Cangiani Luis Henrique, Vicensotti Eduardo, Ramos Guilherme Costa, Oliveira Guiherme José Souza
Centro de Ensino e Treinamento em Anestesiologia (CET), Fundação Centro Médico de Campinas, Campinas, SP, Brazil.
Centro de Ensino e Treinamento em Anestesiologia (CET), Fundação Centro Médico de Campinas, Campinas, SP, Brazil.
Braz J Anesthesiol. 2020 Jul-Aug;70(4):434-439. doi: 10.1016/j.bjan.2020.03.016. Epub 2020 Jul 9.
When planning the management of a predicted difficult airway, it is important to determine which strategy will be followed. Video laryngoscopy is a major option in scenarios with factors suggesting difficult airway access. It is also indicated in rescue situations, when there is tracheal intubation failure with direct laryngoscopy. The objective of the present report was to show the efficacy of using the video laryngoscope as the first device for a patient with a large tumor that occupied almost the entire anterior portion of the oral cavity.
An 85 year-old male patient, 162 cm, 70 kg, ASA Physical Status II, Mallampati IV classification, was scheduled for resection of an angiosarcoma located in the right maxillary sinus that invaded much of the hard palate and the upper portion of the oropharynx. He was conscious and oriented, with normal blood pressure, heart and respiratory rates and, despite the large tumor in the oral cavity, he showed no signs of respiratory failure or airway obstruction. After intravenous cannulation and monitoring, sedation was performed with 1 mg of intravenous midazolam, and a nasal cannula was placed to provide oxygen, with a flow of 2 L min. Then, the target-controlled infusion of remifentanil with an effect site concentration of 2 ng mL was initiated, according to Minto's pharmacokinetic model. Ventilation was maintained spontaneously during airway handling. A trans-cricothyroid block was performed, with 8 mL of 1% lidocaine solution injected into the tracheal lumen. Slight bleeding did not prevent the use of an optical method for performing tracheal intubation. The entire oral cavity was sprayed with 1% lidocaine. The McGraph video laryngoscope with the difficult intubation blade was used, and an armored tube with a guide wire inside was used for tracheal intubation, performed on the first attempt with appropriate glottis visualization.
The video laryngoscope occupies a prominent position in cases in which access to the airway is difficult. In the present case it was useful. It can be used as first choice or as a rescue technique. The video laryngoscope is an appropriate alternative and should be available for facing the ever-challenging difficult airway patient.
在规划预计困难气道的管理方案时，确定应采取何种策略非常重要。视频喉镜是存在提示气道暴露困难因素的情况下的主要选择。在直接喉镜气管插管失败的抢救情况下也可使用。本报告的目的是展示对于一名患有几乎占据整个口腔前部的大肿瘤患者，将视频喉镜作为首选设备的有效性。
一名85岁男性患者，身高162厘米，体重70千克，美国麻醉医师协会（ASA）身体状况分级为II级，马兰帕蒂（Mallampati）分级为IV级，计划切除位于右上颌窦的血管肉瘤，该肿瘤侵犯了大部分硬腭和口咽上部。他意识清醒、定向力正常，血压、心率和呼吸频率正常，尽管口腔内有大肿瘤，但未出现呼吸衰竭或气道梗阻迹象。静脉置管和监测后，静脉注射1毫克咪达唑仑进行镇静，并放置鼻导管以2升/分钟的流速提供氧气。然后，根据明托（Minto）药代动力学模型，开始以效应室浓度2纳克/毫升进行瑞芬太尼靶控输注。在气道操作过程中维持自主通气。进行了经环甲膜阻滞，将8毫升1%利多卡因溶液注入气管腔。轻微出血并未妨碍使用光学方法进行气管插管。整个口腔喷洒1%利多卡因。使用带有困难插管镜片的麦格拉夫（McGraph）视频喉镜，并使用内置导丝的铠装气管导管进行气管插管，首次尝试时即成功清晰显露声门。
视频喉镜在气道暴露困难的病例中占据显著地位。在本病例中它很有用。它可作为首选或抢救技术使用。视频喉镜是一种合适的替代方法，应配备以应对不断带来挑战的困难气道患者。
