Anesthesia for tracheostomy for huge maxillofacial tumor
A 19-year-old female patient, weighted 40 kg, with a huge craniofacial tumor was scheduled for elective tracheostomy due to airway compromization. The tumor invaded the hypo and oropharynx causing displacement of the eyes, nasal obstruction with limited mouth opening and neck extension []. The patient had obstructive sleep apnea, shortness of breath, visual impairment and dysphagia for which gastrostomy was inserted for enteral feeding. The patient had a recurrence of the tumor after surgical intervention and multiple courses of chemo and radiotherapy. The patient absolutely refused any trial to insert an intravenous (IV) cannula as she had a low threshold for pain and on examination, her veins were apparently exhausted and sclerosed from chemotherapy and no vein could not be chosen to apply, EMLA cream. The patient was categorized as impossible to both intubate and ventilate due to severely distorted airway anatomy in uncooperative patient. Communication with the patient was challenging due to dysphonia. With the help of her mother, she reported that her daughter is absolutely refusing IV cannulation and she expressed her fear of pain perception during the tracheostomy procedure. Consent was taken from the patient to take a photo for her. In the high dependency unit, 2 h before surgery, sedation was initiated under full monitoring with baseline non-invasive blood pressure (BP) 111/74 mmHg, heart rate (HR) 92/min, oxygen hemoglobin saturation 98% and respiratory rate (RR) 17/min.\nKetamine (Tekam, Hikma, Jordan) with a dose of 120 mg (3 mg/kg) diluted in 10 ml normal saline was administered through the gastrostomy tube. That was followed by administration of 80 mcg (2 mcg/kg) dexmedetomidine (Precedex; Hospira, Inc., Lake Forest, IL, USA) diluted in 10 ml normal saline. EMLA 5 g cream 5% (Astra Pharma, Inc., Mississauga, Ontario, Canada) was applied over the planned tracheostomy site about 10 cm2 and covered by transparent film dressing (Tegaderm Film, 3M Health-Care, USA).\nIn OR, the patient was sedated yet awake with eye opening to verbal commands. Non-invasive monitoring was applied for the patient (BP, electrocardiogram, pulse oximetry). BP was 105/70 mmHg, HR: 89/min, RR: 16/min and O2 Sat: 98%. A 24G IV cannula was inserted in the left antecubital vein guided by ultrasound without complaint. 5 ml lidocaine 1% + adrenaline 1/200,000 were infiltrated over tracheostomy site by the surgeon after IV was secured with full cooperation by the patient. Cuffed tracheostomy tube size 6.0 mm tube was easily inserted. No changes in vital signs were observed during the procedure. On the following day, the cuffed tracheostomy tube was replaced by a fenestrated one; to allow the patient to speak. The mother informed the team that her daughter was highly satisfied and had no recall of the procedure.