A prospective randomized controlled study comparing intravenous dexmedetomidine plus ketamine combination with intravenous dexmedetomidine alone for awake fibreoptic nasotracheal intubation

Abstract

Background The purpose of this study was to compare the efficacy and safety of dexmedetomidine versus dexmedetomidine and ketamine for sedation during awake fibreoptic intubation (FOI) in patients posted for elective surgeries. Ninety-eight American Society of Anesthesiologists Physical Status (ASA-PS) I–II patients with difficult airway and scheduled for elective surgeries were enrolled in this study after institutional ethics committee approval. Patients were randomly allocated into 2 groups, i.e. 49 patients in each group. Group D patients received 1 μg/kg dexmedetomidine IV over 10 min in 100-mL normal saline followed by a continuous infusion at 0.5 μg/kg/h till FOI and 5-mL normal saline followed by saline infusion. Group DK patients received 1 μg/kg dexmedetomidine IV over 10 min in 100-mL normal saline. Further, they received IV ketamine 15 mg as a bolus of 5 mL, followed by continuous infusion of ketamine at 20 mg/h until the end of intubation. The primary objective was to compare the efficacy of the combination of IV dexmedetomidine and ketamine with IV dexmedetomidine alone as sedation for FOI. Vocal cord movement, sedation, coughing, facial grimace score, recall of procedure, and haemodynamics were also compared in both groups. Results Demographic data, vocal cord movement, cough score, facial grimace score, total drugs used, hoarseness, sore throat and level of recall were comparable in both groups. Haemodynamics were significantly better in group DK at 2, 3, 4 and 5 min compared to group D. Conclusions Addition of ketamine to dexmedetomidine did not improve intubating conditions, reduce cough or improve recall of FOI. However, patients remain sedated when ketamine was used with dexmedetomidine. The study was not registered prospectively in any clinical trial registry.

Anesthesia for a Patient with Base of Tongue Mass undergoing Transoral Robotic Surgery: A Case Report

“… 12 It is usually performed while the patient is conscious and able to maintain airway reflexes. 14 , 15 As recommended by the 2022 ASA Practice Guidelines for Management of the Difficult Airway 12 , nasal AFOI was performed in this case rather than a surgical tracheostomy owing to the anatomical and clinical presentation of the base of tongue mass. 13 , 15 Ideally, a reinforced tracheal tube should be used to prevent compression by the retractor or robotic arms.…”

“… 14 , 15 As recommended by the 2022 ASA Practice Guidelines for Management of the Difficult Airway 12 , nasal AFOI was performed in this case rather than a surgical tracheostomy owing to the anatomical and clinical presentation of the base of tongue mass. 13 , 15 Ideally, a reinforced tracheal tube should be used to prevent compression by the retractor or robotic arms. 11 However, to facilitate TORS procedure, it requires the head to be in full extension and the length of the tracheal tube needs to be appropriately chosen to allow for this head extension 16 , hence the use of nasal RAE.…”

Comparative review of airway anesthesia and sedation methods for awake intubation

“…Table 2 describes recent comparative evidence of various methods of intravenous sedation for awake intubation [24,25 ▪ ,26,27,28 ▪▪ ,29–33]. Many studies assessed the efficacy of intravenous dexmedetomidine in the setting of awake intubation, and revealed that it often led to shorter time to intubation, higher patient satisfaction, greater hemodynamic stability, fewer incidences of oxygen desaturation and/or hypercarbia postintubation, decreased coughing, and better intubating conditions [24,25 ▪ ,26,27,28 ▪▪ ,29–33]. Furthermore, Jamgade et al [25 ▪ ] assessed the effect of the addition of intravenous ketamine to dexmedetomidine, and found that it led to shorter intubation times compared with dexmedetomidine alone, while better preserving hemodynamic stability.…”

“…Though not every combination of sedatives has been assessed in a randomized trial, it is likely that a balanced technique with multiple sedatives can provide the benefits of each sedative, while minimizing the risks associated with each medication. Table 2 describes recent comparative evidence of various methods of intravenous sedation for awake intubation [24,25 ▪ ,26,27,28 ▪▪ ,29–33]. Many studies assessed the efficacy of intravenous dexmedetomidine in the setting of awake intubation, and revealed that it often led to shorter time to intubation, higher patient satisfaction, greater hemodynamic stability, fewer incidences of oxygen desaturation and/or hypercarbia postintubation, decreased coughing, and better intubating conditions [24,25 ▪ ,26,27,28 ▪▪ ,29–33].…”

“…Multiple studies also assessed the use of opioid-based sedation techniques for AFOI, including fentanyl, remifentanil, and sufentanil [24–27,28 ▪▪ ,29,31,32]. Xu et al [24] demonstrated that a target-controlled infusion of remifentanil led to decreased coughing compared with intravenous dexmedetomidine, though also resulted in a higher incidence of patient recall and hypoxia, without improvement in success rate on first intubation attempt.…”