The AFOI with Intravenous Dexmedetomidine as an Airway Management Technique of Choice in Planned Maxillofacial/ Panfacial Injury Reconstruction Surgeries – A Case Series.

Abstract

Maxillofacial trauma poses significant airway management challenges for anesthesiologists due to the risk of difficulty in ventilation and difficulty in intubation. Effective airway management is critical during elective surgeries, as both the anesthesiologist and surgeon require adequate space for their respective tasks, particularly when maxillomandibular fixation is necessary for reconstructing facial fractures. Awake fiber-optic intubation(AFOI) is most preferred in the anticipated difficult airway management. Adequate sedation with effective airway topical anesthesia is of para? mount to achieve that as well as to improve intolerance, alleviate discomfort, and achieve successful AFOI. Dexmedetomidine is a preferred sedative due to its effectiveness without significant respiratory depression, providing better tolerability in AFOI compared to other agents. AFOI with dexmeditomide sedation also enhances patient comfort ,provides good hemodynamic stability , better intubating conditions and significantly improves clinical outcomes. We have presented AFOI with Dexmedetomidine sedation as the most appropriate approach in a series of cases with anticipated difficult airway due to panfacial/maxillofacial trauma undergoing elective facial bone reconstructive surgeries.

Keywords

Introduction

Image 1.2—3d ct face of different facio-maxillary injuries with AFOI procedure steps

DISCUSSION

Maxillofacial trauma presents significant challenges for anesthesiologists due to potential airway complications, making airway management a primary concern. Effective management requires rapid coordination among anesthesiologist and surgical team, emphasizing the importance of maintaining a patent airway while performing elective surgeries.The surgeon needs access to an unobstructed field and in most cases; either intermaxillary or maxillomandibular fixation is required intraoperatively for adequate reconstruction of facial fractures. Essentially the anaesthesiologist and the surgeon are competing for the same space.Clinically, patients may present with edema, mobility issues, and potential complications like distorted anatomy , airway obstruction and possible haemorrhage.[2]Failure to secure the airway can lead to severe morbidity and mortality, often arising from difficulties in intubation and ventilation associated with facial injuries. Research indicates , up to 38% of individuals with facial injuries may experience ventilation challenges and studies reveal that 30% of perioperative deaths are attributed to failures in airway management, underscoring the gravity of this issue.[4]

Awake fiberoptic intubation (AFOI) is a critical technique employed by anesthesiologists when faced with anticipated difficult airways.The ability to predict and assess the risk factors associated with difficult airway management is vital, as it allows for timely intervention and preparation [5].Over the years, advancements in fiberoptic technology have enhanced the application and success rates of AFOI, leading to its widespread recognition as a highly effective method. In cases where challenges like difficult laryngoscopy, difficult mask ventilation, risk of aspiration, or rapid desaturation are anticipated, AFOI is often the preferred option. [1,2] For this case series, the Ambu aScope fiberoptic bronchoscope system was employed for AFOI, which integrates modern technology to facilitate better outcomes and ease of use in difficult airway management.[6,7]

Successful AFOI necessitates a high degree of patient cooperation, which in turn requires careful preparation and additional staff support. The American Society of Anesthesiologist (ASA) and  Difficult Airway Society (DAS) guidelines endorse AFOI as the primary approach in such contexts, highlighting the need for an optimized process emphasizing not just technical skills but the overall performance in managing a cooperative, spontaneously ventilating patient.[8,9] A key component of successful AFOI is the incorporation of a structured approach, often framed by the strategy recommended by the DAS, which emphasizes sedation, topicalization, oxygenation, and performance. Among various sedation options, dexmedetomidine has emerged as a favorable choice due to its potent sedative properties without inducing respiratory depression. It effectively reduces salivary secretion, fostering optimal conditions for fiberoptic intubation while also maintaining hemodynamic stability and enhancing patient comfort. Research comparing dexmedetomidine to other sedative agents, such as propofol and remifentanil, suggests it provides superior sedation and patient tolerance during AFOI. In various studies, patients receiving dexmedetomidine have experienced better endoscopy scores and less awareness of the intubation process. Despite its advantages, dexmedetomidine can lead to side effects, particularly impacting cardiovascular stability, including hypotension and bradycardia. These effects may become more pronounced at higher doses, necessitating careful monitoring and dose adjustments. [10-12]We have employed a dosing strategy for dexmedetomidine with an initial loading dose of 1 mcg/kg for 10 minutes, followed by a maintenance infusion of 0.7 mcg/kg/hr. This regimen has been shown to achieve adequate sedation,good hemodynamic stability and optimal outcomes for AFOI with better intubating condition.

The provision of supplemental oxygen is an essential aspect of AFOI, especially with high-flow nasal oxygen (HFNO) being recommended by the DAS. Several other techniques for oxygen delivery are also employed. In clinical practice, using nasal cannulae for supplemental oxygen has proven effective, enhancing patient satisfaction during the procedure.Topical anesthetics play a crucial role in the AFOI process, with lignocaine being the most widely used agent. The use of higher concentrations of local anesthetic, along with vasoconstrictors like xylometazoline, can significantly improve airway patency, reducing bleeding and enhancing the ease of intubation.[1,3]In this set of cases,we have used nasal canula for oxygen support and lignocaine in the form jelly as well as spray for topical anesthesia along with vasoconstrictor support  that has given excellent results.

Despite its overall success rate of around 99%, AFOI is not without risks. Complications can range from minor adverse effects like hoarseness to more severe incidents, including laryngospasm and airway injury, particularly in less experienced hands. Challenges such as inadequate local anesthesia, oversedation, and mucosal bleeding can contribute to the procedure's failure. Thus, meticulous planning and operator proficiency are essential for minimizing complications and ensuring favorable outcomes.[13-15]Overall we have reported AFOI with Dexmedetomidine sedation as a excellent approach for airway management in anticipated difficult airway due to maxillofacial/panfacial trauma planned for facial reconstructive surgeries.Moving forward, there is a compelling need for further research to refine Dexmedetomidine sedation protocols and dosages to continuously improve the safety and efficacy of AFOI, ultimately benefiting patient care in challenging airway situations.

In conclusion, AFOI with dexmeditomide sedation is remains the most preffered technique for the management of anticipated difficult airways due to maxillofacial/panfacial trauma for elective facial bone reconstructive surgeries.This technique not only optimizes the procedural approach but also enhances patient comfort ,provides good hemodynamic stability , better intubating conditions and significantly improves clinical outcomes.

ACKNOWLEDGEMENT

We are sincerely thankful to Dr. Ridhdhi and our technical support team of OT especially sister Aarti pal, Nazo bano. Manjeet and Anuj brother with for their preparation and cooperation .We are grateful to our surgical teams as well for their patience and support.

SOURCE OF SUPPORT/ FUNDING: None

CONFLICT OF INTEREST: None

CONSENT OBTAINED FROM  PATIENTS: Yes.

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