Anesthesia and Cancer Flashcards
1
Q
What does cancer result from?
A
- Accumulation of genetic mutations that causes dysregulation of cellular proliferation (alteration in DNA structure)
- inherited traits
- mutaiton of normal gene into an oncogene
- inactivation of tumor suppressor gene (p53)
- Fundamental cellular event in malignancy: alteration in DNA structure
- immune surveillance destroys many malignant cells
- HIV/immunosuppressant disrupt protective mechanism
- Most cancers produce solid tumors
2
Q
What does TNM stand for?
A
tumor
nodes
metastatic disease
3
Q
What carincogens are estimated to be responsible for 80% of cancers in the United States?
A
- Tobacco
- alcohol
- sunlight
4
Q
Most common cancers?
A
- Prostate (men), breast (women)
- lung #2 in both male/female (leading cause of death)
- Colon Ca 2nd leading cause of death
5
Q
What are some pathological changes in the hematologic system with cancer?
A
- Anemia
- bone marrow suppression
- GI ulceration and anemia due to invasion
- Neutropenia- decrease WBC
- Thrombocytopenia
- hypercoagulable state; risk of thromboembolic events
- Hypercalcemia
6
Q
Pathological effects of cancer on neuromuscular system?
A
- myofascial pain and peripheral neuropathies
- spinal cord compression
- metastatic brain tumors, most often from lung and breast Ca
- presents usually as mental deterioration, focal neurologic deficits or seizures
7
Q
Pathologic changes in pulmonary system during cancer?
A
- Pulmonary edema/CHF
- Recurrent pleural effusions
- pneumonitis
- Lung Ca specifically
- squamous cell (25-40%)–> hypercalcemia
- adenocarcinoma (30-50%)–> hypercoagulable/osteoarthritis
- large cell (10%)–> gynecomastia
-
small cell (15-24%)–> inappropriate ADH secretion/ectopic corticotropin secretion
- eaton-lambert
- myasthenice syndrome
8
Q
What is pulmonary osteoarthropathy?
A
Pulmonary osteoarthropathy- condition that affects some lung Ca pt-clubbing, spoon shaped nails, inflammation/swelling/pain in hands, fingers, knees ankles
9
Q
What are some other various pathological changes that can occur system wide?
A
- Anorexia/weight loss- hyperalimentation
- electrolyte abnormalities
- hypercalcemia d/t bone mets
- Na and K changes with N/V/D
- Adrenal insufficiency- tumor or suppression of adrenals with corticosteroid rx
- ectopic hormone production (specific small cell LC)
10
Q
What are some pathological changes from cancer in cardiac system?
A
- Malignant involvemnt of pericardium (pericardial effusion)
- electric alternans or paroxysmal a fib
- pericarial tamponade
- most common with lung Ca
- Drug induced CMP
- impariment of LVF for as long as 3 years after d/c of therapy
- SVC Obstruction
11
Q
What is SVC obstruction? What causes it?
A
Metastatic spread to mediastinum
- venous engorgment above the waist, dyspnea and airway obstruction
- increased ICP from increase in CVP
- Compression of great vessels may lead ot syncope
- hoarseness/dyspnea may indicate tracheal compression
12
Q
Concerns with mediatsinal masses?
S/S of concerning mediatsinal mass?
A
- Always perserve spontaneous respiration
- never induce general anesthesia
- sometimes the only thing keeping the airway open is the patient spontaneously breathing
- if need general anesthesia- need bypass on standby
S/S of concerning mediastinal mass
- JVD
- irritable
- nausea
- hoarseness
13
Q
Pathological changes in renal system with cancer
A
- decreased clearance
- drug induced nephrotoxicity/nephrotic syndrome
- ureteral obstruciton>> hydronephrosis
- hyperuricemia
14
Q
Pathologic hepatic system effects from cancer?
A
- Damage to hepatocytes
- coagulopathies
- DIC common with hepatic metastasis - poor prognosis
15
Q
Metabolic complications with cancer?
A
- Catabolic state- cancer burns through energy
- diarrhea
- poor nutritional status- chekc albumin
- volume depleted state
- hypotension
16
Q
What are paraneoplastic syndromes?
A
- Affects 8% of pt with cancer
- some come in as emergency. 80% occur before dx of ca
- Fever/cachexia
- neuro abnormalities: limbic encephalitis, cerebellar degeneration, lambert-eaton myasthenia syndrome and myasthenia gravis
- endocrine adnormalities: SIADH, Hyper calcemia, cushing syndrome, hypoglycemia
- Renal abnormallities: nephritis, amyloidosis
- derm abnorm.
