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Correspondence |
* University of North Carolina, Chappel Hill, USA
J.N. Medical College, A.M.U., Aligarh, India, E-mail: replytomoin{at}rediffmail.com
To the Editor:
Awake intubation in the patient with a potentially difficult airway is a stimulating procedure which may be associated with wide hemodynamic changes. To attenuate this response, blunting of airway reflexes is required without losing the patient’s cooperation. Dexmedetomidine (DEX), a highly selective 
2 agonist, has the unique property of sedating and providing analgesia without affecting the patient’s respiration.1,2 It has been successfully used for attenuating the stress response to laryngoscopy.3 We report a patient in whom DEX with topical anesthesia provided favourable conditions for awake fibreoptic intubation. After approval by the Board of Studies, informed consent was obtained.
A 62-yr-old ASA II patient (175 cm, 64 kg) with faciomandibular abnormalities secondary to an old gunshot wound was scheduled for plastic facionasal reconstruction. His preanesthetic airway evaluation revealed a mouth opening of 1 cm, and a distorted nasal septum with patent left nasal passage.
Awake fibreoptic intubation was planned. DEX 1 mg·kg–1 iv diluted to 10 mL with 0.9% normal saline was given over ten minutes. Four percent lidocaine oral gargle and nebulization was used to anesthetize the oral cavity and supraglottic area. In addition, bilateral superior laryngeal nerve blocks were performed. A 7.0-mm internal diameter endotracheal tube (ETT) was pre-mounted over the fibrescope. Flexible fibrescopy was done via the left nostril with a continuous flow of 3 L·min–1 oxygen through the suction port. It required 40 sec for maneuvering the fibrescope to visualize the carina. While the ETT could not be railroaded on the first attempt, a slight rotation of the ETT and a deep breath facilitated its correct placement in the trachea. The whole procedure took about 100 sec, with the patient remaining awake and responsive to command throughout.
During the awake intubation, the patient’s SpO2 remained between 97% and 99%. The heart rate varied from 88 to 96 beats·min–1 and maximum systolic blood pressure was 124 mmHg, a rise of 16 mmHg from the immediate pre-fibrescopy value. The next day, the patient described his experience of fibrescopy procedure as only mildly uncomfortable. We believe that DEX 1 mg·kg–1 iv contributed to the stability of the hemodynamic course during this brief, but intense procedure.
References
1 Belleville JP, Ward DS, Bloom BC, Maze M. Effect of intravenous dexmedetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology 1992; 77: 1125–33.[Medline]
2 Ebert TJ, Hall JE, Barney JA, Ulrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology 2000; 93: 382–94.[Medline]
3 Scheinin B, Lindgreen L, Randell T, Scheinin H, Scheinin M. Dexmedetomidine attenuates sympathoadrenal responses to tracheal intubation and reduces the need for thiopentone and perioperative fentanyl. Br J Anaesth 1992; 68: 126–31.
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