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ACVN - ANAESTHESIA > Anesthesia for airway, dental, ocular surgey > Flashcards

Anesthesia for airway, dental, ocular surgey Flashcards

1
Q

What are the risks with dental surgery?

A

risk of aspiration due to water
risk of hypothermia due to cold water
- staff fatigued as often last surgery of the day
- patients often geriatric/ have underlying conditions
- painful
- access to head and mouth difficult

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2
Q

What are the anaesthetic considerations for dental surgery? dental 6

A
  • pain
  • haemorrhage
  • hypothermia
  • aspiration of fluids
  • length of procedure - 30 mins to 5 hours
  • concurrent disease
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3
Q

What are the anaesthetic considerations for a geriatric patient undergoing dental surgery?ndental 5

A
  • reduced cardiovascular reserve
  • refuced functions residual capacity
  • reduced muscle mass
  • prone to hypothermia
  • may have reduced liver and kidney function
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4
Q

What is functional residual capacity? dental

A

the volume remaining in the lungs afer a normal, passive exhalation

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5
Q

What is the normal functional residual capacityin litres? dental

A

3 litres

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6
Q

What else dose functional residual capacity represent? dental

A

the point of the breathing cycle where the lung tissue elastic recoil and chest wall outward expansion are balanced and equal

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7
Q

What are baroreceptors? dental

A
  • a type of mechanoreceptors allowing for relaying information derived from blood pressure within the autonomic nervous system
  • Information is then passed in rapid sequence to alter the total peripheral resistance and cardiac output, maintaining blood pressure within a preset, normalised range.
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7
Q

What are the pre-op considerations for dental surgery? dental

A
  • Blood and urine testing
  • Other diagnostic testing? US/ Xray? ECG?
  • Full clinical exam
  • Anorexic? Common in cats with dental dx. - Other disease processes?
  • Fluid therapy – pre / peri/ post?
  • Premedication - May already be on medication ie nsaids/
    antibiotics
    -breathing system selection
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8
Q

What is MAC sparing? dental

A

Minimum alveolar concentration or MAC is the concentration, often expressed as a percentage by volume, of a vapour in the alveoli of the lungs that is needed to prevent movement
(motor response) in 50% of subjects in response to surgical (pain) stimulus

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9
Q

What are the peri-op anaesthetic considerations? dental 12

A

Analgesia – vital!
- Mac sparing properties
- Airway – cuffed ETT essential
- Dental machines produce water
- protect the airway!
- Mouth pack – must be in place to avoid AP
- Care when turning patient
- Observe tube to ensure not kinking or twisting
- Long procedure- hypothermia/ wet/topping up drugs
- Avoid spring loaded mouth gags esp. in cats
- Look after the eyes! (animal and human!)
- Haemorrhage – mouths can bleed…A LOT! Observe !!
-Positioning – patient will be in same position for a while! Pad joints/ avoid
sores/ atelectasis/ tube care when moving

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10
Q

What is MAC used for? dental

A

compare the strengths, or potency, of anaesthetic vapours

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11
Q

What does a lower MAC value represent? dental

A

s a more potent volatile anesthetic (as you need less to have an effect).

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12
Q

What is atelectasis? dental

A

Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with
alveolar fluid.

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13
Q

What are the benefits of dental blocks? dental

A
  • Combined use of dental blocks with GA will reduce maintenance
    anaesthetic requirements
  • Improve post-operative pain management (for up to 6 hours, maybe
    longer)
  • May improve speed of recovery and return to normal eating pattern
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14
Q

What dental nerve blocks can be performed? dental 4

A
  • Rostral Maxillary (Infraorbital) nerve block
  • Caudal Maxillary nerve block
  • Caudal Mandibular nerve block
  • Mental nerve block
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15
Q

Where does the Infraorbital nerve block (Rostral Maxillary) block? dental

A

Soft tissues, incisor/ canine and premolar teeth

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16
Q

What is the location of the foramen in dogs? dental

A

this is located on the maxilla, dorsal
to the third maxillary premolar.

