Nasotracheal intubation-extubation-intubation and asleep-awake-asleep anesthesia technique for deep brain stimulation

Abstract

BackgroundThe asleep-awake-asleep (AAA) technique and laryngeal mask airway (LMA) is a common general anesthesia technique for deep brain stimulation (DBS) surgery. However, the LMA is not always the ideal artificial airway. In this report, we presented our experiences with nasotracheal intubation-extubation-intubation (IEI) and AAA techniques in DBS surgery for Parkinson’s disease (PD) patients to meet the needs of surgery and ensure patients’ safety and comfort.Case presentationThree PD patients scheduled for DBS surgery had to receive general anesthesia for various reasons. For the first asleep stage, general anesthesia and nasotracheal intubation was completed with routine methods. During the awake stage, we pulled the nasotracheal tube back right above the epiglottis under fiberoptic bronchoscope (FOB) guidance for microelectrode recording (MER), macrostimulation testing and verbal communication. Once monitoring is completed, we induced anesthesia with rapid sequence induction and utilized the FOB to advance the nasotracheal tube into the trachea again. To minimize airway irritations during the process, we sprayed the airway with lidocaine before any manipulation. The neurophysiologists completed neuromoinitroing successfully and all three patients were satisfied with the anesthesia provided at follow-up.ConclusionNasotracheal IEI and AAA anesthetic techniques should be considered as a viable option during DBS surgery.

The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility

“…The stereotactic headframe used to stabilize the head and neck during stereotactic brain surgery makes accessing the airway a challenge, and conventional DL is of limited use in such scenarios [ 42 , 43 ]. Few studies proposed alternative airway management modalities, including using a flexible FOB, an intubating laryngeal mask airway (ILMA), a gum elastic bougie, a lightwand (e.g., Trachlight™), and videolaryngoscopy (VL) in some difficult airway scenarios [ 44 , 45 , 46 , 47 , 48 ]. The airway operators should know in advance that the in-place headframe may make it difficult to access the upper airway and thus have a contingency plan to handle the airway, should the need unexpectedly arise.…”

Anesthesia for deep brain stimulation system implantation: adapted protocol for awake and asleep surgery using microelectrode recordings

“…MER may not be incorporated into asleep DBS procedures due to the potential for anesthetics to suppress or alter neuronal activity [ 5 , 17 , 20 ], and the surgeon may prefer to have the conscious cooperation of the patient. Asleep-awake-asleep procedures have been developed to address this, in which deeper sedation is initially induced but discontinued during MER to allow the patient to wake up to the point of cooperation, and then resumed for the completion of the procedure [ 18 , 33 ]. This approach may, however, see some patients who are slow to rouse from sedation or remain too groggy to participate in the MER feedback.…”