La dexmédétomidine et une faible dose de kétamine assurent une sédation adéquate pendant l’intubation fibroscopique vigile

Abstract

P Pu ur rp po os se e: : We report the use of the alpha 2 agonist, dexmedetomidine, with low-dose ketamine as a safe and effective treatment strategy to provide adequate comfort and sedation for a patient who fulfilled criteria of a difficult airway and required awake fibreoptic intubation (AFOI).C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 52-yr-old male with prostate cancer presented for radical prostatectomy. He reported several failed intubations with previous surgeries and airway examination was consistent with a difficult intubation. In addition, previous fibreoptic intubations were unsuccessful. The patient reported extreme apprehension concerning his airway management.The goal of medicating patients for AFOI includes providing comfort and sedation without causing a change in ventilatory status. Dexmedetomidine has a high affinity for the alpha 2 receptor and results in sedation without change in ventilatory status. In addition, dexmedetomidine is a potent anti-sialgogue which makes it desirable for cases involved with airway instrumentation. A loading dose of dexmedetomidine followed by a continuous infusion provided comfort and sedation within ten minutes. While bradycardia and hypotension have been reported with dexmedetomidine use, concurrent low-dose ketamine was employed in this case for it's cardiostimulatory properties and no bradycardia and hypotension were noted. The airway was anesthetized with selective nerve blocks and conditions for airway instrumentation were excellent. There was no change in oxygen saturation or ventilatory status during the administration of medications or airway manipulation. The patient was comfortable, sedated and tolerated the procedures well. There was no recall of the procedure.C Co on nc cl lu us si io on n: : Dexmedetomidine and concurrent low-dose ketamine provided sedation and comfort to this patient who required an AFOI. des difficultés d'intubation prévisibles et la nécessité d'une intubation fibroscopique vigile (IFV). Éléments cliniques : Un homme de 52 ans, atteint d'un cancer de la prostate, a été admis pour une prostatectomie radicale. La mention d'intubations impossibles lors d'interventions chirurgicales antérieures concordait avec l'examen des voies aériennes qui laissait prévoir des difficultés d'intubation. Des intubations fibroscopiques précédentes avaient aussi échoué. Le patient s'est dit très inquiet de subir une intubation. La médication qui accompagne l'IFV vise le confort et la sédation sans

Conscious sedation for awake fibreoptic intubation: a review of the literature

“…41,42 We identified 19 articles, five RCTs 13,29,43-45 and 14 case reports and case series [46][47][48][49][50][51][52][53][54][55][56][57][58][59] describing the use of dexmedetomidine for AFOI, usually as the sole agent but occasionally in combination with midazolam 43 or ketamine. 60 Although a TCI system for dexmedetomidine has been described for awake intubation, 47 it is generally administered as a slow bolus (usually 1 lgÁkg -1 over 10-20 min) to avoid peak-dose hypertension (which may exacerbate a bradycardia-related fall in cardiac output) followed by an infusion (usually of 0.1-0.7 lgÁkg…”

“…A previous case report had described the addition of ketamine to dexmedetomidine for AFOI, and its effects in countering the bradycardia associated with the latter may amount to a better use for this combination. 60 …”

Vía aérea “fisiológicamente” difícil: nuevo concepto a considerar – Caso clínico vía aérea difícil fisiológica

“…Una alternativa de sedoanalgesia en la UCI puede ser el uso de dexmedetomidina y/o ketamina, que brindan sedación adecuada y permiten mantener ventilación espontánea y la hemodinamia 27,28 . Entre las limitaciones existentes en este caso, podemos citar disponer sólo de un fibroscopio muy fino para el diámetro del tubo que la paciente requería.…”

Large Dose Dexmedetomidine in a Patient during Sedation for Invasive Oral Procedure

“…Dexmedetomidine also produces analgesia [2] and amnestic effects [7], and it has antisialagogue properties [8].…”