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Functional endoscopic sinus surgery is among the most challenging of ENT procedures for a variety of reasons including the need for immobility, hemostasis, and, especially, gentle emergence from anesthesia. Anesthesiologists have contributed significantly, using anesthetic techniques to mitigate intraoperative hemorrhage into the surgical field, thus significantly improving visualization of the surgical field. Functional endoscopic sinus surgery (FESS) strives to enable direct examination in situ with subsequent correction of encountered chronic changes and barriers which limit sinus drainage and aeration. The use of supraglottic airway (SGA) over endotracheal tubes (ETT) appears additionally advantageous, providing reduced incidence and severity of coughing intraoperatively and during emergence. Propofol/remifentanil total intravenous anesthesia (TIVA) with spontaneous respiration (PRTSR) is considered by some an optimal strategy to avoid emergence problems and provide flexibility, and minimize nausea, vomiting, and estimated blood loss (EBL), while ensuring rapid induction and emergence.
Awake fiberoptic intubation (AFOI) has the potential to trigger hypertension, tachycardia and hypoxia or hypercarbia. Patients who require fiberoptic-guided endotracheal intubation for the clipping or coiling of an intracranial aneurysm pose particular challenges for the safe completion of both procedures. This chapter presents a case study of a 56-year-old female with a poorly documented history of difficult intubation presented for elective clipping of a middle cerebral artery aneurysm. The case discussion highlights the considerations for awake endotracheal intubation in the patient with an unsecured aneurysm. The indications for AFOI in this case are essentially the same as for any difficult airway: concern for the ability to visualize the glottic opening via direct laryngoscopy combined with concern for the ability to mask ventilate. Hypercarbia or hypoxia during an awake fiberoptic intubation are frequently due to loss of respiratory efforts in a narcotized patient.
Therapeutic hypothermia has been shown to improve outcome in patients after cardiopulmonary resuscitation and might prove helpful for other circumstances in which a compromise of neurologic function is expected. Cooling a patient to mild or moderate hypothermia is usually performed by conductive, convective surface cooling, cold infusions, gastric lavage, passive cooling by leaving the anesthetized patient uncovered in a cool environment, or through a combination of these methods. Endovascular cooling techniques seem to be superior for rapid induction of hypothermia and for maintenance of stable temperature as compared with surface-cooling techniques. The majority of therapeutic hypothermia trials for brain protection have involved surface-cooling techniques that require mechanical ventilation in intubated and paralyzed patients. Drugs such as meperidine, dexmedetomidine, clonidine, nefopam, and buspirone alone, as well as in various combinations, reduce the shivering threshold and thus complement external and internal cooling.
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