Dexmedetomidine vs. Propofol-Fentanyl for Bispectral Index (BIS)-Guided Sedation During Awake Fiberoptic Intubation in Neurosurgical Patients With Anticipated Difficult Airways: An Observational Study

Introduction Awake fiberoptic intubation (AFOI) is commonly employed in neurosurgical patients with anticipated difficult airways to minimize spinal cord compression and intracranial pressure fluctuations, although procedural discomfort remains a major limitation. This prospective observational study evaluated the AFOI with two commonly used conscious sedation regimens-dexmedetomidine and a propofol-fentanyl combination-guided by Bispectral Index (BIS) and the Observer’s Assessment of Alertness/Sedation (OAA/S) scale, along with spray-as-you-go (SAYGO) topical anesthesia. Outcomes assessed included AFOI conditions - cough severity and intubation conditions; time to achieve target sedation (BIS value of 70); hemodynamic changes; total intubating attempts; intubation time; correlation between BIS and OAA/S; perioperative complications; and postoperative recall. Methods Forty consecutive adult patients undergoing AFOI for elective neurosurgical procedures received conscious sedation with either dexmedetomidine (Group D) or propofol-fentanyl (Group PF) as part of routine clinical practice. Conscious sedation was titrated using BIS, and the corresponding OAA/S scores were assessed. Airway topicalization was achieved using the SAYGO technique. Results Patients receiving propofol-fentanyl demonstrated superior intubation conditions compared with dexmedetomidine, as evidenced by higher total intubation scores (7.80 ± 0.62 vs. 7.11 ± 1.24; p = 0.039) and shorter intubation times (16.10 ± 10.95 vs. 27.79 ± 21.18 seconds; p = 0.036). Additionally, the propofol-fentanyl group also exhibited less coughing, better endotracheal tube tolerance, lower lignocaine requirements, and improved postoperative recovery profile with fewer complaints of sore throat during the first 48 hours after surgery. Procedure recall was absent in both groups. Conclusion In routine clinical practice, BIS-guided conscious sedation with a propofol-fentanyl combination was associated with better intubating conditions and procedural tolerance than dexmedetomidine during AFOI in high-risk neurosurgical patients. The SAYGO technique further enhanced patient comfort and safety, providing a practical alternative to conventional airway nerve blocks.