title: Management of a tumor in the distal trachea while maintaining spontaneous ventilation.
abstract: A 50-year-old man with carcinoma of the trachea presented for debulking. Due to the distal location of the tumor, a tracheostomy was not feasible. We were asked to provide general anesthesia but to maintain spontaneous ventilation. Sedation was provided with dexmedetomidine 0.7 μg/kg per hour. Following induction with ketamine 2 mg/kg, the trachea was sprayed with 5 ml of 4% lidocaine and, with assistance from the surgeon, a Cook™ Airway Exchange catheter was placed with the distal end just beyond the tumor. We then connected the proximal end to a manual jet ventilator to provide oxygen supplementation and, if necessary, positive-pressure ventilation. Subsequently, the surgeons were able to completely debulk the tumor and examine the airway down to the carina. Spontaneous ventilation was maintained throughout the case, with additional boluses of ketamine as necessary. The patient woke up after the procedure and had no delirium, nightmares, or recall. Dexmedetomidine worked synergistically with ketamine by preventing hypertension, hypersecretion, and postoperative delirium that is often seen when using ketamine alone. The successful use of ketamine and dexmedetomidine in this case demonstrates that this method may be applicable to other clinical situations where deep sedation and maintenance of spontaneous ventilation is required.
authors.affiliation: The Department of Anesthesia, Miller School of Medicine, University of Miami, 1611 NW 12 Avenue, Room C301, Miami, FL 33136, USA. rmarks@med.miami.edu
authors.forename: Roger
authors.initials: R
authors.lastname: Marks
authors.forename: Leigh
authors.initials: L
authors.lastname: Tanner
authors.forename: Brett
authors.initials: B
authors.lastname: Wenleder
mesh_terms: D000768:Anesthesia, General; D000778:Anesthetics, Dissociative; D054810:Deep Sedation; D020927:Dexmedetomidine; D004562:Electrocardiography; D006526:Hepatitis C / Q000150:complications; D006801:Humans; D006993:Hypnotics and Sedatives; D007649:Ketamine; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration; D015656:Respiratory Mechanics; D014134:Tracheal Neoplasms / Q000601:surgery*
chemical_list: D000778:Anesthetics, Dissociative; D006993:Hypnotics and Sedatives; D020927:Dexmedetomidine; D007649:Ketamine
references.citation: Anaesthesia. 1973 May;28(3):293-6
references.pmid: 4713950
references.citation: Anesthesiology. 1995 May;82(5):1117-25
references.pmid: 7741286
references.citation: Anesthesiology. 1982 Feb;56(2):119-36
references.pmid: 6892475
references.citation: Anesthesiology. 2002 Sep;97(3):592-8
references.pmid: 12218525
references.citation: Br J Anaesth. 1970 Oct;42(10):875-85
references.pmid: 5475444
references.citation: Can J Anaesth. 2003 Jun-Jul;50(6):607-10
references.pmid: 12826556
references.citation: N Engl J Med. 2010 Mar 11;362(10):e35
references.pmid: 20173033
references.citation: Anesth Analg. 1966 Jan-Feb;45(1):29-40
references.pmid: 5325977
references.citation: Anaesthesist. 1979 Jan;28(1):20-3
references.pmid: 760587
references.citation: Anaesthesia. 1978 Apr;33(4):307-11
references.pmid: 27120