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17
Q

Why should you take care when performing a Infraorbital nerve block (Rostral Maxillary) in cats and brachys? dental

A

The foramen is located at the level of the
medial canthus of the eye, so take care in animals
with differing anatomy

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18
Q

Where does the Caudal Maxillary nerve block? dental

A

all bones of the maxilla, the soft and hard palates, soft tissues of the
nose, upper lip and dentition rostral to the maxillary second molar

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19
Q

Where is the location of the foramen when performing Caudal Maxillary nerve block? dental

A

Needle inserted just caudal and central
to the last maxillary molar

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20
Q

Where does the mandibular nerve block block? dental

A

entire hemimandible teeth of the lower jaw

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21
Q

What is the location of the foramen when performing mandibular nerve block? dental

A

Needle inserted percutaneously at
the ventral angle of the mandible,

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22
Q

Where does the mental nerve block block? dental

A

lower incisors, skin and tissues rostral to the foramen

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23
Q

What is the location of the foramen in mental nerve blocks? dental

A

ventral to the rostral root of the second premolars.

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24
Q

what equipment do you need to perform a local block?dental

A

Preparation of equipment
- sterile needle and syringe
- Local agent i.e., lidocaine/ bupivacaine – pre calculate max dose (consider
Intubeaze –cats)
- Scrub
- Alcohol wipe/ liquid ( care around eyes)
- Sterile gloves
- Recording of doses/times

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25
Q

What are the anaesthetic considerations for post-op of the dental patient? dental

A
  • Analgesia! Re-assess/ pain score
  • Keep warm
  • Dry off as much as possible - REMOVE MOUTH PACK/ GAG
  • Tempt to eat/ nutrition going forward
  • Continue fluids if needed
  • Opportunity to toilet
  • Thorough discharge advice for owners - expect some bleeding
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26
Q

What are the pre-op considerations for ocular surgery?

A
  • Is the animal experiencing pain?
  • Could the eye rupture?
  • Are there any underlying diseases present ie Diabetes Mellitus
  • Is the animal on any specific medication?
  • What is the procedure being performed?
  • Full clinical examination and history -
    Preoperative screening if indicated
  • Premedication
  • Preparation – DO NOT use Hibiscrub on an eye
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27
Q

What are the peri-op considerations for ocular surgery?

A

Anaesthetic considerations (along with all the normal things)
- Preventing further trauma to eye ‘pre and post op’/ preserving sight/ care
with bair hugger warming devices around eye
- Maintenance of central eye for intraocular procedures
- Analgesia
1- Management of intraocular pressure
2- Oculo-cardiac reflex

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28
Q

What is normal intraocular pressure?

A

between 15-20mmHg

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29
Q

How is intraocular pressure determined?

A

a balance of aqueous humour production and
absorption, and other factors i.e. pupil size, corneoscleral rigidity, extra
ocular muscle tone and vascularity of the globe)

30
Q

How do you manage intra-ocular pressure?

A
  • Avoid acute increases in intra-ocular pressure to prevent damage to the eye- Maintain a normal Co2 (capnography monitoring important)
  • Avoid coughing on intubation and extubation
  • Avoid vomiting/ straining to defaecate/urinate/
  • Avoid drugs that may have emetic effects i.e. morphine
  • Be aware of the effects of drugs on IOP and use drugs judiciously ( eg avoid ketamine)
  • Avoid neck restraint / jugular pressure
  • Positioning – avoid ‘head down’ position
31
Q

What is the oculo-cardiac reflex?

A

Reduction in heart rate (sudden) associated with traction on the eye or
surrounding structures due to stimulation of the trigeminal and vagal nerves

32
Q

What do you administer if the oculo-cardiac reflex occurs?

A

anticholinergics

33
Q

What is the most common technique for maintaining a central eye?

A

neuromuscular blockage

34
Q

How would you maintain andequate analgesia during ocular surgery?

A
  • Pre-emptive and multi-modal
  • Prevent self mutilation- vital in all cases
  • opioids, NSAIDs, Topical local drops etc
  • Retrobulbar block
35
Q

What does the retobulbar block block?

A

cranial nerves II, III, IV, V
(Ophthalmic and maxillary branches) and VI.

36
Q

What are the post-op considerations for ocular surgery?

A

Analgesia
- Buster collar
- Fluid therapy if needed
- Patient warming
- Continue medication as needed i.e. topical eye medication
- Feed
- Opportunity to defecate.
- Prevent coughing/ vomiting post op esp if IOP increased
- Consider re-sedation / top up if anxious/ fractious

37
Q

whattypes of airway surgery are available?