- rheumatologic abnormalities
- hema abnormlalites
17
Q
What is Lambert Eaton syndrome?
A
- antibodies develop to voltage-gated calcium channel receptors
- commonly associated with SCLC
- Can cause NMB sensitivity and major potentiation
- not frequently dx, usually will be recognized when administered anesthesia
18
Q
How is cancer treated?
A
Multimodal therapy is most common
- Surgery
- traditional chemo: various MOA
- Targeted chemo: monoclonal antibodies
- radiation therapy: MOA is damage to DNA
- Ablation therapy
- RFA: primary liver tumors and metastases, localized lung, kidney, adrenal gland, and bone tumors
- Cancer vaccines and immunomodulators
19
Q
MOA Alkylating agents?
A
Form reactive molecules that cause DNA cross-linking problems such as abnormal base pairing and strand breaks that interfere with primarily with DNA but also RNA, protein synthesis and replication
20
Q
MOA antimetabolites?
A
Structural analogs of folic acid, purines, or pyrimidines that block enzymes necessary for nucleic acid and protein synthesis
21
Q
MOA antitumor antibiotics?
A
form complexes with DNA/RNA that inhibit their subsequent synthesis
22
Q
MOA Microtubule assembly inhibitors?
A
vinca alkaloids and taxanes, both of which act on the mitotic process by interfering wiht microtubulea ssembly or diassembly
23
Q
Adverse effects of Ca treatment?
A
- bone marrow suppression
- cv toxicity
- pulmonary toxicity
- central and peripheral nervous system damage
- renal toxicity
- hepatic toxicity
- gi/endocrine changes
- other: mucositis, ototoxicity, renal insuff.
24
Q
Chemo drugs associsted with CV toxicity?
A
Class: anthracyclines- most commonly associated
Ex: Doxorubicin (adriamycin) & daunorubicin
- dose-related CMP
- Can be acute/chornic
- acut CMP 10% (benign and symptoms usually resolve with d/c
- dysrhythmia, QT prolongation
- acut CMP 10% (benign and symptoms usually resolve with d/c
- Chronic toxicity- LV dysfunction and CMP can occur in an early onset form taht usually appears within 1 yr of treatment and a late-onset form that can emerge much later
- Enhances myocardial depression with anesthetics (acute LV failure during GA, 1 mo after cessation)
PEARLS- BASELINE and periodic ECHO recommended
25
What are some cardiac affects with fluorouracil?
Associated with pericarditis, angina, coronary artery vasospasm, ichemia-related EKG changes, and conduction defects
26
What are some side effects of monoclonal antibodies?
high level HTN
Bevacizumab, trastuzumab, sorafenib (all exampled monoclonal antibodies)
27
Cardiac s/e of radiation to chest?
* Myocardial fibrosis
* pericarditis
* valvular fibrosis
* conduciton abnormalities
* accelerated development of CAD
* Cumulative exposure is a factor
* ALSO can see these effects if patient had radiation has child but is perfectly healthy now
28
What are some anesthesia implications for bleomycin?
Bleomycin has dose-related toxicity
* causes endothelial damage (looks like PNA)--\> type I and type II alveolar necrosis--\> pulmonary fibrosis- no Rx
* pulmonary HTN
* Increased A-a gradient
* **induced hyperoxic pulmonary injury- free radical formation**
* Recommend
* baseline and serial PFT and CXR
* ABG Sao2
* adjust o2 for sat \>90%
* **colloid** v crystalloid (don't want to overhydrate with cyrstalloid)
* corticosteroids
29
What are other drugs that can cause pulmonary toxicity?
* Cyclophosphamide
* busulfan
* methotrexate
* lomustine
* carmustine
* mitomycin
* vinca alkaloids
30
Concerns with methotrexate?
* Fulminant non-cardiogenic pulmonary edema
* progressive inflammation with infiltrates and effusions
* toxicity 8%
31
What are some pulmonary effects with radiation to chest?
* interstitial pneumonities and pulmonary fibrosis
* tracheal stenosis
* airway exam can be completely normal
* smallest tube possible
* if you can't pass, maybe need to wake up
* Symptoms typically begin within first 2-3 months of treatment and usually regresses within 12 months
32
"Pearls" for pulmonary toxicity
* Preop o2 sat, CXR, PFT, ABG
* Intraop exposure to high concentraiton o2 may exacerbate preexisting bleomycin induced lung injury and contribute to postop vent failure
* periop coritcosteroid admin may be of benefit in treating bleomycin-induced pneumonitis
33
What are some renal effects from cisplatin?
