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    Add as FriendAwake fiberoptic intubation with sedation in cardiac

    by: dr nayana kulkarni

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    1 : Awake fiberoptic intubation with sedation in cardiac (high risk) patients-Our experience. Authors: Dr Nayana Kulkarni (Curie Manavata Cancer Center,Nasik) Dr Deo Shirish (Senior Anesthesiologist,Nasik) Dr Vinaya Kulkarni (Lecturer,BJMC Pune-Special thanks)
    2 : Introduction Anesthesia is a skilled art. An Anesthesiologist needs to have fine tuning with the physiology of every patient subjected to anesthesia. Cardiac high risk patients are always a challange. There is high rate of morbidity and mortality associated with surgery and anesthesia in these patients. So we need to find a safer alternative to routine GA induction to increase safety margin.
    3 : Introduction Woodall et al (2008) studied complications of AWFOI without sedation in 200 healthy volunteers. They reported that 46 of them had more than 20% increase in SBP and more than 30% increase in heart rate. Avoiding sedation- loss of hemodynamic stability. On this background we have studied Awake Fibreoptic technique(AWFOI) combined with sedation in cardiac (high risk) patients posted for various types of major onco-surgeries.
    4 : Aims To study the hemodynamic changes during AWFOI with sedation in cardiac (high risk) patients. To study ideal and safe sedation requirements. To suggest recommendations based on findings of present study.
    5 : Materials and methods: Approval from the institutional ethics committee was taken. 30 patients of ASA III were included in the study. Inclusion criteria – patients with long standing Hypertension,Diabetes, H/o Angioplasty, H/o CABG,h/o previous MI(>6 months back). Patient were explained about the procedure in detail and written consent with due risk was taken before the procedure. Patients fasted for 6 hours before the surgery.
    6 : Materials and methods: The protocol of nebulisation with 4% xylocaine 2 ml (80mg) half hour prior to surgery was followed in every patient. All resuscitation equipments were kept ready. Olympus Scope CV-70 was used. After initiation of non invasive monitoring, Oxygen by nasal cannula was connected for 5 minutes. Airway anesthesia was performed as per table 1.
    7 : Table 1: Airway anesthesia
    8 : Sedation protocol Inj Midazolam 0.05 mg/kg to 0.07mg/kg. Inj Fentanyl 1-2microgram/kg. Patients were instructed to indicate pain or distress by elevating their arm. O2 by nasal cannula was taped. Endoscopies were performed using Olympus CV-70, scope displayed on monitor. Modified Stewart score was kept between 5-7 for optimal sedation level.(consciousness 2-3, airway 2, activity 1-2). Patients were assessed at 5min post Midazolam and airway anesthesia, 10 min post fentanyl and then procedure was started.
    9 : protocol Parameters monitored during the procedure. Pulse rate(PR) Heart rate(HR) ECG Oxygen saturation(SPO2) Noninvasive Blood pressure(SBP,DBP) RPP. All readings were taken at 5min intervals. SBP and HR, MAP, RPP at end of procedure were compared to the baseline level. Statistical analysis was done using microsoft office excel 2007. Paired t-test was used to check whether the difference between the parameters (at 0 min and 20 min) was significant.
    10 : Readings were taken at: O min- pt connected to monitor (baseline) 5min- post Midazolam and intra-tracheal xylocard, airway anesthesia 10 min- post Fentanyl, start of procedure 15 min- reading 20 min – end of procedure. (For all parameters).
    11 : Results Table 1: Demographic characteristics of study subjects.
    12 : Table 1:Pulse rate changes and SBP There was no significant difference between the mean pulse rate at baseline and post intubation (p = 0.16) There was no significant difference between the mean SBP at baseline and post intubation (p = 0.11)
    13 : Table 3:Diastolic Blood Pressure and MAP There was no significant difference between the mean DBP at baseline and post intubation (p =0.98) There was no significant difference between the mean MAP at baseline and post intubation (p = 0.42)
    14 : Table 4:Rate Pressure Product There was no significant difference between the mean RPP at baseline and post intubation (p = 0.05)
    15 : Discussion We have studied the hemodynamic response to AWFOI with sedation in cardiac (high risk) patients posted for major onco-surgeries. Woodall et al (2008) conducted AWFOI (with LA) in healthy volunteers without sedation reported that 23% had shown rise in SBP and HR( of >20% and 30% resp.) as a result of avoiding sedation. They concluded that in patients with HT and IHD use of sedation is recommended.
    16 : Discussion Ovassipian et al (1983) have studied hemodynamic changes during Awake FOI. Few studies have used positive pressure ventilation with FOI using LMA,ILMA and endoscopic mask techniques found that problem of gastric insufflation is more frequent.(Yasunaga et al- 2002).
    17 : Discussion We combined AWFOI technique with sedation in cardiac (high risk) patients and found that there are no statistically significant changes in hemodynamic parameters(HR,SBP,RPP) We also found that dosages of Midazolam between 0.05mg/kg to 0.07mg/kg and Fentanyl 1-2µg/kg are safe and effective as the mean SPO2 value (at 0min and 20 min) is not statistically significant.
    18 : Discussion Smith et al (1992) studied CV changes with O2 saturation during FOI under GA and found considerable O2 desaturation. Cole et al(1994) reported 2 FOI failures in 33 patients under GA, stating that safety is maximized by doing the procedure with patients awake. M R Rai (2008) did Remifentanil TCI Vs Propofol TCI for conscious sedation for AFOI: a Double Blind RCT concluded that Remifentanil provided better conditions for AFOI but have a higher incidence of recall. As Remifentanil was unavailable we used Fentanyl and Midazolam as sedative drugs considering the cardiac condition of our patients.
    19 : Conclusion We therefore conclude that Awake Fiberoptic Intubation technique when combined with sedation is safe and effective as regards to hemodynamic stability in cardiac (high risk) patients . The safe sedation dosages of Midazolam and Fentanyl are 0.05mg/kg-0.07mg/kg and 1-2µg/kg respectively. A Study in large group with newer agents like Remifentanil might be even better in cardiac (high risk) patients.
    20 : Thank you
    21 : Poem- Mezolam and Fentanyl Journey Induction with Mezolam and Fentanyl hand in hand, For purpose of GA by anesthesia band, Gives us hemodynamically stable platform to stand, Everything stays under anesthesiologist’s command.   The train of surgery whistles, After getting adequate anesthesia depth, Then starts the journey to the unknown Exploration and the real test, watch your breath!   Our patient travels in quiet tranquility, His stable vitals tell the delivery of best anesthesia quality.   Surgeon as the driver, Anesthesiologist as the guard, And the rest of the OT team keeps Ambience clean, sterile, by striving very hard!    
    22 : As the journey comes to an end, To send the patient back in PICU tent, Team cheers patient for grand welcome, Back in form of number one!   As the patient gets up from slumber, He says where am I? I don’t remember! In real sense, this journey is wonderful, And the experience for everyone is Blissful!!     Dr Nayana Kulkarni.   This proves success of sedation, Adequacy of depth and so- congratulation!  

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