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Thepmankorn P, Sufian MA, Singer O, Gupta S, Grech D, Ballesteros T, Shah SP. Anesthetic Implications of Previously Undiagnosed Temporomandibular Joint Ankylosis: A Case Report. A A Pract 2023; 17:e01640. [PMID: 36706159 DOI: 10.1213/xaa.0000000000001640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Temporomandibular joint (TMJ) ankylosis is characterized by bony fusion that limits TMJ mobility. We present the case of an elderly woman who was brought to the operating room for dental rehabilitation under general anesthesia. The patient had an undiagnosed TMJ ankylosis, which was discovered only after induction of anesthesia due to her nonverbal status and advanced dementia. The surgical team canceled the case due to limited access to the surgical field. We discuss the factors that suggest TMJ ankylosis and propose the perioperative management when TMJ ankylosis is suspected but unconfirmed.
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Affiliation(s)
- Parisorn Thepmankorn
- From the Department of Anesthesia, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Mahir A Sufian
- From the Department of Anesthesia, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Omar Singer
- From the Department of Anesthesia, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Somdatta Gupta
- Department of Anesthesia, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dennis Grech
- From the Department of Anesthesia, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Tomas Ballesteros
- Department of General Dentistry, Rutgers School of Dentistry, Newark, New Jersey
| | - Shridevi Pandya Shah
- From the Department of Anesthesia, Rutgers New Jersey Medical School, Newark, New Jersey
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Naithani B, Sachan M, Singh N, Abbas H, Dube M, Naithani B. Comparative study of intubating conditions and hemodynamic changes during awake fiber-optic intubation using midazolam with fentanyl versus dexmedetomidine in cases of difficult airway. Natl J Maxillofac Surg 2022; 13:201-207. [PMID: 36051793 PMCID: PMC9426700 DOI: 10.4103/njms.njms_208_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/24/2020] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background: The aim of the study is to compare intubating conditions and hemodynamic changes during awake fiber-optic intubation (AFOI) using midazolam and fentanyl versus dexmedetomidine in cases of difficult airway. Materials and Methods: A randomized prospective study was conducted in the department of oral and maxillofacial surgery, with a total of 60 patients, 18–55 years of age, ASA class I–II, of either sex with anticipated difficult airway planned for elective surgery. They were divided into two groups; group I patients received 1 μg/kg of dexmedetomidine and then an infusion of 0.5 to 0.7 μg/kg/hr of dexmedetomidine, whereas group II patients received 1 μg/kg of intra-venous (iv) fentanyl and 0.05 mg/kg of iv midazolam with additional doses of 0.02 mg/kg to achieve a Ramsay Sedation Scale score of ≥2. The ease of placement of the fiber-optic scope and the endotracheal tube and the patient's reaction to placement of the fiber-optic scope were assessed on a scale of 1–4 and were recorded as endoscopist satisfaction score and patient discomfort score, respectively. Results: The endoscopy time ranged from 2.66 ± 1.00 (group I) to 3.90 ± 0.96 (group II) minutes and was found to be statistically significant (p < 0.05). Also, the patient discomfort score was recorded during endoscopy (1–4) and ranged from 1.3 ± 0.53 (group I) and 2.33 ± 0.66 (group II) and was found to be statistically significant (p value < 0.05). Patients undergoing the procedure who received dexmedetomidine were thus more comfortable than those who received fentanyl and midazolam combination. Conclusion: Dexmedetomidine provided better intubating conditions, patient tolerance, higher endoscopist satisfaction, and reduced hemodynamic responses compared to fentanyl and midazolam combinations. Also, the major advantage of dexmeditomidine for preservation of airway with a lesser degree of respiratory depression allows for safer use of AFOI in cases of difficult airway.
