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Ultrasound-guided superior laryngeal nerve block assists in anesthesia for bronchoscopic surgical procedure: A case report of anesthesia for rigid bronchoscopy.

超声引导下喉上神经阻滞辅助麻醉行支气管镜下手术1例

  • 影响因子:1.95
  • DOI:10.1097/MD.0000000000020916
  • 作者列表:"Liao YC","Wu WC","Hsieh MH","Chang CC","Tsai HC
  • 发表时间:2020-07-02
Abstract

INTRODUCTION:Evolving techniques in the field of therapeutic bronchoscopy have led to the return of rigid bronchoscopy in the treatment of complex central airway disease. Rigid bronchoscopy is typically performed under general anesthesia because of the strong stimulation caused by metal instruments. Anesthesia for rigid bronchoscopy is challenging to administer because anesthesiologists and interventionists share the same working channel: the airway. Previously reviewed anesthetic methods are used primarily for short procedures. Balanced anesthesia with ultrasound-guided superior laryngeal nerve (SLN) block and total intravenous anesthesia might provide anesthesia for a prolonged procedure and facilitate patient recovery. PATIENT CONCERNS:A patient with obstructed endobronchial stent was referred for therapeutic rigid bronchoscopy, which requires deeper anesthesia than flexible bronchoscopy. There were concerns of the stronger stimulation of the rigid bronchoscopy, lengthy duration of the procedure, higher risk of hypoxemia, and the difficulty of mechanical ventilation weaning after anesthesia due to the patients co-morbidities. DIAGNOSIS:A 66-year-old female patient presented with a history of breast cancer with lung metastases. Right main bronchus obstruction due to external compression of lung metastases was relieved through insertion of an endobronchial stent, but obstructive granulation developed after 4 months. Presence of the malfunctioning stent caused severe cough and discomfort. Removal of the stent by using a flexible bronchoscope was attempted twice but failed. INTERVENTIONS:Regional anesthesia of the upper airway through ultrasound-guided SLN block combined with intratracheal 2% lidocaine spray was performed to assist in total intravenous anesthesia (TIVA) during rigid bronchoscopy. OUTCOMES:The patient maintained steady spontaneous breathing throughout the procedure without laryngospasm, bucking, or desaturation. Emergence from anesthesia was smooth and rapid after propofol infusion was discontinued. The surgery lasted 2.5 hours without discontinuity, and no perioperative pulmonary or cardiovascular complications were noted. CONCLUSION:Ultrasound-guided SLN block is a simple technique with a high success rate and low complication rate. Application of SLN block to assist TIVA provides sufficient anesthesia for lengthened therapeutic rigid bronchoscopy without interruption and facilitates patient recovery.

摘要

引言: 治疗性支气管镜检查领域的技术不断发展,导致了硬性支气管镜检查在治疗复杂中央气道疾病中的回归。由于金属器械引起的强烈刺激,刚性支气管镜检查通常在全身麻醉下进行。刚性支气管镜检查的麻醉具有挑战性,因为麻醉师和介入医师共享相同的工作通道: 气道。以前审查的麻醉方法主要用于短期程序。超声引导下喉上神经 (SLN) 阻滞和全静脉麻醉的平衡麻醉可能为延长手术时间提供麻醉并促进患者恢复。 患者担忧: 1例支气管内支架阻塞的患者被转诊进行治疗性硬性支气管镜检查,其需要比柔性支气管镜检查更深的麻醉。有人担心刚性支气管镜检查的刺激较强,手术时间较长,低氧血症的风险较高,以及由于患者合并疾病而导致麻醉后机械通气撤机的困难。 诊断: 患者女,66岁,乳腺癌肺转移病史。由于肺转移瘤的外部压迫,右主支气管阻塞通过插入支气管内支架缓解,但4个月后出现阻塞性肉芽。支架出现故障引起严重的咳嗽和不适。尝试使用柔性支气管镜移除支架两次,但失败。 干预措施: 通过超声引导下SLN阻滞联合气管内2% 利多卡因喷雾进行上气道区域麻醉,以辅助硬质支气管镜检查时的全凭静脉麻醉 (TIVA)。 结果: 患者在整个过程中保持稳定的自主呼吸,没有喉痉挛、呛咳或去饱和。停止丙泊酚输注后,麻醉苏醒平稳、迅速。手术持续2.5小时,无间断,无围手术期肺部或心血管并发症。 结论: 超声引导下SLN阻滞操作简单,成功率高,并发症发生率低。应用SLN阻滞辅助TIVA为延长的治疗刚性支气管镜检查提供了充分的麻醉,没有中断,并有利于患者恢复。

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发表时间:2020-01-01
DOI:10.1213/ANE.0000000000003975
作者列表:["Uppal V","Retter S","Casey M","Sancheti S","Matheson K","McKeen DM"]

METHODS:BACKGROUND:Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS:Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS:Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS:Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.

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影响因子:2.27
发表时间:2020-05-01
DOI:10.1213/ANE.0000000000004012
作者列表:["Jean YK","Kam D","Gayer S","Palte HD","Stein ALS"]

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