Intubação nasotraqueal às cegas em paciente acordada candidata à hemimandibulectomia: relato de caso

Daniel de Carli; Nivaldo Simões Correa; Tatiana Castelo Branco Vilar Silva; Eduardo Malta Maradei

doi:10.1590/S0034-70942008000100008

Clinical Information

Intubação nasotraqueal às cegas em paciente acordada candidata à hemimandibulectomia: relato de caso

Blind nasotracheal intubation in awaken patient scheduled for hemimandibulectomy: case report

Daniel de Carli; Nivaldo Simões Correa; Tatiana Castelo Branco Vilar Silva; Eduardo Malta Maradei

http://dx.doi.org/10.1590/S0034-70942008000100008 Braz J Anesthesiol, vol.58, n1, p.55-62, 2008

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JUSTIFICATIVA E OBJETIVOS: A abordagem à via aérea pode utilizar diversos recursos. Manter o paciente acordado, cujo controle seguro da ventilação/oxigenação é incerto, constitui uma opção quando há dúvida quanto à intubação. A intubação nasotraqueal (INT) às cegas é uma alternativa à fibroscopia. RELATO DO CASO: Paciente do sexo feminino, 75 anos, 56 kg, candidata à hemimandibulectomia, com imobilidade cervical por artrodese, abertura bucal de 2,2 cm, retrognatismo moderado, sem protrusão voluntária da mandíbula, distância mento-esternal de 11 cm e mento-tireoidiana de 6 cm, recebendo 5 pontos na escala Wilson. A paciente previamente orientada consentiu com o procedimento. Após monitoração e oxigenação, foi iniciada infusão contínua de dexmedetomidina. Realizado bloqueio dos nervos laríngeo superior e inferior com lidocaína a 2,0% sem vasoconstritor e instilação de lidocaína spray em hipofaringe. Previamente à INT foram administrados ondansetron, midazolam, fentanil e droperidol, permanecendo a paciente acordada e cooperativa. A inserção via nasal de tubo traqueal foi orientada pela sua opacificação e ruídos respiratórios e confirmada por ausculta pulmonar e capnografia. Iniciada infusão contínua de propofol e remifentanil, administrados rocurônio e ventilação controlada. A operação de 60 minutos não teve intercorrências. Ao término, a paciente apresentava ventilação espontânea, sendo extubada e encaminhada à recuperação pós-anestésica, recebendo alta sem queixas. CONCLUSÕES: A INT é alternativa à fibroscopia quando a segurança do controle das vias aéreas é incerta. O prévio esclarecimento da paciente foi essencial. Houve segurança, sem depressão respiratória ou instabilidade hemodinâmica.

Palavras-chave

ANESTESIA, geral, INTUBAÇÃO: nasotraqueal, às cegas

Abstract

BACKGROUND AND OBJECTIVES: Several resources can be used for the approach of the airways. Maintaining a patient awake when control of ventilation/oxygenation is uncertain is an option when intubation is doubtful. Blind nasotracheal intubation (NTI) is an alternative to fiberoptic endoscopy. CASE REPORT: A 75-year old patient, weighing 56 kg, was scheduled for hemimandibulectomy; she presented cervical immobility secondary to arthrodesis, mouth opening of 2.2 cm, moderate retrognatism, voluntary protrusion of the mandible was absent, mentosternal distance of 11 cm and mento-thyroid distance of 6 cm, therefore receiving a score of 5 on the Wilson scale. The patient signed an informed consent after being informed about the procedure. After monitoring and oxygenation, continuous infusion of dexmedetomidine was initiated. Superior and inferior laryngeal nerve block was performed with 2.0% lidocaine without vasoconstrictor and the hypopharinx was anesthetized with a lidocaine spray. Before NTI, ondansetron, midazolam, fentanyl, and droperidol were administered and the patient remained awake and cooperative. Nasal insertion of the tracheal tube was oriented by its opacification and respiratory sounds and the placement was confirmed by pulmonary auscultation and capnography. Continuous infusion of propofol and remifentanil was instituted, vecuronium was administered and controlled ventilation was initiated. The surgery lasted 60 minutes without intercurrences. At the end, the patient was breathing spontaneously, so she was extubated and transferred to the recovery room from where she was discharged without any complaints. CONCLUSION: Nasotracheal intubation is an alternative to fiberoptic endoscopy when safety and control of the airways is uncertain. Informing the patient about the procedure was essential. Safety was assured and respiratory depression and hemodynamic instability was not observed.

Keywords

ANESTHESIA, general, INTUBATION, nasotracheal, blind

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Intubação nasotraqueal às cegas em paciente acordada candidata à hemimandibulectomia: relato de caso

Blind nasotracheal intubation in awaken patient scheduled for hemimandibulectomy: case report

Daniel de Carli; Nivaldo Simões Correa; Tatiana Castelo Branco Vilar Silva; Eduardo Malta Maradei

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