Director: Salvatore Cuffari Anesthetic Perspectives Alessandro BACUZZI, MD Department of Anaesthesia and Palliative care Director: Salvatore Cuffari Varese University Hospital Varese, Italy Department of Anaesthesia and Palliative Care 1

Department of Anaesthesia and Palliative Care Surgical anaesthesia Hypnotics Analgesics (opioid) Muscle Relaxant “Homeostasis” Cardiovascular Respiratory Metabolic Temperature Department of Anaesthesia and Palliative Care 2

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. IONM: evoked EMG Department of Anaesthesia and Palliative Care 3

Tracheal Intubation without NMBA Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. Neuromuscular blocking agents (NMBA)? ? ? IONM: evoked EMG IONM and NMBA Tracheal Intubation without NMBA Hemmerling T.M. BJA 2000 Randholph GW. World J Surg 2004 Marush F. BJA 2005 Chiang FY World J Surg 2010 Birkholz T. Auris Nasus Larynx 2011 I-Cheng Lu. Surgery 2011 Woods AW. BJA 2005 Jong-Man Kang. Korean J Anesthesiol 2009 Fotopoulou G. Fundamental and Clinical Pharmacology 2011 Mencke T. Anesthesiology 2003 Mazen A. Maktabi. Anesthesiology 2003 Department of Anaesthesia and Palliative Care 4

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. Neuromuscular blocking agents (NMBA)? PRO ? ? IONM: evoked EMG Conclusions: The quality of tracheal intubation contributes to laryngeal morbidity, and excellent conditions are less frequently associated with postoperative hoarseness and vocal cord sequelae. Adding atracurium to a propofol–fentanyl induction regimen significantly improved the quality of tracheal intubation and decreased postoperative hoarseness and vocal cord sequelae. Swollen mucosa (SM) and hematomas (*) at both arytenoid cartilages (AC) 24 h after intubation. VP vocal process; LVF left vocal fold; RVF right vocal fold Hematoma (arrow) at the right vocal fold 72 h after intubation. EC epiglottis; AC arytenoid cartilages; LVF left vocal fold. Department of Anaesthesia and Palliative Care 5

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. Neuromuscular blocking agents (NMBA)? CON ? ? IONM: evoked EMG Conclusions: In this special setting of IONM and thyroid surgery, avoidance of NMBA for endotracheal intubation seems not to increase the incidence of laryngeal side effects and lesions. If endotracheal intubation without NMBA is required, the authors suggest a standardized approach using induction agents as propofol and remifentanil. Department of Anaesthesia and Palliative Care 6

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. HOW I DO IT TIVA (Total Intravenous Anaesthesia): PROPOFOL (2 mg / Kg) at induction PROPOFOL (5 – 6 mg · kg −1 · h −1) c.i REMIFENTANIL (0.25 g / kg / min ) c.i. Nondepolarizing NMBAs: CISTARACURIUM BESYLATE (Nimbex) 0.1 mg/Kg at induction ROCURONIUM BROMIDE (Esmeron) 0.3 mg/Kg at induction Feng-Yu Chiang. Surgery 2011;149:543-8 or Relaxant-free intubation: BIS- guide (25-30) plus topical anaesthesia of the airway BIS Department of Anaesthesia and Palliative Care 7

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. HOW I DO IT Orotracheal intubation: EMG endotracheal tube. No creams to lubricate the tube. Lubricate cuff with an aqueous lubricant for intubation. The proper size tube for the individual patient should be determined prior to intubation by the anesthesia provider and/or surgeon. A tube that is one size larger than standard selection is recommended whenever possible to improve electrode contact with vocal cords. Department of Anaesthesia and Palliative Care 8

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. HOW I DO IT Orotracheal intubation: EMG endotracheal tube. No creams to lubricate the tube. Lubricate cuff with an aqueous lubricant for intubation. Check correct positioning : visualize electrode contact with true vocal cords and secure. Use EMG monitor to verify electrode impedance measures less than 10 Kohms and an imbalance less than 2 Kohms on both channels. Reposition if necessary. Department of Anaesthesia and Palliative Care 9

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. HOW I DO IT Orotracheal intubation: EMG endotracheal tube. No creams to lubricate the tube. Lubricate cuff with an aqueous lubricant for intubation. Maintain Midline placement. Do not orient tube to the left or right of the patient’s mouth as this will also rotate the tube’s electrodes and cause a leadoff connection. Check electrode impedance and imbalance values regularly throughout the case. Should impedance or imbalance levels change suddenly during the case and proper electrode to vocal cord contact has been compromised, it is likely that the tube has rotated enough to dislodge an electrode away from the vocal cord. Tube position and orientation should be confirmed and/or modified until electrode impedance/ imbalance values improve to an acceptable level Department of Anaesthesia and Palliative Care 10

Department of Anaesthesia and Palliative Care Surgical anaesthesia and intraoperative neuromonitoring (IONM) of laryngeal nerves in thyroid surgery. Video Def Stresa 27 06 14.mp4 Department of Anaesthesia and Palliative Care 11

Thank you Anesthetic Perspectives Alessandro BACUZZI, MD Department of Anaesthesia and Palliative care Varese University Hospital Varese, Italy alessandro.bacuzzi@gmail.com alessandro.bacuzzi@ospedale.varese.it salvatore.cuffari@ospedale.varese.it Department of Anaesthesia and Palliative Care 12 12