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78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024
December 6 - 9, 2024 | New York City
3132
Navigating The Goiter: Awake Fiberoptic Intubation and Remimazolam Sedation for the Management of an Anticipated Difficult Airway Due to A Retrosternal Mass
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Navigating The Goiter: Awake Fiberoptic Intubation and Remimazolam Sedation for the Management of an Anticipated Difficult Airway Due to A Retrosternal Mass
Mariam ElSaban1, MBBS; Edwin Rho1, MD; Laurence Torsher1, MD; Matthew Vogt1, MD
1. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
CASE DESCRIPTION
•71-years old female with a PMHx of HTN, Hypothyroidism, OSA on CPAP, goiter.
•Presents for a total thyroidectomy for a symptomatic goiter.
CASE WORKUP
•Radiography: Enlarged thyroid lobes
•Right 2*2*8cm and Left 4*4*10cm with compression of trachea to the right at the level of the thoracic inlet.
ANESTHETIC PLAN
•Plan: Airway management with an awake fiberoptic intubation
•Pre-op: Nebulized Lidocaine and Glycopyrrolate.
•Intra-op:
•Remimazolam used for procedural sedation.
•Awake fiberoptic intubation with 6.0 ETT.
•Normal glottic structures viewed, and bilateral tracheal compression below cord visualized.
•6.0 ETT Successfully advanced past narrowing.
•General anesthesia induced and maintained with propofol and remifentanil infusions.
•Uneventful anesthetic and recovery.
DISCUSSION
•Awake fiberoptic intubation (AFOI) is particular useful in the management of difficult airways such as those caused by large thyroid goiter (1-2).
•Effective topical anesthesia improves tolerability and success of AFOI.
•Remimazolam, a novel benzodiazepine with short context-sensitive half life, was our agent of choice to enhance sedation and minimize respiratory depression.
•Recent trial revealed positive findings with shorter intubation time, higher antegrade amnesia with AFOI as compared to precedex (3).
REFERENCES
1.Ahmad I et al. 2022. Difficult Airway Society Guidelines for awake tracheal intubation in adults.
2.Jeffrey et al. 2022. American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.
3.Chen Q et al. 2024 The Saftey and Efficacy of Remimazolam compared to Dexmedetomidine for Awake Tracheal Intubation by Flexible Bronchoscopy: A Randomized, Double Blind, Controlled trial.