Dexmedetmomidine sedation for awake tracheotoy:case report and literature review

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Dexmedetmomidine sedation for awake
tracheotoycase report and literature review
Marianne D. David MD (Senior Anesthesiology
Resident),
Lorenzo De Marchi MD (Clinical Instructor)
?
Department of Anesthesia, Georgetown University
Hospital, Washington, DC 2007, USA
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1. Introduction

• Awake tracheotomy is indicated in patients with
  impending airway obstruction for which
  oropharyngeal intubation with direct laryngoscopy
  or fiber optic bronchoscopy is deemed difficult
  or impossible.
• The anesthetic management for these patients is
  especially challenging because current
  intravenous (IV) agents used for sedation, such
  as propofol,benzodiazepines, and opioids, have
  depressant effects onventilatory drive.

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1. Introduction

• Dexmedetomidine,a centrallyacting
  alpha2-adrenoreceptor agonist, provides moderate
  sedation and analgesia with minimal respiratory
  depression 1,2.
• A case of awake tracheotomy performed with local
  anesthesia using dexmedetomidine for sedation is
  presented.

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2. Case reports

• The patient was a 44-year-old, 45 kg, 157 cm
  woman with a history of metastatic tonsillar
  squamous cell carcinoma status post-chemoradiation
  therapy and radical neck dissection.

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2. Case reports

• Her other comorbidities included hypertension
  and asthma.
• she had significant torticollis and facial edema
  that severely limited her neck movement and mouth
  opening. She also exhibited inspiratory and
  expiratorystridor and aphonia.

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2. Case reports

• A computed tomographic (CT) scanshowed a large
  infiltrative mass in the right neck,supraglottic
  edema, and a deviated trachea that was
  significantly narrowed at the hyoid bone level
  due to mass-effect .

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2. Case reports

• Despite her challenging anatomy, the ear,nose,
  and throat surgeons felt that an emergency airway
  could be established by percutaneous
  transtracheal jet ventilation or tracheotomy if
  needed

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2. Case reports

• Nonetheless, because of her severe airway
  compromise,an awake tracheotomy with local
  anesthesia was planned.
• Due to its faster onset and shorter duration of
  action, we also considered titrating small doses
  of propofol (0.5 mg/kg) to supplement the
  sedation if necessary.

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2. Case reports

• After obtaining her informed consent, the patient
  was brought to the operating room where standard
  ASA monitors were applied and IV sedation was
  initiated with dexmedetomidine.

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2. Case reports

• Because of concern for oversedation, we used the
  lowest recommended loading dose of
  dexmedetomidine at 0.5µg/kg infused over 10
  minutes.

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2. Case reports

• At this point, the patientwas asleep but respo
  nsive to verbal command s, and dexmedetomidine
  was continued at an infusion rate of 0.2µg/kg/hr.
  

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2. Case reports

• This infusion was titrated up to 0.7µg/kg/hr for
  the duration of the case to increase the
  patient's sedation level and minimize discomfort.

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2. Case reports

• The surgical site was infiltrated by the surgeon
  with lidocaine 1 with epinephrine 1100,000.
  Additional local anesthesia was injected at the
  deep tissue and tracheal levels as needed.

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2. Case reports

• Despite the laborious surgical dissection, which
  was due to the patient's significant torticollis,
  she reacted with minimal movement but was
  otherwise cooperative.

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2. Case reports

• Her vital signs did not deviate significantly
  from preoperative values, and she was able to
  maintain spontaneous respiration with arterial
  oxygen saturation (SpO2) of 98 to 100 on three
  L/min of oxygen bynasal cannula.

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2. Case reports

• During deep dissection to expose the tracheal
  rings, however, the patient exhibited some
  discomfort.

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2. Case reports

• Once the team was certain that an airway could be
  established after exposure of the tracheal
  rings,sedation was supplemented with IV propofol
  20 mg, from which she developed airway
  obstruction.

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2. Case reports

• Her SpO2 transiently decreased to 86 but
  returned to 98 after chin lift shortly
  thereafter, a 6 endotracheal tube (ETT) was
  inserted into the tracheal stoma without
  difficulty.

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2. Case reports

• After proper placement of the ETT was confirmed
  by capnography, general anesthesia was initiated
  with sevoflurane and the ETT was then exchanged
  for a 8 Portex tracheostomy tube (Smiths
  Medical, St. Paul, MN, USA).

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2. Case reports

• During general anesthesia, the dexmedetomidine
  infusion was maintained at 0.2 µg/kg/hr until the
  conclusion of the procedure. The patient was
  brought to the recovery room in stable condition.

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3. Discussion

• In these case series, dexmedetomidine provided
  moderate sedation without causing respiratory
  depression and minimal to no hemodynamic
  alterations.

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3. Discussion

• Dexmedetomidine's sedative effect is unique for
  two reasons.
• First, it provides arousable sedation similar to
  that of normal sleep
• second, it has a relative lack of respiratory
  depression.

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3. Discussion

• Dexmedetomidine potentiates the effects of IV and
  inhalational anesthetic agents, and an additive
  effect could explain the exaggerated respiratory
  depression that we observed with coadministration
  of propofol.

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3. Discussion

• Two of the most common adverse reactions
  associated with dexmedetomidine are hypotension
  (30) and bradycardia (9) secondary to the
  attenuation of plasma catecholamine release,

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3. Discussion

• Finally, clinicians should remember that
  coadministration of other IV anesthetcis Could
  potentiate the hemodynamic and respiratory
  effects of dexmedetomidine

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• Thank you
• for your attention!