A

under lying airway condition OR present for treatment of airway condition
- BOAS
- Investigative bronchoscopy e.g. chronic cough, tracheal FO
- Tracheal stenting
- Laryngeal paralysis sx

38
Q

What body systems are affected by BOAS?5

A

airways, GI, skeletal, dermatology, ocular

39
Q

What is BOAS?

A

a group of conditions that have resulted from poor breeding and
body confirmation of dogs with short noses

40
Q

What are the primary abnormalities of BOAS? 4

A
  • Stenotic nares
  • Aberrant nasal turbinate’s
  • Elongated/ thickened soft palate
  • Tracheal hypoplasia
41
Q

What is primary BOAS?

A

identified early on and present before significant clinical signs

42
Q

What is secondary BOAS?

A

as a consequence of long standing increase in inspiratory pressures

43
Q

How do airway abnormalities compromise a patient?

A

PULLING HARDER ON
INSPIRATIONTHIS CREATES NEGATIVE
PRESSURE IN THE THROAT, NECK,
CHEST
THIS CAN CAUSE SECONDARY
RESPIRATORY AND DIGESTIVE
PROBLEMS

44
Q

What are the secondary abnormalities of BOAS?

A

Laryngeal collapse
- Eversion of laryngeal saccules
Gastrointestinal – reflux,
regurgitation

45
Q

What are the anaesthetic considerations for BOAS patients?

A
  • Establishing IV access is important: can rapidly proceed to induction of anaesthesia
    and intubation
  • PREVENT STRESS- if dog becomes stressed, consider sedation prior to IV Cath
    placement OBSERVATION is essential
  • Sedated BOAS patients can easily obstruct (and regurgitate) their airways although
    some sedation can also lead to better breathing
  • Control temperature – normo/hypo-thermic*** preoperatively associated with poorer outcome
  • Sevo over Iso? quicker recovery ….do we want a quick recovery
46
Q

What drugs are commonly used as a pre-med for airway surgery?

A

ACP or Alpha 2 Agonist combined with an opioid are acceptable

47
Q

How can we protect a patients airway for airway surgery?

A
  • Pre-oxygenation
  • intubation stylet may be helpful
  • Have a range of ETT sizes
  • Cuff
48
Q

What can you make sure is available during airway surgery if a patient is a regurge risk?

A
  • have suction available and head down until the airway is secured
49
Q

What are the peri-operative considerations for an airway surgery patient?

A
  • Airway management vital
  • ventilation support? Care with Breathing System choice
  • capnography, BP, pulse ox, ECG
  • observe ventilation
  • Maintain heat, avoid overheating
    Eye care crucial
50
Q

What are the post-op considerations for a patient undergone airway surgery?

A
  • Observation
  • ETT in for a long time in recovery if tolerate
  • Don’t remove tube until actively swallowing and can maintain a patent airway
  • Mild sedation with ACP/ butorphanol can be useful in recovery if dogs are very agitated
  • Care with warming techniques
  • Oxygen supplementation in recovery
  • Pulse oximetry
  • Early discharge
51
Q

What can you give if an airway starts to swell?

A

adrenaline through nebuliser as becomes a vapour for the patient to breathe in, causes vasoconstriction and opens up the airways

52
Q

How do patients with laryngeal paralysis usually present?

A

with stridor, exercise intolerance, panting, coughing
and a hoarse bark

53
Q

\What is stridor?

A

high pitched breath sounds resulting from airflow through an obstructed airway

54
Q

What non surgical management can you do for a patient with laryngeal paralysis?

A

weight loss, exercise restriction and owner education

55
Q

What surgical management can you do for a patient with laryngeal paralysis

A

laryngeal tie back

56
Q

How can a nurse help with a patient in distress from laryngeal paralysis?

A
  • Put patient in a quiet/ stress free environment
  • Do not stress with IV Catheters/ x-rays
  • Use a fan - will cool and also blow air into airways!
  • Oxygen –? If not stressful
  • Start your hospital records/ monitor RR
  • Speak to vet - butorphanol?
  • Leave alone until calm with observation!
57
Q

What are the considerations for atients undergoing laryngeal surgery?