* decreased GFR within 3-5 days
* renal insufficiency and hypomagnesemia are typical presenting signs
* ATN--\> ARF--\> HD
34
What are renal symptoms with methotrexate (antimetabolite)
* usually ok as long as pt gets Leucovorin, prehydraiton and avoidance of other nephrotoxic drugs
* these intervention reduce incidence of renal toxicity
35
Cyclophosphamide renal issues?
Associated with SIADH
Hemorrhaic cystitis--\> can be severe and cause obstructive nephropathy and ARF
36
Ifosfamide renal issues?
Proximal tubule dysfunction marked by proteinuria and glucosuria
37
What are some renal issues with induction chemo and high-dose radiation?
* Induces **tumor cell lysis** that causes release of large amounts of uric acid, phosphate and potassium, especially with large tumor burden (ie hematologic)
* **hyperuricemia** can cause **uric acid crystals** to precipitate in renal tubules, leading to ARF
* Can caues **glomerulonephritis** or **glomerulosclerosis** with permanent injury marked by chornic renal insufficiency and **systemic HTN**
* Life threatening **hyperkalemia** can occur
* hyperphosphatemia leads to hypocalcemia and can increase likelihood for **dysrhthmia**
**PEARLS: NEET ELECTOLYTES BEFORE SLEEP**
**BUN/CR, URINE ANALYSIS**
38
What is a chemo drug associated with liver dysfunction?
What syndrome can TBI cause in the liver?
Methotrexate
* associated with acute liver dysfunction
Radiation is associated with **sinusoidal obstruction syndrome**
* severe liver dysfunction with high mortality
* very sick, fulminate liver failure
* cirrhosis acutely
39
What is association of mucositis and cancer?
* from high-dose chemo and radiation
* patients with mucositis are at risk of infection from spread of oral bacteria
* narcotics frequently required. psudomembrane formation, edema and bleeding **may cause airway compromise or risk of aspiration**
40
What should we be concerned about when someone's had radiation to head/neck?
* Permanent tissue fibrosis
* limited mouth opening
* lmited neck ROM
* may need video laryngo and airway cart
* limited tongue mobility
* trahceal stenosis: unrecognized on physical exam
* **PEARLS**
* preop airway assessment, cervical ROM x ray, ENT consult
* when in doubt, ENT consult!
41
What are some GI/endocrine changes with cancer treatments?
* **N/V/D,** enteritis are common after chem + radiation
* results in dehydration, electrolyte abnormalities and malnutrition
* Radiation to abd may produce permanent **adhesions** and stenotic **lesions** along **GI** **tract**
* **hyperglycemia** from steroid therapy
* **SIADH** seen with **cyclophosphamide, ifosfamide, cisplatin or, from tumor itself**
* Radiation to neck or TBI may cause **hypothyroidism** or panhypopituitarism
* Preop thyroid function tests, CMP, BG, urine specific gravity
42
What are some hematologic system changes with chemo or radiation?
Chemo
* myelosuppression
* chemo's job is to get rid of cells that are rapidly turning over. can't discriminate b/w RBC or own cells that are replicating
* thrombocytopenia and/or platelet dysfunction
* tumors release procoagulants that create hypercoagulable state
* VTE prophylaxis is essential in high risk pt
Radiaiton
* coagulation necrosis of vascular endothelium
* blood vessel can die
* sometimes with radiation, brain tumor is bleeding more and can cause pt to deteriorate until tumor starts to necrose
* post-radiation bleeding
**GET CBC PT/PTT/INR preop**
43
What nervous system changes can high dose cyclophosphamid cause?
* acute delirium
* encephalopathy
* ataxia
44
What nervous system changes can methotrexate cause
?
dementia
45
What nervous system changes can Vinca Alkaloids (Vincrinstine) cause?\>
* Sensorimotor peripheral neuropathy- paresthesia in hands/feet
* Autonomic neuropathy- usually reversible (dysautonomia--\> hypotension)
* **Cuation with regional anehesia: sublinical neurotoxicity may be present**
**Cisplatin-** dose dependent damage to dorsal root ganglia--\> large fiber neuropathy
46
What nervous system changes do alkylating agents cause (Cytoxan= cyclophosphamide)
* Plasma cholinesterase inhibition
* prolongs effects of succinylcholine by reducint available plasma cholinesterase enzyme to metabolize the drug
47
General anesthesia considerations with cancer?
