The asleep-awake-asleep anesthetic technique for intraoperative language mapping

OBJECTIVE: We evaluated a combined technique designed for procedures requiring intraoperative language mapping. We planned to induce general anesthesia with endotracheal intubation and hyperventilation and then to awaken and extubate the patient for speech testing. After the latter, endotracheal reintubation and general anesthesia were planned. METHODS: With the patient under intravenously induced sedation, we topically anesthetized the airway with lidocaine that was delivered through a spraying catheter. Fiberoptic endotracheal intubation was then performed on the awake patient, using a modified endotracheal tube. General anesthesia with intravenous propofol or sodium thiopental was induced, the patient's head was attached to a Mayfield holder, and the pin and operative sites were infiltrated with 0.5% bupivacaine with epinephrine. In anticipation of speech mapping, general anesthesia was discontinued and lidocaine was injected into the catheter that was spirally attached to the endotracheal tube. After speech mapping, the awake patients were endotracheally intubated, guided with the fiberoptic laryngoscope or tube changer, and general anesthesia was induced and maintained until termination of the surgery. RESULTS: We did not observe any complications, such as coughing or head movements, during the preparation for general anesthesia, awakening and endotracheal extubation for speech mapping, and post-testing reintubation or induction of general anesthesia. CONCLUSION: The combined technique that we describe abolished the potential discomfort of surgical stimulation on a sedated patient, reduced the duration of wakefulness, and provided a secure airway and the means to hyperventilate our patients before dural opening.