Remifentanil is now under several investigations stimulating great interest especially because it has both analgesic and antitussive properties during awake intubation while allowing communication with the patient to be maintained. describe the cases of sedated AFOI using small doses of midazolam and fentanyl in combination with effective local lidocaine airway anesthesia, reporting good results on the success of the procedure with minimal hemodynamic changes and with minimal discomfort for the patient. Sufentanil has been compared with fentanyl, and it has shown to obtain deeper and longer analgesia, presently shorter episodes of respiratory depression, but if used alone for AFOI, it can induce a greater incidence of recall. However, opioids have the risk to induce respiratory depression. It has been described that sufentanil, alfentanil, fentanyl, and other opioids minimize the alteration elicited by fiberoptic intubation. In Table 1, a synthesis of the effects or the more commonly used drugs to manage AFOI is presented.Ĭommonly, opioids combined with benzodiazepines are utilized for sedation in AFOI. Anyhow, it is commonly arduous to provide these conditions using a single medication or approach. The ideal drug to obtain these conditions should, therefore, be short-acting and easily titratable to obtain an adequate sedation level, with minimal effects on spontaneous ventilation. It is remarkable for patients undergoing sedated but awake AFOI to have decreased anxiety, discomfort, and hemodynamic disturbances.
In order to achieve the ideal conditions for AFOI, the patient should be comfortable, compliant, does not present excessive oropharyngeal secretion or blood, and with the ability to maintain spontaneous ventilation to tolerate the passage of a fiberscope in order to facilitate fiber-optic intubation. The sedation may alleviate the awake intubation, but it requires conscientious administration and continuous monitoring as it can lead to airway obstruction and hypoxemia, while inadequate sedation could lead to discomfort, anxiety and excessive sympathetic discharge.ĭifferent pharmacological approaches have been reported to obtain conscious sedation and prevent cardiovascular changes during AFOI such as local anesthetics, benzodiazepines, opioids, α2 adrenoceptor agonists and less commonly propofol or ketamine. When AFOI is effectuated without sedation, it is commonly related to patient discomfort and severe hemodynamic responses, inducing catecholamine release by sympathetic stimulation, sympathetic stimulation, which may result in increased heart rate and blood pressure, arrhythmia, and cause myocardial ischemia and infarction in patients with risk factors, such as hypertension and ischemic heart disease. Proper local anesthesia also seems to reduce sedation doses of midazolam and fentanyl. During AFOI, coughing and laryngospasm in reaction to intubation can be problematic, so an effective airway local anesthesia is mandatory for the comfort of the patient and subsequent success of the procedure. This methodology could be conducted in totally awake patients after airway local anesthesia, under conscious sedation or by combining both approaches to limit airways reactivity. Īwake Fiberoptic Intubation (AFOI) is considered the Gold Standard in patients with a predicted difficult airway. Up to 30% of all deaths attributable to anesthesia are related to difficult airway management. The estimated incidence of patients with difficult airway during clinical anesthesia is 1-18% in these patients with a difficult airway, the anatomy is frequently different from normal, and the inadequate airways management may result in hypoxemia, hypoventilation, aspiration, brain damage or even death.
0 kommentar(er)