* Correction of nutrient deficiencies, electrolyte abnormaliites, anemia, and coags
* sometimes will tolerate lower Hgb to minimize transfusions
* Labc: cbc, coag, LFT, serum electrolytes
* Test: CXR ,echo, PFT, o2 sat, VS
48
What are anesthesia concerns with pt on Bevacizumab?
Surgery delayed 4-8 weeks post Bevacizumab r/t increased risk of bleeding an dpostop wound complications
49
Anesthesia considerations with doxorubicin?
Doxorubicin- cardiac toxic, cmp, arrhythmia
Wathc EKG- some chemo agnest cause arrhythmias
50
Anesthesia considerations with belomycin?
* Pulmonary fibrosis
* ABG o2 sat
* carefully titrate IV fluid replacement d/t risk of developing interstitial pulmonary edema r/t impaired lymphatic drainage in lungs
* use colloid vs crystalloid
* avoid high concentration o2
* o2 sat \>90 and fio2 \<30
51
What are some anesthesia considerations with methotrexate?
Avoid n2o, augments toxicities
52
Which anesthesia med is not a good choice for Cyclpophosphamide's?
Succinylcholine- may have prolonged response (drug-induced pseudocholinesterase deficiency)
53
What do you need to watch for with administration of muscle relaxants to patient's recieving chemo/radiation treatment?
Paraneoplastic syndromes like eaton lambert
54
When a patient has been on steroid therapy, what is the lenght of time when you should be concerned for adrenal suppression?
What would be a treatment?
20 mg of prenisone for longer than 3 weeks
* Can supplement adrenal suppression with 100mg IV hydrocortisone at induction with 100 mg q 8 hours for first 24 hours after surgery
55
What are some recommendations for pain management in cancer patients?
* Anesthetics and analgesic have immunomodulatory properities
* regional is best
* IV opioids tend to blunt NK cell activity
* regional anesthesia preferred
* however, watch coags. use multimodal treatment
* must assess and doc baseline neuropathetis if regional concidered
* may need increased requirements for analgesia
* NSAIDs effective for bone pain
* most common type of cancer pain
* Opioid admin
* Adjuncts: antidepressants, anticonvulsants, gabapentin, ketamine
* Nerve blocks- neurolysis (with celiac plexus block with alchol/phenol)
* goal is sensory destruction whiel sparing motor/autonomic function
* Corticosteroids
* decrease pain perception, have sparing effect on opioid requirement
* improve mood, increase appetite, lead to weight gain
56
What are considerations for managing nausea/vomiting in cancer patient
* Treatment of nv
* metoclopramide
* droperidol- black box for antipsychotic range (qt prolongation)
* zofran
* cannabis
* (also haloperidol, benadryl, ativan)
* Patient will often verbalize a high degree of anxiety related to the potential for nausea and vomiting
* must provide reassurance tha tmeasures will be taken to control nausea and vomiting
57
What is involved in a cordotomy? Dorsal rhizotomy?
* Cordotomy- interrupt the spinothalamic tract in the spinal cord and is considered for treatment of unilateral pain involving lower extremity, thorax, or UE
* Dorsal rhizotomy- inovlved interruption of sensory nerve roots
* used when pain is localized to speicifc dermatome levels
* dorsal column stimulators ro deep brain stimulators may be used in selected patients
58
Considerations with lung cancer and anesthesia?
* Leading cause of cancer death
* Presenting clincial signs- cough, hemoptysis, wheezing, stridor, dyspnea, or pneumonitis from airway obstruction
* Mediastinal masses may cause hoarseness (recurrent laryngeal nerve compression), SVC syndrome, cardiac dysrhythmias, of CHF from pericardial effusion and tamponade?
* Generalized weakenss, fatigue, anorexia, weight loss common
59
Where do squarmous cell cancers originate? presenting signs?
* Arise in major bronchi or their primary divisions
* grow slowly and reach large size before detected
* Hemoptysis, bronchial obstruction with associated atelectasis, dyspnea and fever from pneumonia are common presenting signs
60
Where do adenocarcinomas of lung originate? Present signs?
* Originate in lung periphery
* Tumors commonly present as subpleural nodules
* have tnedency to invade plera and induce pleural effusions
* Difficult to differentiate morphologically
61
Where do large cell carcinomas arise from?
