[Remifentanil-propofol for bronchoscopic fiber optic intubation under capnographic control]

We report a case of a 41-years-old woman presenting for revision of a secondary reconstructive procedure using the modified Tagliacozzi upper arm flap after subtotal maxillectomy. Because of the pedicle flap the upper arm was fixed in a pre-facial position and so fiberoptic intubation was required. After routine pre-anesthetic preparations and topical anesthesia of the nares and nasopharynx a CO2 measuring catheter as well as a O2 catheter to administer 100% oxygen was inserted deeply into the left naris. At that time, a continuous infusion of 0.05 microgram/kg/min remifentanil and 2 mg/kg/h propofol was started. After 4 min, fiberoptic intubation was performed through the right nare without any technical difficulties in conscious sedation of the patient. During the entire fiberoptic intubation SaO2 was constant at 100% and capnogram tracings with etCO2 values ranging from 31 to 33 mmHg were displayed on the monitor. At the end of this second surgical procedure with fixed pre-facial upper arm position the patient was uneventfully extubated fully awake. For the time period of fiberoptic intubation the patient had complete amnesia.

With the use of nasal capnography and capnometry in addition to simultaneous O2 administration during fiberoptic intubation under extreme conditions excellent analgosedation with propofol and remifentanil could be provided without compromising our patients' safety. The presented CO2 measuring and O2 administering device represents a simple and cheap expansion of standard anesthetic monitoring during fiberoptic intubation.