Extubation of the surgically resected airway — a role for remifentanil and propofol infusions

Saravanan, Palanikumar; Marnane, Conor; Morris, E.

doi:10.1007/bf03022625

Cited by 9 publications

(7 citation statements)

References 25 publications

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“…Remifentanil infusions have been extensively described as a method of providing conscious sedation for awake fibreoptic intubation in the spontaneously breathing patient [115][116][117][118][119] and evidence is emerging to support a similar strategy during emergence and extubation [120][121][122][123][124][125]. Several factors influence the dose of remifentanil necessary to prevent coughing at extubation, and relate to patient characteristics, surgical procedure and the anaesthetic technique.…”

Section: General Principlesmentioning

confidence: 99%

Difficult Airway Society Guidelines for the management of tracheal extubation

Mitchell¹,

Dravid²,

Patel³

et al. 2012

Anaesthesia

428

139

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SummaryTracheal extubation is a high‐risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri‐operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post‐extubation care.

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Section: General Principlesmentioning

confidence: 99%

Difficult Airway Society Guidelines for the management of tracheal extubation

Mitchell¹,

Dravid²,

Patel³

et al. 2012

Anaesthesia

428

139

View full text Add to dashboard Cite

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“…However, if unanticipated abnormalities are observed, tracheal reintubation is possible by readvancing the bronchoscope and railroading the tube over it. 10 A third option was the use of a videolaryngoscope during the extubation phase to determine vocal cord function 11 and verify the absence of supraglottic edema; this method would also assist with reintubation if required. However, it would not allow us to visualize the anastomosis or rule out tracheomalacia.…”

Section: Discussionmentioning

confidence: 99%

“…5 Similarly, descriptions of optimal management after a tracheal resection have been published. 6,7,10 The uniqueness of our case was that we needed to combine both strategies to exclude potential postthyroidectomy complications, achieve a cough-free emergence, and avoid tension on the new tracheal anastomosis-all in a patient with a suspected difficult airway in whom reintubation would have been challenging.…”

Section: Discussionmentioning

confidence: 99%

“…5 Following tracheal resection, early extubation is desirable to avoid the effects of positive-pressure ventilation on the new anastomosis; devices crossing the new anastomosis are not ideal, and the chin-to-chest guardian suture increases the difficulty of reintubation. Numerous published case reports discuss extubation management after thyroidectomy 4,5,11 or tracheal resection, 10 and the described case required consideration of both.…”

Section: Résumémentioning

confidence: 99%

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Extubation of a difficult airway after thyroidectomy: use of a flexible bronchoscope via the LMA-Classic™

Ellard

Brown

Wong

2011

Can J Anesth/J Can Anesth

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Purpose We report an extubation strategy for a patient scheduled for thyroidectomy who had several factors indicating that it would be a difficult extubation. Clinical features A 75-yr-old man with thyroid cancer presented for total thyroidectomy. He had anatomical features predictive of a difficult upper airway. Therefore, his trachea was intubated while he was awake using a flexible bronchoscope. The tumour had invaded the trachea, necessitating total thyroidectomy, 3-cm tracheal resection, and primary tracheal anastomosis. The left recurrent laryngeal nerve (RLN) was inherently involved in the tumour and sacrificed. A ''guardian suture'' placed between the chin and the chest maintained the head and neck in flexion, thereby avoiding traction on the tracheal anastomosis. Immediate postoperative extubation was desirable, given the new tracheal anastomosis; however, complicating factors included left RLN paralysis, tracheal anastomosis, potential for tracheomalacia or supraglottic airway swelling, and the guardian suture preventing neck extension. In addition, there were anatomical features raising the suspicion of difficult reintubation should it be necessary. With the patient deeply anesthetized, the endotracheal tube was removed and replaced with the Laryngeal Mask Airway (LMA)-Classic TM as a bridging device to facilitate bronchoscopic examination. It allowed us to visualize the tracheal repair, tracheal movement, vocal cord function, and supraglottic structures. The patient emerged from anesthesia and was extubated uneventfully. Conclusion We describe a viable extubation strategy used in a patient after complex thyroid surgery involving tracheal resection. By using the LMA-Classic TM as a bridging device and to facilitate bronchoscopic examination, we were able to address the above concerns and safely manage the extubation phase in this patient. RésuméObjectif Nous pre´sentons les re´sultats d'une strate´gie d'extubation pour un patient devant subir une thyroı¨dectomie et chez qui plusieurs facteurs indiquaient que l'extubation serait difficile. Caractéristiques cliniques Un patient de 75 ans ayant un cancer de la thyroı¨de devait subir une thyroı¨dectomie totale. Ce patient pre´sentait des caracte´ristiques anatomiques pre´dictives d'une intubation difficile. Sa trache´e a donc e´teí ntube´e à l'aide d'un bronchoscope a`fibres optiques alors qu'il e´tait e´veille´. La tumeur avait envahi la trache´e, ne´cessitant une thyroı¨dectomie totale, une re´section trache´ale de 3 cm et une anastomose trache´ale primaire. Le nerf re´current larynge´gauche e´tait gravement touche´par la tumeur et a e´te´sacrifie´. Une « suture du gardien » , mise en place entre le menton et la poitrine, maintenait la teˆte et le

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“…Recently, Saravanan and Coll [69], reported the case of a patient that was weaned from mechanical ventilation and extubated under sedation with remifentanil, 3 mcg/Kg/h, and propofol, 1.25 mg/Kg/h. Nonetheless, low dose infusion of opioids does not impair patient alertness and may act on respiratory drive avoiding excessive respiratory rate caused by factors other than respiratory failure.…”

Section: Spontaneous Breathingmentioning

confidence: 99%

Opioids and Mechanical Ventilation

Cavaliere¹,

Masieri²

2009

CDT

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In last years opioids have been increasingly utilized to sedate patients during mechanical ventilation. First, in Hypnotic Based Sedation (HBS), they were added to hypnotics because of their analgesic properties. Successively, in Analgesic Based Sedation (ABS), both sedative and analgesic properties were utilized and opioids were given alone; hypnotics were added only if adequate sedation was not achieved at maximum dosage. Apart from their analgesic and sedative properties, opioid effects on respiratory function are of particular value in many mechanically-ventilated patients. Dose-dependent inhibition of respiratory drive may usefully prevent spontaneous breathing during controlled ventilation, particularly when permissive hypercapnia is applied, or decrease excessive respiratory rate during assisted or noninvasive ventilation. Even cough inhibition can be valuable in some conditions, for instance, during respiratory weaning and endotracheal tube removal in patients that should not cough because of a recent tracheal resection. On the other hand, excessive respiratory depression may cause hypoventilation and apnea during assisted or spontaneous ventilation and lengthens the weaning process. In order to take advantage from positive effects and to avoid negative ones, opioid dosage should be thoroughly titrated. On this basis remifentanil has become increasingly popular as the opioid agent most suitable for ABS because of its unique, favorable pharmacokinetics.

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Extubation of the surgically resected airway — a role for remifentanil and propofol infusions

Cited by 9 publications

References 25 publications

Difficult Airway Society Guidelines for the management of tracheal extubation

Difficult Airway Society Guidelines for the management of tracheal extubation

Extubation of a difficult airway after thyroidectomy: use of a flexible bronchoscope via the LMA-Classic™

Opioids and Mechanical Ventilation

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