Emergency Airway Management During Awake Craniotomy: Comparison of 5 Techniques in a Cadaveric Model

Abstract

Background: During awake craniotomy, securing the patient's airway might be necessary electively or emergently. The objective of this study was to compare the feasibility of airway management using a laryngeal mask airway (LMA) and 4 alternative airway management techniques in an awake craniotomy simulation.Methods: After completing a questionnaire, 9 anesthesia providers attempted airway management in a cadaver positioned to simulate awake craniotomy conditions. Following the simulation, participants rated and ranked the devices in their order of preference.Results: Only 3 approaches resulted in the successful securement of an airway device for 100% of participants: LMA (median; interquartile range time to secure the airway 6 s, 5 to 10 s), fiberoptic bronchoscopy through an LMA (41 s; 23 to 51 s), and video laryngoscopy (49 s; 43 to 127 s). In contrast, the oral and nasal fiberoptic approaches demonstrated only 44.4% (154.5 s; 134.25 to 182 s) and 55.6% (75 s; 50 to 117 s) success rates, respectively. The LMA was the fastest and most reliable primary method to secure the airway (P=0.001). After the simulation, 100% of participants reported that an LMA would be their first choice for emergency airway management, followed by fiberoptic intubation through the LMA (7 of 9 participants) if the LMA failed to properly seat. Conclusions:We demonstrated that an LMA was the fastest and most reliable primary method to secure an airway in a laterally positioned cadaver with 3-pin skull fixation. Fiberoptic and video laryngoscope airway equipment should be readily available during awake craniotomy procedures, and an attempt to visualize the vocal cords through the LMA should be attempted before removing it for alternative techniques.

Airway Management in Neuroanesthesia

“…Supraglottic airway devices used during awake surgeries are a feasible option. According to some authors, these should be the first choice for emergency airway management, followed by fiberoptic intubation through the laryngeal mask airway ( 50 ).…”

Simulation in Anesthesia for Perioperative Neuroscience: Present and Future

“…The authors found that a laryngeal mask airway (LMA) was adequate and timely for securing the airway compared with intubation with a direct or video laryngoscope. In a subsequent study utilizing a cadaveric model, Gruenbaum et al 17 confirmed that the LMA was the quickest and most reliable primary technique for securing an emergency airway during an awake craniotomy.…”

“…These models can simulate complex cranial base surgery, intraventricular tumor resection, and anterior cervical discectomy and fusion 10 . Anesthesiologists can practice managing significant blood loss and resuscitation, traumatic injuries, and airway complications 10,17,18 …”

“…10 Anesthesiologists can practice managing significant blood loss and resuscitation, traumatic injuries, and airway complications. 10,17,18 Mathematical (Computational) Models Mathematical models are used to understand and predict various aspects of neuroanesthesia by simulating brain dynamics during anesthesia, neurophysiological changes during spine surgery, and cerebral blood flow during craniotomy. 19 These models provide insights into the brain's response to anesthetic agents, potential neurological changes during surgery, and blood flow dynamics during different stages of a craniotomy.…”

“…This simulation scenario has contributed to the development of clinical frameworks for emergency high-risk airway management in neuroanesthesia. 12,17 In a mannequin study by Brockerville et al, 12 the most effective device for emergency airway control during surgery for deep brain stimulation and intraoperative imaging with a stereotactic headframe was assessed. The authors found that a laryngeal mask airway (LMA) was adequate and timely for securing the airway compared with intubation with a direct or video laryngoscope.…”