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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 50-52

Intubation quality and hemodynamic response in endotracheal intubation with ultrasound-guided bilateral superior laryngeal nerve block: Case series


Department of Anesthesiology, Pain Management, and Intensive Care, Sanglah General Hospital, Udayana University, Denpasar, Bali, Indonesia

Date of Submission26-Aug-2020
Date of Decision30-Sep-2020
Date of Acceptance05-Oct-2020
Date of Web Publication8-Feb-2021

Correspondence Address:
Dr. Agus Tri
Department of Anesthesiology, Pain Management, and Intensive Care, Sanglah General Hospital, Udayana University, Denpasar, Bali
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_191_20

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  Abstract 


General anesthesia works centrally, causing loss of consciousness and blocking the pain response. Some of the general anesthesia techniques are using laryngoscopy and intubation. The side effects of endotracheal intubation, for instance, are stimulating cough reflex, laryngospasm, and sympathetic nervous system response that increases catecholamine levels. The side effects are increases in blood pressure and heart rate. Hereby, a big consent for anesthesiologists thus intravenous, topical, and regional drugs are usually needed to facilitate this action. Using a muscle relaxant to facilitate intubation is often performed but does not suppress the hemodynamic responses. Intubation with superior laryngeal nerve block technique has an equivalent quality compare with muscle relaxant uses. This technique can prevent hemodynamic responses from laryngoscopy endotracheal intubation.

Keywords: Hemodynamic response, intubation quality, superior laryngeal block


How to cite this article:
Tri A, Gede Widnyana I M, Kresna Sucandra MA, Agung Senapathi TG. Intubation quality and hemodynamic response in endotracheal intubation with ultrasound-guided bilateral superior laryngeal nerve block: Case series. Bali J Anaesthesiol 2021;5:50-2

How to cite this URL:
Tri A, Gede Widnyana I M, Kresna Sucandra MA, Agung Senapathi TG. Intubation quality and hemodynamic response in endotracheal intubation with ultrasound-guided bilateral superior laryngeal nerve block: Case series. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Mar 1];5:50-2. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/50/308888




  Introduction Top


The clinical use of muscle relaxants in anesthesiology is to provide a muscle relaxation condition to facilitate the endotracheal intubation and the operator activities during general anesthesia. The side effects caused by nondepolarizing muscle relaxant may present as hypotension, tachycardia, dysrhythmia, bradycardia, even cardiac arrest, as well as bronchoconstriction, allergic reaction, and anaphylactic shock. On the other hand, depolarizing muscle relaxants has side effects such as bradycardia, ventricular dysrhythmia, hyperkalemia, increasing intraocular pressure and intragastric pressure, myalgia, masseter muscle spasm, fasciculation, and the worst that we fear is malignant hyperthermia.[1],[2],[3],[4],[5]

Endotracheal intubation can be performed using intravenous anesthesia drugs that can be combined with local and regional anesthesia. The combination of general and regional anesthesia for intubation is often done recently for short duration procedure and operation technique with airway management difficulties. Superior laryngeal nerve block (SLNB) is a useful technique to facilitate endotracheal intubation by providing patient comfort, inhibits cough, and avoid laryngospasm due to the blockade of the nerve impulse. This block causes loss of sensation in the epiglottis and vocal cord lead to vocal cord relaxation, and thereby facilitate the endotracheal intubation.[2],[3],[6],[7],[8],[9]

?Case Reports

Five patients aged 17–65 years old with physical status American Society of Anesthesiology I–II (ASA I–II). All of the patients were scheduled for the surgery with general anesthesia. The vital signs were all recorded with noninvasive monitoring devices such as electrocardiography, automatic blood pressure (BP), and pulse oximetry. In the operating room, the patients were induced with propofol 1–2 mg/kg, and coinduction with fentanyl 1–2 μg/kg, then continued with oxygen and air (1:2) with sevoflurane 1–2 mean alveolar concentration. We performed ultrasound-guided SLNB. The ultrasound probe was placed on the neck to visualize the superior laryngeal nerve, and 2 mL of lidocaine 2% was administered in the right and left superior laryngeal nerve, respectively (the onset of action approximately 3–5 min). The hemodynamic was recorded (BP and heart rate [HR]) right before intubation. The intubation quality score was assessed by a score published by Helbo-Hansen Raulo and Trap-Anderson. The complications after SLNB (hoarseness, swallowing problem, and odynophagia were calculated and categorized as none (2–3), mild-moderate (4–6), and severe criteria (7–9).

