Fiberoptic intubation via laryngeal mask airway under general anesthesia in the patients with halo vest

Since 1991, we gave anesthesia to 155 patients with halo vest. All of 128 whose airways could be kept patent by laryngeal mask airway (LMA) were successfully intubated fiberoptically via LMA using the tube exchange catheter under general anesthesia. Four patients developed airway obstruction during the induction of anesthesia, two of whom were awakened and subsequently intubated by awake fiberoptic intubation. In one patient LMA could keep the airway patent. In the other patient, cervical immobilization by halo device was released and the intubation was performed with a laryngoscope. For 8 patients, awake fiberoptic intubation was chosen from the preoperative evaluation of the positioning of head and neck. Fifteen patients were intubated with a laryngoscope without trying LMA fiberoptic intubation. No patient developed neurological injury attributed to the intubation. LMA fiberoptic intubation has several advantages. Patients do not feel discomfort under general anesthesia. Ventilation is kept continued until LMA is removed. Even less experienced residents can intubate easily and safely without assistance. However, we must carefully diagnose and select the patient whose airway can be kept patent under general anesthesia. The motionless pictures of the intubation procedures can be seen on the web site: www.hosp.go.jp/~kobe/.     

Neuroleptanalgesia for awake pronation of surgical patients

Pronation of anesthetized patients may result in complications. Neuromuscular block increases the risk. To minimize the risk, the authors devised a technic of "awake pronation," evaluating its feasibility, in 11 consecutive patients in a 1-year period for 12 operations; all attempts were successful and without complicatons. Neuroleptanalgesia is achieved with droperidol and fentanyl, topical anesthesia of the upper airway is induced with lidocaine, awake intubation is performed orotracheally under direct vision, and pronation is accomplished with patient cooperation.     

Use of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders.

Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation.     

Elective oral tracheal intubation in cervical spine-injured adults

There is controversy regarding the optimal mode of elective tracheal intubation in the patient with an unstable cervical spine following trauma. A ten-year review of 150 patients with traumatic cervical spine injuries with well-preserved neurological function, presenting for operative stabilization, was conducted to compare neurological outcome with the mode of tracheal intubation. Preoperative neurological deficits were identified in 49 patients (33%); most were single-level radiculopathies. Intubation occurred after induction of general anaesthesia in 83 patients (55%) and in 67 patients (45%) the tracheas were intubated with the patient awake. One hundred and six patients (71%) underwent oral tracheal intubation and 44 underwent nasal tracheal intubation. Ten intubations were deemed to be difficult requiring more than one attempt to effect intubation. Cervical spine immobilization during intubation was documented in 86 patients (57%). Weighted traction or manual in-line traction were the two manoeuvres most commonly employed to maintain spinal alignment during intubation. After surgery, two patients had new neurological deficits. There were no differences in neurological outcome whether intubation was performed while the patient was awake or under general anaesthesia, or comparing oral tracheal intubation with all other techniques (P = 0.5, Fisher exact test). Also, in-line traction did not affect neurological outcome. Oral tracheal intubation with in-line stabilization, either performed after induction of general anaesthesia or with the patient awake, remains an excellent option for elective airway management in patients with cervical spine injuries.     

An unnoticed dislocation of the dens axis in a patient with primary chronic polyarthritis undergoing intensive therapy

Involvement of the cervical spine is seen in 40%-60% of all patients with rheumatoid arthritis. Consequences are instability of the upper cervical column with pain and neurological deficits, in some cases tetraplegia, and sudden death. From this reason special care has to be taken in the management of those patients, even when they are comatose or anesthetized, to avoid sudden spinal cord compression with irreversible neurological deficits. We report a 49-year-old female with a history of rheumatoid arthritis for more than 10 years. Because of an adhesive ileus complicated by septicemia, she underwent abdominal surgery twice followed by prolonged mechanical ventilation under high doses of sedative drugs. After reduction of the tranquilizer doses tetraplegia with respiratory insufficiency was found. Neurophysiological and X-ray examinations showed spinal cord compression due to dislocation of the odontoid process, a rare but typical complication in patients with rheumatoid arthritis. It was not possible to determine the date of the dislocation, but it might have been caused by intubation or respositioning. Although the patient underwent immobilization and surgical fusion of the upper cervical spine, there was no improvement in the neurological status and she died 5 months later. In patients with advanced rheumatoid arthritis a detailed medical history, clinical examination, and radiography are necessary before general anesthesia or intensive care with intubation is considered. If an unstable cervical spine is suspected, intubation should be performed by fiberoptic technique under light sedation. Regional anesthesia should be preferred over general anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)     

