P029: AWAKE FIBER-OPTIC INTUBATION IN A PATIENT WITH ENLARGED GOITER USING DEXMEDETOMIDINE
Paola Aranda Valderrama, MD, Ricardo P Plata Aguilar, Santiago Luis, MD, Enrique Huertas, MD, Meghan Huertas; Cleveland Clinic Florida
An enlarged thyroid gland producing tracheal deviation is a cause difficult intubation and is challenging for anesthesiologist. A 71-year-old female with enlarged goiter causing narrowing and right tracheal deviation was scheduled for total thyroidectomy. We describe in detail the case of a successful awake fiber optic intubation (AFOI) and discuss the significance of a careful approach.
Introduction: AFOI is the gold standard for the management of the anticipated difficult airway. Mild sedation and local anesthetic techniques are frequently used to provide patient comfort and to improve intubation conditions but this may also leads to lose protecting reflexes and airway obstruction therefore requiring careful administration and monitoring. Dexmedetomidine is a very attractive option for these particular cases because of its pharmacologic properties of sedation, anxiolysis, hypnosis, analgesia and anti-sialagogue effects with a relative lack of respiratory depressant effect.
Case report: A 71-year old female was evaluated by the ENT department at our institution due to history of diffuse Goiter and slowly progressive dysphagia for solids (swallowing pills). The patient refused surgery in the past because she is a Jehovah's Witness and did not want to have blood transfusion. PMH includes hypertension and non-insulin dependent diabetes under control with lisinopril and metformin.
Laboratory work-up was compatible with biochemically normal thyroid function. A CT scan of the neck revealed a markedly enlarged multinodular goiter with the right lobe measuring 8.2 x 7.8 x 11.1 cm and the left lobe measuring 4.6 x 4.5 x 8.9 cm. The trachea showed mild narrowing and was deviated to the right. The right lobe of the thyroid extended into the substernal mediastinum. She was diagnosed with massive goiter and was scheduled for Total Thyroidectomy.
Airway assessment showed adequate mouth opening, protruding incisors, mild limitation of neck mobility and Mallampati´s class II. The anesthetic plan formulated was to perform an awake fiberoptic intubation. ASA basic monitoring was placed. Dexmedetomidine bolus of 1 mcg/kg over 10 min followed by continuous infusion at 0.2 mcg/kg/h was initiated. Nebulized Lidocaine and then 4 % Lidocaine was used initially for topical airway anesthesia and glossopharyngeal block. Patient was placed in sniffing position and oral endotracheal intubation was performed using flexible bronchoscope and a 6.00 mm ETT. After intubation an arterial line was placed and general anesthesia was maintained with Isoflurane. The Procedure was completed successfully with an EBL of 300 ml. She was extubated fully awake in the OR with no complications and then, transferred to PACU. Postoperative recovery was uneventful.
Discussion: AFOI has been recommended for patients with difficult airway and should be considered as an early option for airway management in patients with large thyroid causing alterations to the normal anatomy of the airway. There is important evidence supporting the use of dexmedetomidine to provide sedation without negative effects on ventilation.