Emergency Airway Management During Awake Craniotomy

Emergency Airway Management During Awake Craniotomy: Comparison of 5 Techniques in a Cadaveric Model:



Background:

During awake craniotomy, securing the patient’s airway might be necessary electively or emergently. The objective of this study was to compare the feasibility of airway management using a laryngeal mask airway (LMA) and 4 alternative airway management techniques in an awake craniotomy simulation.

Methods:

After completing a questionnaire, 9 anesthesia providers attempted airway management in a cadaver positioned to simulate awake craniotomy conditions. Following the simulation, participants rated and ranked the devices in their order of preference.

Results:

Only 3 approaches resulted in the successful securement of an airway device for 100% of participants: LMA (median; interquartile range time to secure the airway 6 s, 5 to 10 s), fiberoptic bronchoscopy through an LMA (41 s; 23 to 51 s), and video laryngoscopy (49 s; 43 to 127 s). In contrast, the oral and nasal fiberoptic approaches demonstrated only 44.4% (154.5 s; 134.25 to 182 s) and 55.6% (75 s; 50 to 117 s) success rates, respectively. The LMA was the fastest and most reliable primary method to secure the airway (P=0.001). After the simulation, 100% of participants reported that an LMA would be their first choice for emergency airway management, followed by fiberoptic intubation through the LMA (7 of 9 participants) if the LMA failed to properly seat.

Conclusions:

We demonstrated that an LMA was the fastest and most reliable primary method to secure an airway in a laterally positioned cadaver with 3-pin skull fixation. Fiberoptic and video laryngoscope airway equipment should be readily available during awake craniotomy procedures, and an attempt to visualize the vocal cords through the LMA should be attempted before removing it for alternative techniques.

The abstract for this study was presented at the 2019 Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Annual Meeting in Phoenix, AZ.

A.Q.-H. is supported by the Mayo Clinic Professorship, a Clinician Investigator Award, the Florida Department of Health Cancer Research Chair Fund, and the National Institute of Health (R43CA221490, R01CA200399, R01CA195503, and R01CA216855). B.F.G. is supported by a grant from the Foundation for Anesthesia Education and Research and a Clinical Translational Science Award from the National Center for Advancing Translational Science, a component of the National Institute of Health (UL1TR001863). The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official view of the National Institute of Health.

The authors have no conflicts of interest to disclose.

Address correspondence to: Shaun E. Gruenbaum, MD, PhD. E-mail: gruenbaum.shaun@mayo.edu.

Received June 9, 2020

Accepted August 26, 2020

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