Case 1

A 22-year-old, male, ASA-Physical Status 1, Patient with a diagnosis of inferior concha hypertrophy dextra et Sinistra underwent conchotomy. The patient was induced with propofol 150 mg and coinduction with fentanyl 100 μg. An ultrasound was performed on the neck to identify the superior laryngeal nerve and local anesthetic lidocaine 2% was administered in the right and left superior laryngeal nerve 2 mL each and waited for the onset of local anesthetic for 5 min. The BP was 110/65 mmHg (mean arterial pressure [MAP] 80 mmHg) and HR 70 times/min before intubation. The intubation quality score was 8 (good), the vocal cord was still moving, and mild cough. The BP was 115/70 mmHg (MAP 85 mmH) and HR 72 times/min after intubation procedure with SLNB score was 5 (mild side effects). The patient had swallowing problems and hoarseness.

Case 2

A 52-year-old, male, ASA-Physical Status 1, patient with a diagnosis of maxillary sinusitis and inferior concha hypertrophy dextra underwent? Caldwell Luc Surgery and conchatomy with? general anesthesia with orotracheal intubation and facilitated with SLNB. The BP was 110/70 mmHg (MAP 80 mmHg) and the HR was 60 times/min before intubation with intubation quality score was 6 (good). The BP was 120/80 mmHg (MAP 85 mmHg) and HR was 62 times/min after intubation. The side effects SLNB was 4 (mild side effects). The patient had a swallowing problem.

Case 3

A 55-year-old, female, ASA-Physical Status 2, patient with soft-tissue tumor of the humerus dextra region suspect malignant spindle cell tumor (high-grade sarcoma) underwent an open biopsy with GA-OTT and facilitated with SLNB. The BP was 95/55 mmHg (MAP 68 mmHg) and HR was 65 times/min before intubation with intubation quality score was 7 (very good). The BP was 100/60 mmHg (MAP 73 mmHg) and HR was 68 times/min after intubation. The side effects SLNB score was 3 (no side effect).

Case 4

A 45-year-old, female, ASA-Physical Status 1, patient with breast cancer sinistra underwent open biopsy, under general anesthesia with GA-OTT, and facilitated with SLNB. The BP was 110/65 mmHg (MAP 80 mmHg) and HR was 70 times/min before intubation with intubation quality score was 6 (good). The BP was 110/70 (MAP 83 mmHg) and HR was 75 times/min postintubation. The side effects SLNB score was 3 (no side effect).

Case 5

A 45-year-old, male, ASA-physical Status 2, patient with squamous cell carcinoma of the tongue underwent bimanual palpation with GA-OTT and facilitated with SLNB. The BP was 120/65 mmHg (MAP 83 mmHg) and HR was 80 times/min before intubation, the intubation quality score was 6 (good) and postintubation BP was 135/75 mmHg (MAP 88 mmHg) and HR was 82 times/min. The side effects of SLNB score was 4 (mild side effects). The patient had a swallowing problem.


  Discussion Top


In short duration surgery that requires endotracheal intubation, it is common to use reversal agent such as anticholinesterase drugs to recover patient's spontaneous breathing after a large dose of muscle relaxant. These anticholinesterase drugs have side effects such as bradycardia, hypotension, nausea, and vomiting. An inadequate reversal administration can cause recurarization or muscle relaxation again due to the residual muscle relaxant that has not been metabolized in the circulation.[2],[3] The use of a combination general with regional anesthesia technique for intubation is often done recently. Several cases, such as short duration surgery and or cases with airway management difficulties, use specific nerve block for intubation and become the option to achieve effective anesthesia for intubation.[9]

This SLNB technique uses local anesthetic drugs that suppress the reflexes and even blunts the sensation of the specific nerve involved in laryngoscopy and intubation. In SLNB, the blockade of nerve impulses causes loss of sensation in epiglottis and vocal cord and relaxes the vocal cord to facilitate endotracheal intubation when the endotracheal tube passes through the vocal cord.[2],[10]

