Lakhasly

Awake intubation for a patient with huge mass on the neck Case presentation

Patient: 76 years old File no.: 9441002006 Admission : 21-10-2017 Data surgery: 24-10-2017 Debulking surgery / RT Lat.Fifty milligrams of lidocaine is slowly applied to the nasal mucosa bilaterally.Mass in neck / Ca Pillary thyroid

Echo LVE??=5.9 LVES?=2.9 IVS?=1.3 PWP= 1.3 AoRoot=3.5 LA=3.3 RV=2.3 EF=45% Aorta v= 1.7 Tricuspid v= 38 Mirtal v= 3 Grade 1 diastolic dysfunction Grade 1 TR Grade 1 Mitral regur Mild LVH EF=45% Hypokinesia in IVS

Past history oThe patient had hemi thyroidectomy 20 years ago oOne year ago C/O RT sided Lateral neck swelling that caused to him continuous neck pain and diffi culty of breathing.The patient may exhibit sedation, loss of consciousness and seizures After awake intubation starting to do IV induction with : 100 mg kitamen 100 mg pentothal 100 mg tracrium *The patient is ready to go through surgery

Our patient after surgery transferred to recovery room with normal vital signs Discussion

oOur choice of lidocaine is especially advantageous because this drug is available in a number of preparations (injectable and viscous oral solutions, jelly, ointment, metered dose spray), as well as a variety of concentrations (1%, 2%, 4%, 5% 10%).oU/S showes matted lymph nodes oThe patient admitted and operated for lymph nod excisional biopsy oPathology confirmed papillary thyroid cancer oThe patient was sent to oncology department in Al-Bashir hospital for radio-therapy oThe opinion was to do total excision of the mass oThe patient returned into our hospital to do the excision oAfter one year the patient came with huge right side neck swelling that interfere with his breathing oPatient was seen in different hospital in which they refused to do it from surgical and anesthisological point of view

Loading...Total doses of applied local anesthetic should be tabulated, and administration kept well within the therapeutic window

• Preparing the patient Studies on the peak serum concentrations after topically applied lidocaine are available, and when preparing the patient for awake intubation it is easy to keep within guidelines that will maintain sub toxic blood levels.WHICH LOCAL ANESTHETICS AND WHICH PRECAUTIONS SHOULD WE TAKE?

Awake intubation for a patient with huge mass on the neck
Case presentation

Patient: 76 years old
File no.: 9441002006
Admission : 21-10-2017
Data surgery: 24-10-2017
Debulking surgery / RT Lat. Mass in neck /
Ca Pillary thyroid

Echo
LVE∆∆=5.9
LVES∆=2.9
IVS∆=1.3
PWP= 1.3
AoRoot=3.5
LA=3.3
RV=2.3
EF=45%
Aorta v= 1.7
Tricuspid v= 38
Mirtal v= 3
Grade 1 diastolic dysfunction
Grade 1 TR
Grade 1 Mitral regur
Mild LVH
EF=45%
Hypokinesia in IVS

Past history
•The patient had hemi thyroidectomy 20 years ago
•One year ago C/O RT sided Lateral neck swelling that caused to him continuous neck pain and diffi culty of breathing.
•U/S showes matted lymph nodes
•The patient admitted and operated for lymph nod excisional biopsy
•Pathology confirmed papillary thyroid cancer
•The patient was sent to oncology department in Al-Bashir hospital for radio-therapy
•The opinion was to do total excision of the mass
•The patient returned into our hospital to do the excision
•After one year the patient came with huge right side neck swelling that interfere with his breathing
•Patient was seen in different hospital in which they refused to do it from surgical and anesthisological point of view

Loading…

Present
•The patient admitted to our hospital in 21-10-2017 with huge mass on the neck
•After being Seen by anesthesiologist , it was decided that it was difficult to intubat this patient because there is a huge mass closing the breathing airway
•Decided to do awake intubation with local anesthesia
SERGICAL ANATOMY OF LARYNX

HOW DO WE PREPARE OUR PATIENT FOR AN AWAKE INTUBATION ?
WHICH LOCAL ANESTHETICS AND WHICH PRECAUTIONS SHOULD WE TAKE?

• Preparation for awake intubation often employs techniques of topical anesthetic application. As with any other pharmaceutical agents, these drugs can be toxic when used inappropriately. Total doses of applied local anesthetic should be tabulated, and administration kept well within the therapeutic window


• Preparing the patient
  Studies on the peak serum concentrations after topically applied lidocaine are available, and when preparing the patient for awake intubation it is easy to keep within guidelines that will maintain sub toxic blood levels. it was shown that after receiving 800 of topical lidocaine :


• peak serum levels in normal adults were well within safe levels.


• A variety of patient factors may affect the absorption and neurotoxicity of local anesthetics including hypercarbia, hyperpyrexia, hepatic disease, and inability to swallow (resulting in pooling against the mucosa).
  REGIONAL AND TOPICAL ANESTHESIA FOR ENDOTRACHEAL INTUBATION

Airway analgesia
In most patients airway analgesia can be achieved by planning blocks for four distinct anatomic areas:
nasal cavity
pharynx
hypopharyn
larynx and trachea.
In each area 100 mg of lidocaine will typically suffice to provide adequate analgesia
Be prepared to treat toxicity
Being prepared to treat toxicity in these patients is crucial. The patient may have a compromised airway, be at risk of aspiration or both. Treating the patient for local anesthetic toxicity leads to :
distracts the clinician from the task at hand (i.e., awake intubation)
puts the patient at risk of airway compromise and aspiration
introduces a new set of compromising reactions to be dealt with. The patient may exhibit sedation, loss of consciousness and seizures
After awake intubation starting to do IV induction with :
100 mg kitamen
100 mg pentothal
100 mg tracrium
*The patient is ready to go through surgery

Our patient after surgery transferred to recovery room with normal vital signs
Discussion

•Our choice of lidocaine is especially advantageous because this drug is available in a number of preparations (injectable and viscous oral solutions, jelly, ointment, metered dose spray), as well as a variety of concentrations (1%, 2%, 4%, 5% 10%).
•Typically, a viscous or ointment preparation is used in the nose. Fifty milligrams of lidocaine is slowly applied to the nasal mucosa bilaterally.
• Likewise, 50mg are applied to the base of the palatoglossal arches.
•One hundred milligrams of viscous or injectable
Conclusion
•Be careful when you go to anesthesiat the patient with difficult intubation , you should examine the airway and respiratory organs before deciding to do anything and you must prepare the equipments for difficult intubation
•In our patient we examined the patient epiglottis before awake intubation and we took the required precautions
•There must be qualified assistants with the anesthesiologist