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El Sharkawy RA. Efficacy of Adding Low-Dose Ketamine to Dexmedetomidine Versus Low-Dose Ketamine and Propofol for Conscious Sedation in Patients Undergoing Awake Fiber-optic Intubation. Anesth Essays Res 2019; 13:73-78. [PMID: 31031484 PMCID: PMC6444948 DOI: 10.4103/aer.aer_181_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Conscious sedation is the key for successful AFOI. This trial was conducted to compare the effectiveness of dexmedetomidine and low dose of ketamine against propofol and low dose ketamine. Materials and Methods: Sixty patients subjected for general anesthesia were invited to participate in the study and randomly allocated into two equal groups: D-K (n = 30) had been received a bolus dose of both ketamine 0.5mg /kg and dexmedetomidine 1ug/kg over 10 min. Then continuous infusion of ketamine 0.5mg /kg and dexmedetomidine 1ug/kg. The second group (P-K group) (n = 30): had been received a bolus dose of both ketamine 0.5mg/kg and propofol 1mg/kg over 10 min. Then continuous infusion of ketamine 0. 5mg/kg and propofol 1mg/kg. Results: The intubation time was statistically significant shorter within the D-K group (58.9 ± 6.1) versus P-K group (63.4 ± 5.3) with p-value 0.02. The shorter time needed to achieve the OAA/S score = 2 was in the D-K group (2.25 ± 0.75) versus (2.9 ± 0.79) in P-K group with (P-value 0.004). The intubation scores were insignificant different between both groups except vocal cord opening which was statistical better among D-K group with P-value 0.03. The significant hypotensive recorded data were among P-K group while the decreased heart rate were recorded in D-K group. Eighty percentages of patients had excellent score of satisfaction within the D-K gp against 47% among the patients within P-K gp with P-value 0.01. Conclusion: The concomitant administration of low dose of ketamine with dexmedetomidine had better intubation time and sedation scores with higher patient satisfaction scores than the combination of propofol and low dose of ketamine.
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Affiliation(s)
- Reem Abdelraouf El Sharkawy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Tsukamoto M, Hitosugi T, Yokoyama T. Awake fiberoptic nasotracheal intubation for patients with difficult airway. J Dent Anesth Pain Med 2018; 18:301-304. [PMID: 30402550 PMCID: PMC6218389 DOI: 10.17245/jdapm.2018.18.5.301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/12/2018] [Accepted: 09/11/2018] [Indexed: 11/15/2022] Open
Abstract
Awake fiberoptic nasotracheal intubation is a useful technique, especially in patients with airway obstruction. It must not only provide sufficient anesthesia, but also maintain spontaneous breathing. We introduce a method to achieve this using a small dose of fentanyl and midazolam in combination with topical anesthesia. The cases of 2 patients (1 male, 1 female) who underwent oral maxillofacial surgery are reported. They received 50 µg of fentanyl 2-3 times (total 2.2-2.3 µg/kg) at intervals of approximately 2 min. Oxygen was administered via a mask at 6 L/min, and 0.5 mg of midazolam was administered 1-4 times (total 0.02-0.05 mg/kg) at intervals of approximately 2 min. A tracheal tube was inserted through the nasal cavity after topical anesthesia was applied to the epiglottis, vocal cords, and into the trachea through the fiberscope channel. All patients were successfully intubated. This is a useful and safe method for awake fiberoptic nasotracheal intubation.
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Affiliation(s)
- Masanori Tsukamoto
- Department of Dental Anesthesiology, Kyushu University Hospital, Fukuoka, Japan
| | - Takashi Hitosugi
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Takeshi Yokoyama
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Rajan S, Talukdar R, Tosh P, Paul J, Vasu BK, Kumar L. Hemodynamic Responses and Safety of Sedation Following Premedication with Dexmedetomidine and Fentanyl during Fiberoptic-assisted Intubation in Patients with Predicted Difficult Airway. Anesth Essays Res 2018; 12:11-15. [PMID: 29628546 PMCID: PMC5872845 DOI: 10.4103/aer.aer_176_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: Awake fiberoptic intubation (AFOI) is the gold standard for the management of predicted difficult airway, and inappropriate sedation is a major cause leading to its failure. Aims: The primary objective was to compare the heart rate (HR) changes that accompany AFOI following sedation with dexmedetomidine and fentanyl. Secondary objectives included comparison of changes in blood pressure, patient comfort, ease of intubation, and degree of sedation. Settings and Designs: This prospective double-blinded randomized study was conducted in a tertiary care institution. Subjects and Methods: Forty patients with anticipated difficult airway requiring AFOI were included in the study. Group A received dexmedetomidine 1 μg/kg whereas Group B received fentanyl 2 μg/kg. After topical anesthesia of the airway, AFOI was performed. Statistical Analysis Used: Fisher's exact test, independent two-sample t-test, and Mann–Whitney U-test were used as applicable. Results: The hemodynamic parameters were comparable in both the groups except at 1 min postintubation when fentanyl group had significantly higher HR. There were lower alertness and muscle tone scores in dexmedetomidine group. Total comfort score was significantly higher in fentanyl group. Though more patients in dexmedetomidine group showed that no reaction to intubation and more patients in fentanyl had slight grimacing, the difference was insignificant. The ease of intubation was similar in both the groups. Conclusion: Though dexmedetomidine1 μg/kg and fentanyl 2 μg/kg premedication results in comparable hemodynamics and ease of intubation, in view of enhanced patient comfort, dexmedetomidine premedication is advantageous in patients with anticipated difficult airway undergoing AFOI.