A
  • Pre oxygenate
  • Reduce stress
  • Anti tussive drugs- often useful after surgery
  • VS will want to assess laryngeal function prior to surgery but following
    induction- care with premedication/ induction doses
  • Assess larynx under a light plane of anaesthesia
  • Pain management
58
Q

What post-op care can you provide to a patient who has just has laryngeal surgery

A
  • Very close observation
  • Aspiration Pneumonia a huge risk in recovery period
  • Pain assess
  • Avoid collars/ things around neck - utilise harnesses
  • Food- if dry food- avoid dusty partials – wet and make into balls
  • Elevated feeding and water
  • Avoid excitement / consider sedation if needed
59
Q

How do patients undergoing bronchoscopy present?

A

chronic cough, suspected lung infection, feline
asthma, airway parasites, chronic aspiration pneumonia, neoplasia
- Some patients may have poor saturation on
room air

60
Q

What can be given as a bronchodilator?

A

terbutaline

61
Q

What are the pre-op considerations for bronchoscopy?

A
  • History and clinical exam
  • Assess degree of respiratory compromise
  • Rule out cardiac disease
  • Further tests
  • Blood tests depending on patient - BGA
  • Xray’s
62
Q

How would you stabilise a patient undergoing bronchoscopy?

A
  • O2 and sedation if needed
  • Inhaled bronchodilators
  • Systemic steroids and anti- tussive medication
63
Q

What pre and peri-op anaesthetic considerations are there for bronchscopy?

A
  • May not be able to maintain an ETT in place
  • Some larger ETT can fit the scope inside
  • Can give flow by oxygen delivered via a urinary
    catheter down the side of the scope in the tracheabut remember- what goes in must come out !
  • Pre-oxygenation
  • Airway protection is crucial
  • Animal can get cold (Coupage/ uncovered blankets)
64
Q

What airway management can you do for bronchoscopy?

A
  • large diameter ET tube- pass scope through
  • Small diameter ET tube – extubate and use TIVA (total intravenous anaesthesia)
  • Consider SGAD (ie V-gel) / LMA (laryngeal mask)
65
Q

What anaesthetic considerations are there for bronchscopy?

A
  • minimal stress
  • Propofol and ketamine have bronchodilatory effects
  • Appropriate depth for induction
66
Q

What monitoring is useful for bronchoscopy?

A

pulse ox and doppler

67
Q

What potential issues can occur peri-operatively? bronchoscopy

A
  • Hypoxia
  • Bronchoconstriction (after BALs?)
  • Desaturation and shark fin capnograph
  • Reduced compliance
  • Laryngeal oedema – cats
  • Airway/ lung rupture - possible during FO removal or biopsy
68
Q

What equipment can you prepare for a bronchoscopy?

A
  • Endoscope (take pre sample)
  • Sterile saline
  • Collection pots
  • Mouth gag? (not spring loaded in cats)
  • Urinary catheter
  • Syringes
  • Emergency box/ induction agent
69
Q

What are the considerations for the recovery period from bronchscopy?

A
  • Animal may have cough
  • Can easily occlude in recovery period
  • Constant monitoring until walking
  • Keep head elevated and use towels to prevent occlusion
  • Be prepared!
  • THINK DIC! (Dead in cage)
  • pulse ox
  • oxygenation
70
Q

What post-op complications can occur after bronchoscopy?

A
  • Haemorrhage in the airways
  • Desaturation of oxygen
  • Pneumothorax due to damaged bronchi - May be a tension pneumothorax
71
Q

What options are there for airway management?

A
  • Mask
  • Endotracheal tube (ETT)
  • Laryngeal mask (LMA) - ? bronchoscopy
  • Supraglottic device (V-Gel)
72
Q

What are the challenges for dental, ocular and airway surgery?

A
  • Access to head/ eyes is limited
  • Avoid breathing systems that require access near head i.e. Magill
  • Use appropriate monitoring devices – may need to attach pulse ox somewhere other than tongue
  • Capnography is important to ensure tubing isn’t kinking – remember some patients ie BOAS can have higher etc02 - Can be difficult to assess depth
  • Consider eye/ mucous membrane lubrication

ACVN - ANAESTHESIA (12 decks)

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