopy intubation, post-intubation condition, and endoscopy tolerance as scored by the anesthetists were observed. The satisfaction of the operator regarding the procedure and the satisfaction of the patient 24 h after the surgery were also recorded. We recorded the success rate of the first intubation, intubation time, and hemodynamic changes during the procedure and also the adverse events.Results: Better intubation scores, operator satisfaction, and satisfaction of the patient were observed in the cricothyroid membrane puncture anesthesia group than in the topical anesthesia group (p &lt; 0.05). The intubation time in the cricothyroid membrane puncture anesthesia group was less than that in the topical anesthesia group (p &lt; 0.05). There were no significant differences in the patient tolerance scores, the success rate of the first intubation, hemodynamic changes, and adverse events between both the groups.Conclusion: Compared with topical anesthesia, cricothyroid membrane puncture anesthesia provided better intubation conditions and less intubation time with greater satisfaction of the patient and operator during endoscopic intubation.Clinical Trial Registration: URL: http://www.chictr.org.cn/showproj.aspx?proj=42636, Identifier: ChiCTR 1900025820.

Anaesthesia management of a case of huge neck mass due to cervical spine chondrosarcoma with distorted anatomy

Chondrosarcoma is the tumor which affects bone and soft tissue with only 2% spinal involvement. Anesthetic management becomes challenging in patients with cervical chondrosarcoma. Here, we are presenting a case of huge neck mass due to cervical spine chondrosarcoma in 70 year old male hypertensive patient. The patient has distorted anatomy with mucosal edema with left tracheal deviation and compression from right side. Awake Nasal Fiberoptic intubation was done with cuffed ETT no 8. The neck mass was removed and Anterior Cervical Discectomy and Fusion (ACDF) with bone grafting. The case was managed with adequate analgesia, replacement of fluids and Blood and Blood products. Considering complex cervical spine surgery and airway edema the patient was shifted to Surgical Intensive Care Unit (ICU) for elective ventilation and advanced monitoring. After serial ABG and proper weaning the patient was extubated next morning smoothly. Extensive preoperative evaluation, planning, clinical judgement and skilled experienced personale are essential for proper execution of difficult airway cases.

Anaesthesia management of a difficult airway patient with severe aortic stenosis for major oncosurgery

Over the past few decades, oncosurgical procedures are increasing in number, require considerable expertise and training for anaesthetising such patients. Aortic Stenosis itself poses great challenge, causes significant increase in morbidity and mortality in the perioperative period. Head, neck oncosurgical procedures with difficult airway requiring awake fiberoptic intubation in such patients adds to the challenge.We describe once such case of previously operated Carcinoma of oral cavity with new growth involving mandible for excision of tumour with neck dissection and mandibular reconstruction with a free Fibula flap. This patient now presented with anticipated difficult airway with restricted mouth opening and a recent diagnosis of severe Aortic stenosis with mean gradient across aortic valve of 52mmHg and valve area 0.8 cm2.Such patient requires multidisciplinary team approach by cardiologist, anaesthesiologist, surgeon and intensivist to prevent perioperative morbidity and facilitate early recovery.

Comparative Study Between Dexmedetomidine and Fentanyl as Sedatives in Awake Fiberoptic Intubation in Cervical Spine Surgeries

Background Various drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them have various side effects. Aim The aim of this study was to compare the effects of dexmedetomedine and fentanyl as regards sedative effects, hemodynamic stability, intubation time and intubation attempts success during awake fiberoptic intubation. Material and Methods A randomized double-blind prospective study was conducted on a total of 40 patients scheduled for elective cervical spine surgeries who were randomly allocated into two equal groups (n 20): (group A) patients received a bolus dose of dexmedetomidine of 1 mcg/kg over 10 min followed by a continuous infusion of dexmedetomidine at 0.5 mcg/kg/h. and fentanyl group (group B) received dose of 1 μg/kg over 10 min followed by 0.5 μg/kg/hr. Sedation score (Ramsy sedation score), hemodynamic variables, oxygen saturation, intubation time and intubation attempts were noted and compared between the two groups. Results Ramsy Sedation Score was significantly favorable (P &lt; 0.001) in group A in comparison to group B, moreover better hemodynamic stability during intubation (P &lt; 0.05) and less intubation attempts were observed in group A in comparison to group B. Conclusion The results of our study showed that dexmedetomidine provides optimum sedation without compromising airway or hemodynamic stability and with favorable intubation time and less intubation attempts during AFOI in comparison to fentanyl.

A PROSPECTIVE RANDOMIZED STUDY TO EVALUATE THE ANALGESIC AND SEDATIVE EFFECTS OF FENTANYL AND MIDAZOLAM TO NALBUPHINE AND MIDAZOLAM IN PATIENTS UNDERGOING AWAKE FIBEROPTIC

Background- Awake nasal or oral flexible fiberoptic intubation (AFOI) is technique of choice in known or anticipated difficult airway . The main aim was to have calm and cooperative patient who can follow verbal commands while maintaining adequate oxygenation . In our study, we compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubationmore tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Material and Methods– A prospective, randomized comparison study among patients between the age of 18 and 60yrs of either sex, with anticipated difficult airway . We compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubation. The primary objectives of our study were to observe the level of sedation, intubation score and OAS score after completion of procedure. The secondary objectives included assessment of patient comfort, intubation time, hemodynamic changes and complications. Results – We found that comfort score and intubation time were significant lesser in Group which received fentanyl and midazolam than Group which received nalbuphine and midazolam . (p<0.05). The intubation attempt was similar in both groups (P>0.05). Conclusion– we concluded that both regimens used in this study provided comparable intubating conditions, better sedation and analgesia was observed in group fentanyl for airway procedure events. Our study concluded fentanyl to be the drug of choice for blunting of pressor response in such patients.

Anesthetic management of an achondroplastic dwarf with difficult airway and kyphoscoliosis for total abdominal hysterectomy

Achondroplasia is a common form of dwarfism and possesses multiple anesthetic challenges including securing of intravenous line, monitoring and calculating drug dosage, spine abnormality, difficulty in mask ventilation and endotracheal intubation, obesity, cardiopulmonary and neurological system abnormality. There is multiple systems involvement, therefore thorough preanesthetic check ups, investigations and planning for anesthesia is important. Here we came across 36 years old female patient, achondroplasic dwarf (height- 100cm) with thoracolumbar kyphoscoliosis, fused cervical spine, short neck and restricted neck movement with mild pulmonary restrictive disease for total abdominal hysterectomy. Patient also had complained of generalized weakness and fatigue. She had a limited neck extension and short neck possesses anticipated difficult intubation, therefore we planned awake fiberoptic intubation with smaller size endotracheal tube for airway management and general anesthesia in a patient with difficult airway and spine for total abdominal hysterectomy. As the spread of the drug in regional anesthesia is unpredicted, we planned general anesthesia with awake fiberoptic intubation to avoid the risk of neurological injury while extending the neck during laryngoscopy for tracheal intubation due to restricted neck movement.