They say that anesthesiology is 95% comfy and relaxed and the other 5% is “oh shit”! It’s a great career choice — pretty flexible hours, great patient contact, broad spectrum medicine, crisis management, leadership role, etc.
There happened to be an interesting case in the OR — awake tracheostomy for a patient coming in from home.
The Difficult Airway in Head and Neck Tumor Surgery
Our patient had two prior tracheotomies all with successful decannulation. His most recent trach was about 2.5 months ago (which a fiberoptic intubation was used with a 6.0 ETT). He had a neck cancer with a rapidly growing tongue base tumor that seems to be less responsive to chemo than his shrinking neck tumor. Because of the enlarging size of the tongue base tumor, he is starting to notice worsening stridor without his trach. The ENT surgeon evaluated his airway just days before and deemed it unintubateable. Therefore, my plan was to have a pedi FO scope with 5.0 cuffed ETT (smallest available in our OR), glidescope, emergency cric supplies (14g angio cath, 3cc syringe with plunger removed and 7.0 ETT adapter hooked into the end of the syringe), jet ventilator and tubes, and ENT surgeon.
We decided to use a bit of midazolam as well as Precedex for the awake trach. The dosing on the package says 1 mcg/kg for 10 minutes then 0.7 mcg/kg/hr. We started with 0.5 mcg/kg for 10 minutes then 0.5 mcg/kg/hr. This regimen worked well as we started it in preop and monitored his SpO2 as he dozed off but was easily aroused to voice and gentle touch.
The Role of Dexmedetomidine for Awake Trach
Monitors were placed in the OR and we used a face mask running 10 L/min O2 with ETCO2 monitoring. Every now and then he would obstruct while lying supine, therefore, we placed a nasal trumpet to aid the obstruction. The surgeon localized the surgical area. See video for procedure.
The patient coughed once the trachea was perforated, but it was short lived as the surgeons were able to place the trach and hookup to our anesthesia circuit. After confirming ETCO2, we pushed propofol IV and the remainder of the case was performed under general anesthesia (direct laryngoscopy and biopsy by surgeon).
Key take home points
- Effective communication with the patient pre-op: expectations, sedation, potential complications.
- Arm yourself! Do this like you would a difficult airway! Fiberoptic intubation supplies, glidescope, emergency cricothyroidotomy supplies, backup LMA, extra hands on deck (grab your anesthesia colleagues, anesthesia techs, extra help!), ENT… it never hurts to be over prepared!
- Deliberate, effective communication with the ENT colleague across the drape.
- Document any intubation performed, tools used, trachs placed so your anesthesia colleagues will know what worked in the past to secure an airway.
- Breathe a sigh of relief bc these kind of cases are extremely uncommon! Pat yourself on the back for a job well-done!
Now check out this amazing Case Report on a patient with a massive maxillofacial tumor!
Love. Laughter. Life. Medicine. 