* Peripheral in origin and present as large, bulky tumors
* metastasize early and preferentially to CNS
62
Where do small cell carcinomas arise from? metastisize to?
* Central bronchial origin and ahve high frequency of early lypmhatic invastion
* epseically to lymph nodes in mediastinum, mets to liver, bone, CNS, adrenal glands and pancrease
* SVC syndrom may result
* Propensity to produce polypeptides and ectopic hormones that result in metabolic abnormalities
63
Surgical procedures for lung cancer?
* Diagnositc- flexible fiberoptic bronchoscopy
* Fine-needle aspirations by fluoroscopy
* VATS
* bx, wedge rsection, lobectomy
* Mediastinoscopy
* lymph node bx
* hemorrhage, and pneumothorax most frequent
* Right innominate compression (aka, right brachiocephalic)
* can lose pulse ox/art line waveform if compressed
* put art line on R side so we know innominate is being compressed
* Thoracotomy
* complex, pneumonectomy
64
Concerns for lung cancer surgery?
* PFT essential : predicted postop pulmonary function is also assessed
* in general, if prediced postop FEV1 \<0.8L , patients are poor candidates for pneumonecrtomy
* involvemnt of lung impacts ventilation
* increased incidence of associated CAD
* Pain- patient receiving txmt for cancer-releated pain may have up-regulated opioid receptors
* Ectopic endocrine effects (small cell carcinoma)
* 3% pt are cushinoid
* 60% with lung Ca have inappropriate ADH (SIADH)
65
Anesthesia management for diagnositc bronchoscopy?
* Genral- TIVA, large ETT (at least 8/9)
* MAC
* Ultasound guided bronch takes longer and ETT is preferred
* ebus- get bronch, send off to pathology and see if they got a good sample
66
Anesthesia management for VATs case?
* General
* aline, fluid restriction, lateral position, single lung ventilation (doublt lumen ETT/ Bronchial blocker),
* One lung ventilation
* peep on up lung
* cpap on down lung
* Frequent ABGS
* Pulmonary insufficienncy after lung tissue resection- plan ETT post op
* Pneumothorax- chest tube
* potential for masive blood loss during sx resection
* thoracic epidural for post op pain managmenet- place prior ot induction
* Hemorrhage possible
* t &c, 2 large bore IV, check h&h intraop, blood warmer, 2 prbc in room with 2 on hold
* Monitor UOP- because limiting fluid
* Lateral position- V/Q mismatch, nerve injuries
67
Anesthesia managmeent for mediastinoscopy?
* General
* ETT, controlled ventilation (concern, pneumo)
* Tumor location? Compression trachea with NMB--\> may need awake fiberoptic intubation for ETT
* Scope--\> pressure on R subclavian--\> loss of pulse--\> false dx arrst (Pulse ox L and A line R)
* Stretch of vagus or trachea--\> bradycardia
* vocal cord problems
68
Anesthesia management considerations for thoracotomy?
* General
* aline, central line, fluid restriction, lateral position, lung isolation, one-lung ventilation, thoracic epidural
* **One- lung ventilation**
* peep on up lung
* cpap on down lung
* **Pulmonary** **insufficiency** after lung tissue resection- plan ETT postop
* **Pneumothorax**- chest tub
* **thoracic epidural** for postop pain management- placed prior to induction
* don't dose until after induction
* **Hemorrhage** possible
* t& c, 2 large bore ivs, chekc h& h intraop, blood warmer
* potential for massive blood loss during sx resection
* Monitor UOP
* Lateral position- V/Q mismatch, nerve injuries
Same consideration as VATS but experience a LOT more pain
69
What type of double lumen tube do we usually use?
L double lumen tube. - typically lose ventilation RUL with R double lumen ETT
sized based on height
check placement on insertion with bronch and after patient moved laterally
70
Concerns for breast cancer surgery?
* Poor venous access- avoid IV on operative side if possible
* Monitor placement- avoid BP cuff on operative side
* Tamoxifen
* increased risk of thomboembolic events
* DVT
* PE
* Stroke
* If on doxorubicin chemo- cardiotoxicity with CMP
* If radiation therapy= pulmonary fibrosis
* Isosulfan blue dye for LN mapping- associated with anaphylaxis 1%
* transiently affects oximetry
* If s in axillary n area- wont' want NMB on board!!! choose short acting when putting to sleep
71
Anesthesia management for various breast cancer surgeries?
Bx?
Lumpectomy?