CASE REPORT: Dexmedetomidine for awake fibreoptic intubation and awake self‐positioning in a patient with a critically located cervical lesion for surgical removal of infra‐tentorial tumour

Cervical lesions compressing the spinal cord pose a significant risk of exacerbating the existing neurological condition during tracheal intubation and subsequent positioning. Awake fibreoptic‐assisted intubation is a suitable option in such situations. We describe how the use of dexmedetomidine for sedation during awake fibreoptic intubation also facilitated self‐positioning before surgery in a patient with a cervical cord compressive lesion and raised intracranial pressure undergoing excision of a cerebellopontine angle lesion in the lateral position, without any adverse neurological outcome.     

Dexmedetomidine and awake fiberoptic intubation for possible cervical spine myelopathy: a clinical series

For many anesthesiologists, awake fiberoptic endotracheal intubation (AFOBI) is the preferred method of intubation when treating patients with symptoms or signs of cervical spinal cord compression. The advantage of this method is to minimize cervical spine movements that could contribute to neurologic impairment. In patients who are anxious or poorly cooperative, adequate sedation in addition to topicalization of the airway may be key to minimize patient discomfort and assist in successful intubation, but imposes the risk of respiratory depression. Dexmedetomidine has the advantage of producing sedation without a significant decrease in respiratory drive. We are now reporting our experience of a series of AFOBI using dexmedetomidine for sedation. A retrospective chart review was conducted on the anesthetic records of patients, who had undergone an awake fiberoptic endotracheal intubation (AFOBI) using dexmedetomidine for sedation. These were patients in whom AFOBI was indicated because of signs or symptoms of cervical spinal cord compression. Dexmedetomidine provided adequate sedation. We did not encounter any loss of airway or airway obstruction during the intubation. The patients had excellent cooperation for post-intubation neurologic examination. Thirteen patients developed transient hypotension after induction of general anesthesia that was managed with boluses of phenylephrine or ephedrine.     

Direct laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury

Perioperative airway management in trauma victims presenting with penetrating thoracic spine injury poses a major challenge to the anesthesiologist. To avoid further neurological impairment it is essential to ensure maximal cervical and thoracic spine stability at the time of airway manipulation (e.g., direct laryngoscopy and endotracheal intubation). Airway management in the prone position additionally increases the incidence of cervical/thoracic spine injury, difficult ventilation, and difficult airway instrumentation. Although awake fiberoptic intubation of the trachea is considered the gold standard for airway instrumentation in patients with posterior thoracic/cervical trauma, this technique requires the patient's cooperation, special equipment, and extensive training, all of which might be difficult to accomplish in emergency situations. We herein present the first reported case of an adult trauma patient who underwent direct laryngoscopy and endotracheal intubation under general anesthesia in the prone position. Although the prone position is not the standard position for airway instrumentation with direct laryngoscopy and endotracheal intubation under general anesthesia, our experience indicates that this technique is possible (and relatively easy to perform) and might be considered in an emergency situation.     

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction

PURPOSE: To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction. Clinical features: A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature. CONCLUSION: Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.     

Case of awake intubation in semi-sitting position for a patient with myasthenia gravis combined with cervical disc hernia utilizing Pentax-AWS Airwayscope

We report a case of awake intubation utilizing Pentax-AWS Airwayscope in semi-sitting position. A 74-year-old man with myasthenia gravis and cervical disc hernia was scheduled for distal gastrectomy under general anesthesia. He could not move his head due to severe cervical disc hernia and also could not sufficiently breathe due to the fatigue of respiratory muscles by myasthenia gravis in supine position. With fentanyl bolus administration and lidocaine spray for laryngotracheal anesthesia, we performed awake intubation in semi-sitting position with AWS from cranial side. The patient did not buck during intubation and no hemodynamic change was observed.     