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Affiliation(s)
- Sunil Rajan
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Rittick Talukdar
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Pulak Tosh
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Jerry Paul
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Bindu K Vasu
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Lakshmi Kumar
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
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Kumar P, Kaur T, Atwal GK, Bhupal JS, Basra AK. Comparison of Intubating Conditions using Fentanyl plus Propofol Versus Fentanyl plus Midazolam during Fiberoptic Laryngoscopy. J Clin Diagn Res 2017; 11:UC21-UC24. [PMID: 28893016 DOI: 10.7860/jcdr/2017/26479.10220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/06/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Awake nasal or oral flexible fiberoptic intubation is the airway management technique of choice in known or anticipated difficult airway, unstable cervical fracture, limited mouth opening (as in temporomandibular joint disease), mandibular-maxillary fixation and severe facial burns. Both optimal intubating condition and patient comfort are important for fiberoptic intubation. Optimal intubating conditions provided by an ideal sedation regimen would ensure haemodynamic stability, patient comfort, attenuation of airway reflexes and amnesia. AIM To compare the intubating conditions using fentanyl plus propofol versus fentanyl plus midazolam during fiberoptic laryngoscopy. MATERIALS AND METHODS A prospective, comparative and randomized study was conducted on 60 patients of either gender aged between 18 and 60 years belonging to the American Society of Anaesthesiologists (ASA) grade-I or II scheduled for elective surgery. Patients were randomly allocated into two groups of 30 each. In group I, patients received i.v. fentanyl 1 μg/kg+ propofol 1 mg/kg to achieve an adequate level of sedation that is Ramsay Sedation Scale (RSS) score of 3. In group II, patients received i.v. fentanyl 1 μg/kg + midazolam 0.03 mg/kg to achieve RSS= score of 3. Haemodynamic parameters (heart rate, systolic and diastolic blood pressure, mean arterial pressure), SpO2, EtCO2, total comfort scale values and patient's tolerance were assessed during preoxygenation, fiberscope insertion and endotracheal intubation. RESULTS Fentanyl plus midazolam group showed better patient comfort and maintenance of oxygen saturation than fentanyl plus propofol group during fiberoptic intubation. CONCLUSION Both fentanyl plus midazolam and fentanyl plus propofol regimes are suitable for fiberoptic intubation. Fentanyl plus midazolam appeared to offer better tolerance, preservation of an airway and spontaneous ventilation, while maintaining haemodynamic stability.
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Affiliation(s)
- Parmod Kumar
- Professor and Head, Department of Anaesthesiology and Intensive Care, GMC and RH, Patiala, Punjab, India
| | - Tripat Kaur
- Associate Professor, Department of Anaesthesiology and Intensive Care, GMC and RH, Patiala, Punjab, India
| | - Gurpreet Kaur Atwal
- Junior Resident, Department of Anaesthesiology and Intensive Care, GMC and RH, Patiala, Punjab, India
| | - Jatinderpaul Singh Bhupal
- Retired Professor and Head, Department of Anaesthesiology and Intensive Care, GMC and RH, Patiala, Punjab, India
| | - Ajay Kumar Basra
- Junior Resident, Department of Anaesthesiology and Intensive Care, GMC and RH, Patiala, Punjab, India
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Li CW, Li YD, Tian HT, Kong XG, Chen K. Dexmedetomidine-midazolam versus Sufentanil-midazolam for Awake Fiberoptic Nasotracheal Intubation: A Randomized Double-blind Study. Chin Med J (Engl) 2016; 128:3143-8. [PMID: 26612286 PMCID: PMC4794886 DOI: 10.4103/0366-6999.170260] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Awake fiberoptic intubation (AFOI) is usually performed in the management of the predicted difficult airway. The aim of this study was to evaluate the feasibility of dexmedetomidine with midazolam (DM) and sufentanil with midazolam (SM) for sedation for awake fiberoptic nasotracheal intubation. METHODS Fifty patients with limited mouth opening scheduled for AFOI were randomly assigned to two groups (n = 25 per group) by a computer-generated randomization schedule. All subjects received midazolam 0.02 mg/kg as premedication and airway topical anesthesia with a modified "spray-as-you-go" technique. Group DM received dexmedetomidine at a loading dose of 0.5 μg/kg over 10 min followed by a continuous infusion of 0.25 