Mastectomy?
Radical mastectomy/node dissection
* Bx
* local with sedation
* general- after radiology with needle placement
* Lumpectomy- GA
* Mastectomy- GA
* Radical mastectomy/node dissection- GA, ETT
72
Procedures performed for colon/GI cancer sx?
* Diagnostic- endoscopy
* Laparoscopic
* Laparotomy- radical surgical resection (blood vessels and lymph nodes)
73
Anesthesia concerns for clon/GI cancer surgery?
* Radiation
* diarrhea
* cystitis
* Pain
* pt receiving treatment for cance-rrelated pain may have upregualted receptors and need more drug
* Bowel prep--\> hypovolemic--\> tachycardia/hypotension
* Ascites--\> low albumin level, and affect intrathoracic pressure
* anemia
74
Concerns with hipec surgery?
* Sx- take out organs like whipple
* high dose chemo instilled in abd for one hour
* causes lots of tumor lysis and electolye disturbances
75
Anesthesia management during endoscopy?
* Sedation
* GA- TIVA (propofol)\<-- if pt can't respond to name, general anesthesia
* natural airway- NC- 2/Chin lift
76
Anesthesia concerns during laparoscopic procedures\>
* General ETT ?RSI?
* Regional- epidural
* Hypovolemia--\> avoid drugs which cause hypotension and/or decrease doses
* avoid N2O
* Drugs that are protein bound --\> lower doses if low protein lab value
* anemia, lower MAC
* Avoid metoclopramide wiht obstruciton - contraindication
77
Anesthesia managment for laparotomy?
* General? RSI? \<-- full stomach, opioid slowing stomach
* Regional- epidrual
* hypovolemia--\> avoid drugs which cause hypotension
* avoid n2o- distention of bowel
* drugs that are protein bound--\> lower doses if low protein
* anemia, lower MAC
* **Avoid** **metoclopramide**
* laparotomy- muscle relaxation needed for retractors
* utilize multimodal!!
* blood transfusion during sx resection of colorectal cancers is associated with decrease in length of patient survivial
78
What are some various procedures that can be performed for prostate ca?
* Laparotomy- radical prostatectomy
* lap or robotic
* minimally invasive prostatectomy
* cystoscopy-transurethral resection (TURP)
* laser
* Radiation therapy
* external beam
* implantation of radioactive seeds
79
ANesthesia concerns for prostate ca surgery?
* Surgery vs radiation rx
* hormone therapy- for metaststic type
* resistance to rx--\> bone pain
* chemotherapy- cyclophosphamide, 5FU, Cisplatin, doxorubicin- alone or in combo
* High dose prednisone- subjective improvement
* positioning: lateral, sometime steep t-berg
* cognizant of pt eyes and vent changes
* lots of blodo loss possible
* when robot docked, pt needs to be completely paralyzed
80
Anesthesia management for TURP?
* General
* Regional
* epdiural
* spinal
* TURP- systemic absorption of irrigation fluid--\> volume overload
* not as big of concern now that we don't use glycine
* DIlutional hyponatremia a concern
* regional anesthesia- allows assessment of neuro when hyponatremia is concern
* Laser
* general
* eye prection, fire risk
* regional
* epidural
* spinal
81
Concerns for head/neck cancer sx?
* Possibility of distorted airway anatomy
* review imaging studies and develop plan
* dysphagia--\> increased risk for aspiration
* ENT surgeon at bedside during induction
* esp if airway concern
* positioning- sometimes patients far away, need stellar IV
82
Anesthesia management for diagnosit suspension laryngoscopy/scope
* Fiberoptic rigid scope
* general TIVA w ETT (large size)
* jet ventilation
* arms tucked
83
Anesthesia management for neck dissection?
* General
* hold NDMR for nerve preservation
* Radical neck disection
* general with ETT (maybe awake, maybe trach at beginning)
* Aline, 2 large bore IV, T&C, hold NDMR
* General with ETT- oral vs nasal depends on sx exposure
* impaired ROM and mouth opening- fiberoptic
* dyspnea-upright positioning
* tracheal compression concern- avoid NMV
* Airway may be inaccessible during case
* concern with ETT compression- use armored tube
* trachea- tube connections/access to pull ETT and reconnect
84
Postop consideraiton for head/neck surgery?
* prevent PONV
* must provide reassurance that measure will be taken to attempt to contorl PONV
* Treatment PONV
* anti emetics
* anesthetic technique
* adjuncts
