General Anesthesia
the latest American Society of Anesthesiologists Difficult Airway
A Retrospective Study of Success,
Failure, and Time Needed to Perform
Awake Intubation
Thomas T. Joseph,* Jonathan S. Gal,* Samuel DeMaria, Jr,*
Hung-Mo Lin,*† Adam I. Levine,*‡§ and Jaime B. Hyman*
(Abstracted from Anesthesiology, 125:105–114, 2016)
Departments of *Anesthesiology, †Population Health Science and Policy,
‡Otolaryngology, and §Structural and Chemical Biology, Icahn School
of Medicine, Mount Sinai Hospital, New York, NY.
lthough awake intubation is considered the “standard of care”
A when it comes to patients with difficult airways, anesthesiolo-
gists may shy away from the procedure because of concerns over
complexity and length of time necessary for successful comple-
tion. The purpose of this study was to determine how long it typ-
ically takes to perform an awake intubation, as well as the
procedure’s effects on hemodynamics and what complications
may arise as a result.
Seven years of anesthetic records from a large academic med-
ical center served as the basis for this retrospective review. Reviewers
set the timeframe for analysis from entry into the operating room
through to time of intubation. Each awake intubation case was pro-
pensity matched with 2 controls, with intubations performed after
the induction of anesthesia. The overwhelming majority of awake
intubation cases involved the use of a flexible bronchoscope.
The median time for awake intubation was 24 minutes, ver-
sus postinduction intubation at 16 minutes. The rate of complica-
tions for awake patients was 1.6%, or only 17 of the total 1085 cases
studied. The most frequent complications observed were mucous
plug, endotracheal tube cuff leak, and inadvertent extubation.
Reviewers determined that the low rate of complications and
statistically insignificant increase in procedural time needed made
awake intubation a safe and quick alternative to postinduction in-
tubation for patients with difficult airways.
COMMENT
Awake intubation has been considered the standard of care
for management of the anticipated difficult airway in adult pa-
tients. Traditionally, this has been accomplished with flexible
fiberoptic bronchoscopy, although more recently awake video lar-
yngoscopy (VL) has been used as well. Nonetheless, many per-
ceived deterrents to awake intubation exist. First, clinicians may
worry about patient anxiety or discomfort during an awake intuba-
tion. Second, successful awake intubation requires anesthetization
of the airway, which demands expertise and takes additional time.
In an era of production pressures, this is a very real concern. Third,
bronchoscopy skills are challenging to acquire and vulnerable to
decay, possibly causing practitioner discomfort with awake
fiberoptic flexible bronchoscopy if not practiced on a regular ba-
sis. Finally, awake intubation may be perceived as potentially dan-
gerous if accompanied by a dramatic sympathetic response.
Although postinduction VL has an expanding role in the man-
agement of difficult direct laryngoscopy with its incorporation into
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Algorithm, nonetheless VL has limitations. These include patients
with extremely limited mouth opening, those with a history of neck
surgery or radiation, and those with certain head and neck masses.
Therefore, awake flexible bronchoscopy remains the mainstay for
management of the anticipated difficult airway, especially for pa-
tients at increased risk of aspiration and those with difficult face
mask or supraglottic ventilation. In an era of increasing production
pressures, it is reassuring to know that awake intubation adds an av-
erage of only 8 minutes to operating room time. Moreover, awake
intubation is almost always successful, and the rates of serious com-
plications or hemodynamic perturbations are low.
Comment by Kathryn E. McGoldrick, MD, FCAI(Hon)
Disclosure: The author declares no conflict of interest.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/SA.0000000000000266
Sugammadex and Neostigmine
Dose-Finding Study for Reversal
of Residual Neuromuscular Block
at a Train-of-Four Ratio
of 0.2 (SUNDRO20)
N. Kaufhold,* S. J. Schaller,* C. G. Stäuble,* E. Baumüller,*
K. Ulm,† M. Blobner,* and H. Fink*
(Abstracted from Br J Anaesth, 116(2):233–240, 2016)
*Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität
München; and †Institut für Medizinische Statistik un Epidemiologie,
Klinikum rechts der Isar, Technische Universität München, München,
Germany.
T he authors undertook this study to evaluate the dose-response
relationship of sugammadex and neostigmine to reverse a
commonly observed residual rocuronium-induced neuromuscular
block from a train-of-four ratio (TOFR) of 0.2 or greater to a
TOFR of 0.9 or greater. Primary outcome measures were the doses
required to achieve this effect in 50% of patients within 2 minutes
or in 95% of patients within 5 minutes, whereas secondary out-
come measures were the doses required for a less advanced accel-
eration, that is, in 50%of patients within 5 minutes or in 95% of
patients within 10 minutes.
This single-center, randomized, parallel-group, double-blinded
study enrolled 99 patients 18 years or older and with American
Society of Anesthesiologists physical status I to III who were under-
going elective surgery under general anesthesia with rocuronium
for tracheal intubation. These patients were randomized to receive
Survey of Anesthesiology • Volume 60, Number 6, December 2016