Awake Anaesthesia in High-Risk Surgeries: A Systematic Review of Techniques, Airway Management, and Patient Outcomes

This systematic review evaluates recent advances in awake anaesthesia techniques in high-risk surgeries. The objective was to synthesize evidence from randomized controlled trials (RCTs) and clinical studies published between January 2020 and June 2025 regarding anaesthetic strategies, airway management, and perioperative outcomes. Awake surgery anaesthesia, especially in neurosurgical and thoracic contexts, has shown benefits in functional preservation, reduced intraoperative complications, and enhanced recovery. Included studies examined the effects of rocuronium-sugammadex regimens in awake craniotomy, extubation depth in nasal surgeries, regional blocks versus nebulization for airway preparation, and particle size optimization in nebulization. Findings revealed that awake approaches decrease arousal time, emergence agitation, and procedural complications while improving patient comfort and airway management. The results highlight the clinical advantages and encourage broader, evidence-based application of awake techniques, though further trials are warranted for standardization. For patients with difficult airways, awake fiberoptic intubation is optimized using superior laryngeal nerve blocks, which show improved intubation conditions and patient comfort compared to nebulization. Among nebulization techniques, particles sized 9-10 μm offer superior patient tolerance, minimal airway reactivity, and shortest intubation preparation. These findings highlighted the importance of individualized anaesthesia planning and support the expanded use of awake techniques in various surgical settings while underscoring the need for further high-quality trials.