KingVision® and dexmedetomidine for opioid-free awake intubation in a patient with Klippel-Feil syndrome for complex percutaneous nephrolithotomy in a prone position: a case report

Dear Editor,
We would like to report a case of opioid-free awake intubation by KingVision® videolaryngoscope (VL) of an ASA 3 70-year-old male with Klippel-Feil syndrome (KFS) as a feasible, safe, and effective alternative method to fibre-optic intubation.
KFS represents a rare congenital disease characterized by different types of fusion of the cervical vertebrae. The prevalence of KFS is unknown due to the lack of studies. It is estimated to occur 1 in 40,000 to 42,000 newborns worldwide [1].
The patient was scheduled for a per­cutaneous nephrolithotomy (PCNL) in a prone position, a well-established minimally invasive technique to shatter and remove renal stones more than 2 cm in size. There has been considerable debate about the best anaesthetic management. The procedure is usually performed under general anaesthesia (GA), but the published literature regarding the use of neuraxial anaesthesia for PCNL is currently sparse. The advantages offered by GA include safety because the patient’s airway is secured in prone position, feasibility to control tidal volume during percutaneous access puncture to minimise injury to the pleura and lungs, and prolonged anaesthesia duration allowing the surgeon to make multiple and higher punctures with minimal patient discomfort, especially in cases with large stone load. It is safe to conduct the procedure under GA for complicated or prolonged procedures [2–4].
The fusion of cervical vertebra in KFS causes cervical instability and limitation of movements. In these cases, the gold standard for a GA is the awake tracheal intubation by using a flexible fibre-optic bronchoscope (FOB) [5, 6]. So that cervical movements, which could produce neurological damages, are minimised. Furthermore, airway management can be challenging in most of these patients because of limitation in the range of neck movement due to cervical immobility, and cervical instability could enhance the risk of neurological injury during intubation. Nowadays awake intubation with VL is a new method that is gaining more and more interest as an alternative to FOB [7]. Although awake intubation by using FOB should be mastered by all modern anaesthesiologists, its use is potentially influenced by several points. First of all, the technique using the FOB is difficult to learn and master because it needs extensive practice and training. However, in clinical practice very few cases require awake intubation. Second, the presence of...


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