氟骨症性颈椎管狭窄症手术的麻醉管理

目的探讨氟骨症性颈椎管狭窄症手术的麻醉特点及管理方法。方法对2009年2月～2014年3月5例氟骨症性颈椎管狭窄症的麻醉管理进行总结。2例术前颈椎活动严重受限,改良Mallampati分级Ⅲ级,考虑可能为困难气管插管,清醒表面麻醉下行纤维支气管镜引导气管插管;余3例为非困难气管插管,行快速诱导直视下Macintosh喉镜气管插管。结果5例均安全度过围术期,无死亡。1例因呼吸功能不全,术后转入ICU病房,次日拔管;余4例术后转入PACU拔管。术后均无麻醉相关并发症,顺利出院。结论氟骨症性颈椎管狭窄症患者困难气道发生率高,气道管理是围术期麻醉管理的核心问题。     

The safety of awake tracheal intubation in cervical spine injury

As a referral centre for cervical spine injuries, we have routinely performed awake tracheal intubation when intubation was indicated. A retrospective case control study was undertaken to review the frequency of neurological deterioration and aspiration associated with our approach. Neurological deterioration was assessed by a change in level of injury or neurological grade at admission and discharge. Four hundred and fifty-four patients with critical cervical spine and/or cord injuries were reviewed over an eight-year period. A case group of 165 patients underwent tracheal intubation awake within two months of injury. A control group of 289 remained unintubated during the same period. A comparison of spinal neurological status between admission and discharge revealed no statistically significant difference in neurological deterioration between the two groups. This occurred despite a greater injury severity score in the case group. No evidence of aspiration during intubation was documented. We conclude that awake tracheal intubation is a safe method of airway management in patients with cervical spine injuries.     

Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: tracheal perforation due to unsuccessful fiberoptic tracheal intubation

A 77-year-old man was scheduled to undergo a cervical lymph node biopsy under general anesthesia. Although awake, nasotracheal fiberoptic intubation was initially planned because of an anticipated difficult airway, the attempt was unsuccessful. Orotracheal intubation was subsequently performed under direct laryngoscopy without difficulty. After initiating positive pressure mechanical ventilation, subcutaneous and mediastinal emphysema developed. The cause of this emphysema was considered to be tracheal perforation after an unsuccessful attempt at fiberoptic tracheal intubation.     

Posterior cervical spine stabilization under local anesthesia

A technique is described for posterior cervical stabilization with spinous process wiring and fusion performed with the patient under local anesthesia and using corticocancellous demineralized bone matrix allograft. In patients with unstable cervical spines, posterior stabilization and fusion with local anesthesia allowed patient interaction with the surgeon during crucial parts of the operation. The technique was well tolerated and no untoward complications occurred. The technique has not been described for the neurologically intact patient with cervical spine trauma. The purpose of this report is to document the facility and advantages of this technique over traditional general anesthesia with autograft use. Nineteen patients were treated surgically at the author's institution. Local anesthesia was used in 12, and general anesthesia was used in 7. Allograft was used in 12 and autologous iliac crest graft was used in 7 patients. The indications for surgery were instability or neurologic deficit. Blood loss and operative times were favorable when compared with general anesthesia and autograft. The fusion extended by one level in 6 of 19 patients. One patient had preoperative neurologic deficit. All 19 follow-up patients were Frankel grade E. There is no need for endotracheal intubation, the patient serves as his or her own spinal cord monitor, and the surgeon is able to be aware immediately of any threat to neurological function. Demineralized bone matrix allograft has been shown to effectively induce osteogenesis by osteoinduction as well as osteoconduction. Its use eliminates the need for autograft harvesting and permits the use of local anesthesia alone for cervical spine posterior stabilization. The more neurologically intact the patient, the more this technique is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cervical stabilization with halo fixation: anesthetic implications--case reports

Halo fixation is often used to provide stability in patients with unstable cervical spine. These fixation devices pose unique challenges to the anesthesiologists encountered while securing an airway. Management of airway in patients with halo fixation is complicated by the fixed position, limited access to the face, and immobilization of neck. We managed two different patients, one in which halo fixation was done for atlanto-axial dislocation (AAD); and the other, who came with halo fixation and underwent wound debridement under general anesthesia. In the former case, procedure was carried out with laryngeal mask anesthesia and patient breathing spontaneously whereas, in the later case, procedure was performed after securing the airway using awake fiberoptic intubation technique.     

Anesthetic management of two patients with amyotrophic lateral sclerosis (ALS)

We experienced anesthetic management of two cases of amyotrophic lateral sclerosis (ALS). Case 1. A 46-year-old woman underwent emergency operation for ileus. Abdominal muscle relaxation and analgesia were obtained by combined spinal and epidural anesthesia. To avoid prolongation of muscle relaxation, awake intubation without muscle relaxants was performed. After the operation, she awoke smoothly and was extubated without any complications. Case 2. A 65-year-old woman underwent emergency operation for gastric fistula malfunction. We performed anesthetic management only with epidural anesthesia. During and after the operation, she was in good general condition and had no pain. For the patients with ALS, prolongation of muscle relaxation and residual neuromuscular block effect may cause difficult tracheal extubation and postoperative respiratory complications. We observed carefully the condition of the patients with ALS, and were able to choose the minimum invasive anesthetic methods for each case.     