These multiple case reports show that the quality of intubation in all patients whereas in the SLNB, we found there were complete jaw relaxation and easy laryngoscopy, one patient with the vocal cord still moved, and one patient with mild cough reflex when the endotracheal tube was inserted. We can conclude from this case report that the quality of intubation in the was very good while some patients still had cough reflex due to inadequate block of the vocal cord. Some difficulties we face in this SLNB, i.e., obese patient or have a short neck which makes them hard to identify hyoid bone and inject local anesthetic in a proper position. Cough reflex and moving vocal cord can be caused by the spreading of lidocaine just in the surface of the trachea and does not block the internal part of the superior laryngeal nerve. The effect is some parts of the trachea still able to feel the sensation when the endotracheal tube passes through the trachea and triggers the cough reflex and vocal cord to move.[3],[11]

From this case report, we obtained that the MAP and HR before and after intubation in the use of muscle relaxant increased more than in the SLND. This is consistent with the theory that the use of intravenous muscle relaxants for intubation only relaxes the skeletal muscles but still stimulates sympathetic response and results in the increase of BP and HR [Table 1]. While the intubation facilitated with SLNB blunts the pain sensation that occurs when inserting a laryngoscope on endotracheal intubation, so there is no sympathetic stimulation occurs.[7],[12]
Table 1: Characteristic of subjects

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The MAP and HR were measured just before and right after intubation. In the use of muscle relaxants, both MAP and HR increased more than those in the SLNB. In this case report, we obtained that score of the postoperative side effects was low when we performed SLNB to facilitate intubation. The incidences of postoperative sore throat, cough, and hoarseness could be caused by several factors due to irritation of the laryngotracheal mucosa by inappropriate tracheal tube diameter, endotracheal cuffs design, larger endotracheal cuffs volume, bad intubation maneuver, coughing or bucking, and surgical manipulation in the larynx and vocal cord.[2],[3],[4]


  Conclusion Top


The intubation quality which facilitated by the SLNB is equivalent to the muscle relaxant, but the hemodynamics responses are much better in the SLNB group and the side effects that occur are minimal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abeer A, Dalia S, Abdel RY. Superior laryngeal nerve block as an adjuvant to General Anesthesia during endoscopic laryngeal surgeries A randomized controlled trial. Egypt J Anaesth 2015;31:167-74.  Back to cited text no. 1
    
2.
Christopher MB, Fernando AZ, Douglas RB, Steven HR. A historical perspective on use of the laryngoscope as a tool in anesthesiology. Anesthesiology 2004;4:1003-6.  Back to cited text no. 2
    
3.
Chelly JE. Airway blocks. In: Peripheral Nerve Blocks: A Color Atlas. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004. p. 177-84.  Back to cited text no. 3
    
4.
Canty DJ, Poon L. Superior laryngeal nerve block: An anatomical study comparing two techniques. J Clin Anesth 2014;26:517-22.  Back to cited text no. 4
    
5.
Hanggia P. Intubation quality and haemodynamic response in endotracheal intubation after superior laryngeal and transtracheal block compared to muscle relaxant. Malang Neurol J 2012;4:13-4.  Back to cited text no. 5
    
6.
Miller RD. Pharmacology of muscle relaxants and their antagonists. In: Miller's Anesthesia. 7th ed. United States: Churchill Livingstone Elsevier; 2012. p. 859-912.  Back to cited text no. 6
    
7.
Morgan GE, Mikhail MS, Murray MJ. Airway management. In: Clinical Anesthesiology. 4th ed. New York: Lange Medical Books McGraw-Hill; 2012. p. 91-116.  Back to cited text no. 7
    
8.
Sivakumar RK. Rajasekar, Pradeep S, Heber A. Efficacy of bilateral superior laryngeal nerve block for diagnostic direct laryngoscopy. Int J Sci Stud 2017;4:25-7.  Back to cited text no. 8
    
9.
Stoelting R. Neuromuscular-blocking drugs. In: Pharmacology and Physiology in Anesthetic Practise. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2016. p. 208-45.  Back to cited text no. 9
    
10.
Ono Y, Kakamu T, Kikuchi H, Mori Y, Watanabe Y, Shinohara K. Expert-performed endotracheal intubation-related complications in trauma patients: Incidence, possible risk factors, and outcomes in the prehospital setting and emergency department. Emerg Med Int 2018;2018:5649476.  Back to cited text no. 10
    
11.
Andrew S, Raymond T. Sonographically guided superior laryngeal nerve block during awake fiberoptic intubation. Int Anesth Res Soc 2015;4:12-5.  Back to cited text no. 11
    
12.
Brown DL. Airway block anatomy. In: Atlas of Regional Anesthesia. 3rd ed. United States: Saunders Elsevier; 2006. p. 1993-5.  Back to cited text no. 12
    



 
 
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