1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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.
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

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.
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

10. 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

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

12. Thank you Anesthetic Perspectives
Alessandro BACUZZI, MD
Department of Anaesthesia and Palliative care
Varese University Hospital
Varese, Italy
Department of Anaesthesia and Palliative Care 12 12