Anesthetic management of cesarean section in a patient with severe obesity

A 35-year-old pregnant woman (weight, 129.5 kg; height, 156 cm; 37 weeks of pregnancy) with a body mass index of 53 was scheduled for a cesarean section. It was thought that epidural or spinal anesthesia might result in complications due to her severe obesity. It was therefore decided to use general anesthesia following awake intubation. Her baby was delivered, and her Apgar scores at 1 and 5 minutes after delivery were 8 and 9 points, respectively. During surgery, she developed hypoxia due to upper shift of the diaphragm. After surgery, she was extubated after improvement of her oxygenation under spontaneous breathing. This case demonstrates that difficulties may be encountered during anesthetic management of a severely obese patient undergoing cesarean section.     

Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway

Anaesthetic management of a parturient with predicted difficult airway presenting for caesarean section (CS) is not a straightforward decision: general anaesthesia should be avoided because intubation can be impossible and a "cannot intubate, cannot ventilate" scenario might ensue, on the other hand regional techniques can be unsuccessful or, though rarely, have complications that require emergency intubation. The case is presented of a primigravida admitted to hospital at 37 weeks' gestation with hypertension, intrauterine growth retardation and oligohydramnios. After a few days' observation, it was decided to proceed with an elective CS. The preoperative airway examination revealed a poor mouth opening with an interdental distance of 20 mm and a Mallampati class IV. The patient was classified as a case of difficult intubation and the following anaesthetic options were considered: epidural anaesthesia, spinal anaesthesia and awake fibreoptic intubation followed by general anaesthesia. The pros and the cons of these techniques were explained to the patient and it was suggested that awake fibreoptic intubation was the safest option. The patient gave her consent, so an uneventful nasal awake fibreoptic intubation was carried out under local anaesthesia. This case report offers the opportunity to underline the risk to perform a central blockade in a parturient with predicted difficult intubation, arguing that the safest course of action is an awake fibrescopic intubation, besides some controversial points to safely perform awake fibreoptic intubation in obstetric patients are discussed.     

Management of difficult intubation in a patient with ankylosing spondylitis--a case report

We describe a case of difficult intubation in a patient suffering from ankylosing spondylitis undergoing total hip replacement surgery. The anesthetic management of 42 year old patient with difficult airway is discussed. Failure of epidural anesthesia procedure necessitated general anesthesia. The problems of performing awake fibreoptic intubation and other alternative techniques to secure the airway are described. Cervical spine involvement in ankylosing spondylitis is of great concern for the anesthetist. Longstanding progressive course of this disease leads to fibrosis, ossification and ankylosis of entire spine and sacroiliac joints. Cervical spine mobility is decreased and in severe cases total fixity occurs in a flexed position. Patient may also have atlanto-occipital and temporo-mandibular joint involvement as well. Cricoarytenoid cartilages involvement may result in upper airway compromise. Furthermore cervical spine vertebrae are prone to fractures, especially on hyperextension and may lead to spinal cord transection and quadriplegia. In this case report we describe the airway management of such patient with fixed rigidity of cervical spine and thoracolumbar kyphosis.     

Experience of lumbar epidural insertion in 573 anesthetized patients

Performing regional blockade on anesthetized patients may increase the risk of postoperative neurologic complications, because these patients cannot respond to painful stimuli. In orthopedic patients, especially those with leg fracture, it is sometimes difficult to find a suitable position for epidural catheterization because of pain. This study evaluates the frequency of neurologic complications after lumbar epidural catheter placement in anesthetized adult patients undergoing orthopedic surgery. Among 581 patients, there were 8 failed epidural catheter insertion: the catheter could not be inserted in 4 patients including one dural puncture, and the position of the epidural catheter was judged as inappropriate in 4 patients postoperatively. In the remaining 573 patients, the catheter was inserted uneventfully under general anesthesia, and they received continuous local anesthetic infusion for postoperative analgesia. No neurologic complication related to epidural catheter was observed in these patients. This observation suggests that epidural puncture under general anesthesia may be acceptable in some conditions, for example obtaining appropriate consent, difficulty in positioning when awake, proper monitoring and vigilance, etc.