Airway management and anesthesia for airway surgery: a narrative review.

OBJECTIVE: To discuss and summarize the literature for airway and anesthetic management tools the anesthesiologist can use for airway surgery to both successfully manage the patient's physiological needs and provide the surgeon the optimal surgical conditions with which to perform the surgery safely. BACKGROUND: The airway and anesthetic management of patients presenting for thoracic surgery poses the anesthesiologist with a unique set of challenges, but also a unique set of opportunities to artfully utilize and adapt a variety of management options that has developed over several decades of innovation. Sixty years ago, airway surgery was initially performed with the patient spontaneously breathing and providing anesthesia with halogenated agents and airway topicalization. As medicine entered the latter half of the twentieth century with its development of new airway devices and modern anesthetic agents, most airway surgeries could be safely performed under general anesthesia with secured airways. Today, with continued technological advancements in surgical techniques and an expanding population of challenging patients, the application of nonintubated anesthetic techniques and extracorporeal support is on the rise. METHODS: We conduct a narrative review of the literature on the history of airway and anesthetic management for thoracic surgery, the current management methods and evidence for each modality, and discuss future directions for the field. CONCLUSIONS: While the airway and anesthetic management for airway surgery is challenging, the anesthesiologist has a variety of options including cross-field ventilation, jet ventilation, nonintubated techniques, and extracorporeal support to safely care for the patient. Whichever methods are chosen for the patient and surgery, thoracic surgery remains uniquely positioned in its need for close sharing and collaboration of all airway and anesthetic management decisions between the anesthesiologist and the surgeon.

Perioperative complications in adults with a posterior mediastinal mass: a retrospective observational cohort study.

BACKGROUND: We studied the incidence of perioperative complications in patients presenting with a posterior mediastinal mass and the possible predictors of complications in these patients. METHODS: We conducted a review of the perioperative records of patients aged over 18 years with a posterior mediastinal mass confirmed by computed tomography (CT) who were admitted for surgical procedures relating to the mass during 2004-2014. Perioperative complications were defined as 1) hypoxemia (pulse oximetry < 90% at a fraction of inspired oxygen of 1.0), 2) difficult ventilation (peak pressure > 40 cm H2O or respiratory acidosis with PaCO2 > 60 mmHg), and 3) hemodynamic instability (systolic pressure < 70 mmHg, pulse rate < 40 beats·min(-1) and/or > 120 beats·min(-1) for over five minutes). The review also extended to the first 24 hr postoperatively for cardiovascular and respiratory instability. RESULTS: Forty-three patients underwent 44 procedures, and the surgery entailed resection of the mediastinal mass in all but one patient. All patients received general anesthesia following intravenous induction. In 43 of 44 cases, intubation was achieved uneventfully with direct laryngoscopy after neuromuscular blockade. The incidence of perioperative cardiopulmonary complications was seven of 44 (16%) procedures. Four of these involved severe hypoxemia, two concerned hemodynamic instability, and two led to postoperative respiratory distress. No cardiovascular collapse or complete airway occlusion occurred. All occurrences of intraoperative complications transpired mid-surgery - six of the seven with the patient in the lateral position. Patients who developed complications were more likely to have a mass with a larger diameter and evidence of airway compression on the preoperative CT scan. CONCLUSION: The incidence of perioperative complications in patients with a posterior mediastinal mass is not insignificant; however, no catastrophic airway or cardiopulmonary event was encountered in this study.

Anesthesia for tracheal resection and reconstruction.

Tracheal resection and reconstruction (TRR) is the treatment of choice for most patients with tracheal stenosis or tracheal tumors. Anesthesia for TRR offers distinct challenges, especially for the less experienced practitioner. This article explores the preoperative assessment, strategies for induction and emergence from anesthesia, the essential coordination between the surgical and anesthesia teams during airway excision and anastomosis, and postoperative care. The most common complications are reviewed. Targeted readership is practitioners with less extensive experience in managing airway surgery cases. As such, the article focuses first on the most common proximal tracheal resection. Final sections discuss specific considerations for more complicated cases.

Control of perioperative muscle strength during ambulatory surgery.

PURPOSE OF REVIEW: This review describes strategies to control perioperative muscle strength in patients undergoing ambulatory surgery. RECENT FINDINGS: Although it is impossible to improve muscle relaxation (defined as absence of electrical activity) of intact resting muscle by hypnotics, analgesia is required to prevent pain-evoked muscular contractions during surgery. Regional anesthesia, as well as hypnotics and opioids, promotes intraoperative muscle relaxation. Neuromuscular blocking agents (NMBAs) induce dose-dependent muscle relaxation, but their effects vary widely between individuals, and postoperative residual curarization (PORC) exposes patients to additional risk. Low doses of NMBAs should, therefore, be used, effects be monitored quantitatively by acceleromyography, and residual neuromuscular block be reversed. Acetylcholinesterase inhibitor reversal can cause respiratory side effects, so the lowest efficacious dose should be used: as little as 0.015-0.025 mg kg(-1) of neostigmine is required at a train-of-four count of four with minimal fade. Sugammadex encapsulates steroidal NMBAs. Sugammadex reversal is a viable approach to rapidly antagonize deep levels of neuromuscular block. SUMMARY: Optimal muscle relaxation for ambulatory surgery results from a judicious combination of regional anesthesia, opioids, and low doses of NMBAs. The effects of NMBAs should be monitored quantitatively by acceleromyography and reversed appropriately.