μg·kg-1·h-1, whereas Group SM received sufentanil at a loading dose of 0.2 μg/kg over 10 min followed by a continuous infusion of 0.1 μg·kg-1·h-1. As necessary, since the end of the administration of the loading dose of the study drug, an additional dose of midazolam 0.5 mg at 2-min intervals was given to achieve a modified Observers' Assessment of Alertness/Sedation of 2-3. The quality of intubation conditions and adverse events were observed. RESULTS The scores of ease of the AFOI procedure, patient's reaction during AFOI, coughing severity, tolerance after intubation, recall of the procedure and discomfort during the procedure were comparable in both groups (z = 0.572, 0.664, 1.297, 0.467, 0.895, and 0.188, respectively, P > 0.05). Hypoxic episodes similarly occurred in the two groups, but the first partial pressure of end-tidal CO2after intubation was higher in Group SM than that in Group DM (45.2 ± 4.2 mmHg vs. 42.2 ± 4.3 mmHg, t = 2.495, P < 0.05). CONCLUSIONS Both dexmedetomidine and sufentanil are effective as an adjuvant for AFOI under airway topical anesthesia combined with midazolam sedation, but respiratory depression is still a potential risk in the sufentanil regimen.
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Affiliation(s)
- Cheng-Wen Li
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong 272011, China
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Management of Young Patients with Temporomandibular Joint Ankylosis-a Surgical and Anesthetic Challenge. Indian J Surg 2016; 78:482-489. [PMID: 28100946 DOI: 10.1007/s12262-016-1551-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/05/2016] [Indexed: 12/19/2022] Open
Abstract
Temporomandibular joint ankylosis is a unique disease where fracture of the mandibular condyle or any other cause leading to ankylosis of the joint can lead to multiple problems if not detected and treated early. If affected in early years of life, it may cause facial dysmorphism, restricted mouth opening, and difficulty in eating, speech, and sleep. Early surgery and physiotherapy can restore the joint function to a great extent. Anesthetizing a pediatric patient with this disorder is a definite challenge which needs expertise in difficult airway management.
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Mondal S, Ghosh S, Bhattacharya S, Choudhury B, Mallick S, Prasad A. Comparison between dexmedetomidine and fentanyl on intubation conditions during awake fiberoptic bronchoscopy: A randomized double-blind prospective study. J Anaesthesiol Clin Pharmacol 2015; 31:212-6. [PMID: 25948903 PMCID: PMC4411836 DOI: 10.4103/0970-9185.155151] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Various drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them cause respiratory depression and airway obstruction leading to hypoxemia. The aim of this study was to compare intubation conditions, and incidence of desaturation between dexmedetomidine and fentanyl group during AFOI. Material and Methods: This randomized double-blind prospective study was conducted on a total of 60 patients scheduled for elective laparotomies who were randomly allocated into two groups: Group A received dexmedetomidine 1 mcg/kg and Group B received fentanyl 2 mcg/kg over 10 min. Patients in both groups received glycopyrrolate 0.2 mg intravenous, nebulization with 2% lidocaine 4 ml over 20 min and 10% lidocaine spray before undergoing AFOI. Adequacy of intubation condition was evaluated by cough score and post-intubation score. Incidence of desaturation, hemodynamic changes and sedation using Ramsay sedation scale (RSS) were noted and compared between two groups. Results: Cough Score (1-4), post-intubation Score (1-3) and RSS (1-6) were significantly favorable (P < 0.0001) along with minimum hemodynamic responses to intubation (P < 0.05) and less oxygen desaturation (P < 0.0001) in Group A than Group B. Conclusion: Dexmedetomidine is more effective than fentanyl in producing better intubation conditions, sedation along with hemodynamic stability and less desaturation during AFOI.
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Affiliation(s)
- Sudeshna Mondal
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
| | - Sarmila Ghosh
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
| | - Susmita Bhattacharya
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
| | - Brojen Choudhury
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
| | - Suchismita Mallick
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
| | - Anu Prasad
- Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
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