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Awake intubation and awake prone positioning for anterior/posterior cervical fusion using motor evoked potential monitoring. - 2009-01-09
Moderator - Lauren Berkow, MD.
Awake intubation and awake prone positioning for anterior/posterior cervical fusion using motor evoked potential monitoring.
Case: A 46 year old male presents to the operating room for emergent anterior/posterior cervical laminectomy and fusion status post a fall. He has a history of ankylosing spondylitis and sustained a C5-6 fracture with significant subluxation. He has already been placed in HALO traction. You go to see him in the Neurological ICU and he is sitting up in bed in his traction. Surprisingly, he has no neurological deficits, although he says it hurts a bit when he breathes, probably due to his broken ribs. He is also in a shoulder immobilizer for his dislocated shoulder. He is not overweight and has good mouth opening.
The surgeons are also at bedside and tell you that they plan to do the posterior fusion first and want to position the patient awake and perform a neurological exam prior to general anesthesia. They also plan to use motor evoked potential monitoring intra-operatively.
Part 1: Key Questions:
1. How will you secure the airway in this patient? What are your options?
2. If he was obtunded instead of extremely cooperative, what are your options?
3. What access would you want for this patient? If you are considering central venous access what are the options?
4. Do you want to provide any sedation during needle placement? Those needles are pretty large and unpleasant. What are the pros and cons of sedating the patent?
currie - 2009-03-24
1) awake fiberoptic intubation w/ cervical stablization and sufficient topical anesthetic to blunt the airway, gag and cough reflexes
2) since ankylosing spondylitis can result in restrictive lung dz which decreases FRC in addition to the patient's broken ribs, I would try to avoid versed and narcotics that could potentially cause respiratory depression. Instead, I would use a sedative namely precedex that will not cause respiratory depression to sedate the patient and ensure adequate mask ventilation and oxygenation before performing the fiberoptic intubation w/ cervical stabilization
3) Aline, subclavian central line, (get a supine CVP reading prior to flipping patient), and 2 good IVs
4) I would perform the lines after that patient is asleep and airway secured
Moderator Response
I assume you mean you would place your lines under the precedex sedation and then awaken them for the flip?
sarah - 2009-03-22
I would secure the airway with awake fiberoptic intubation. If he was obtunded, I would want still want to maintain cervical stability and intubate fiberoptically. I would want central access and would consider subclavian or femoral venous access.
Moderator Response
A good intubation plan. Did you plan for an arterial line?Are you concerned about maintaining access to your central line while your patient is in the prone position? Always a challenge, especially if your surgeon plans to use a Wilson frame or chest rolls and pins for the prone portion of the case.
Satwant Samra - 2009-01-26
Here are my answers:
1. An awake, firoptic intubation is justified in the presence of neck being unstable and fixed with Halo.
2. If the patient is obtunded and uncoperative, it is highly unlikely that he will coperate with positioning and neurological assessment after intubation. Explain that to the surgeon. Make an assessment if you think you can adequately ventilate with bag and mask in the presence of Halo. Can you easily insert an LMA if necessary? Can you achieve adequate (or some topical anesthesia? If answer to all three is yes then you can proceed with induction with propofol and short acting muscle relaxant (Sux) or without muscle relaxant (in case you have to back off) and intubate using a specialized laryngoscope that works for you(Bullard works for me)without need for too much extension of neck.
3. You havn't told us about cardiovascular and renal function. If both are Ok: Couple of Big IVs and an a-line should suffice. Most anesthesiologists should be able to do those (without pain) with local anesthesia without sedation as long as you don't transfix the artery for cannulation and scrape off the periosteum of radius at wrist (answers your question # 4) CON: Adequate sedation to nullify the pain of periosteal shearing (a-line) may produce obtundation thus defeating the purpose of whole execise.
Moderator Response
A good plan. especially important to discuss with your surgeon if you think an awake technique would not be indicated.
Kamal Maheshwari - 2009-01-24
1. Awake fibreoptic intubation would be the gold standard for securing the airway. Experienced anesthesiologist, good airway topical anesthesia, drying of airway secretions (with glycopyrrolate), patient cooperation is key for this procedure.
a. Glycopyrrolate (very important)
b. Nebulisation with 4 % lidocaine, 10 % lidocaine spray, 2-4 % lidocaine viscous gargles, Tran tracheal injection with 2-4 % lidocaine should be used.
2. If the patient is obtunded, this is the biggest challenge for anesthesiologist. You definitely need some kind of sedation ,it is what and how this is given that will make a difference. Sleep FOB is a good and safe choice for these patients. Maintaining oxygen saturation, adequate ventilation,( avoiding hypercapnia) stable vitals, minimal neck movement are the goal.
LMA , Fasttrach LMA ,Glidescope , light wand can also be used. Needle Cricothyroiodotomy may have to be performed if other measures fails and patient is not breathing. Question is how well trained we are to do that?
ENT surgeons should be notified and be immediately available if airway cannot be secured in time.
Precedex infusion can be used for sedation, with/without midazolam, and fentanyl with careful titration. One should have a back up plan/good help for airway management.
3. Good IV access is must. 2 large bore peripheral IV or subclavian central line to stay away from neck or IJ central line can be sutured curving downwards all can be used. Decision will depend on duration of procedure, anesthesiologist preference,surgeon. Arterial line for introperative monitoring.
4. Needle placement should be delayed if possible till airway is secured.
Again titration of precedex,midazolam,fentanyl can be used.
Moderator Response
Also a good plan.
Watch closely when you give lidocaine for topicalization-you can overdose elderly patients if you are not careful.
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