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NUNA 692 Principles III > anesthesia for ENT, maxillofacial, ophthalmic, and plastic sx > Flashcards

anesthesia for ENT, maxillofacial, ophthalmic, and plastic sx Flashcards

1
Q

goals for anesthetic management

selecting/preparing for:

A

specialized techniques

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2
Q

goals for anesthetic management

prevention/management of:

A

airway complications

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3
Q

goals for anesthetic management

balance _____ ______ with ______ _______

A

deep relaxation with rapid recovery

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4
Q

goals for anesthetic management

maintaining _____ ______ during intense stimulation

A

CV stability

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5
Q

goals for anesthetic management

muscle relaxation ________ ________

A

without paralytics

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6
Q

goals for anesthetic management

preventing ______ ______

A

airway fire

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7
Q

goals for anesthetic management

minimizing ______ ______

A

blood loss

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8
Q

goals for anesthetic management

CV stability during _____ ______/ ______ stimulation

A

carotid body/vagal stimulation

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9
Q

goals for anesthetic management

preventing/treating post-op ________ _______

A

airway obstruction

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10
Q

goals for anesthetic management

minimizing use of ______

A

N2O

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11
Q

RAE tubes

A

oral and nasal
cuffed, uncuffed, sometimes difficult to fit d/t bend
(keeps circuit out of the surgeons way)

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12
Q

anode tubes

A

armored, reinforced
flexible, resists kinking but can be occluded with biting

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13
Q

laser tubes

A

metal impregnated - reduces risk of fire

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14
Q

most LAs used are _____-______

A

amide-based

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15
Q

varying concentrations of ________ added

A

epinephrine (almost always see some tachycardia with how vascular the face is where injected)

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16
Q

______ still used in some centers - caution when combined with ______

A

cocaine
epinephrine

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17
Q

__________ for secretions

A

anticholinergics

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18
Q

steroids to ____ _____, ______, and prolong ____ _____

A

reduce edema, PONV, and prolong LA effects

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19
Q

high risk for PONV, especially _____ ______ procedures

A

middle ear

(bc youre messing in the area with the CN VIII and once stimulated they can have hours of PONV to deal with)

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20
Q

deliberate hypotension goal: decrease blood loss by ______ ______ while maintaining _______ and _______ autoregulation

A

decrease blood loss by reducing MAP while maintaining cerebral and systemic autoregulation

(technique has lost a lot of favor)

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21
Q

Deliberate hypotension: Maintain MAP greater than or equal to

A

60 mmHg (pts with HTN may need higher)

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22
Q

deliberate hypotension - ________ required*

A

arterial line (best practice)

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23
Q

deliberate hypotension is common for ______ _______ and ______ cases

A

extensive dissections and FESS

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24
Q

FESS

A

functional endoscopic sinus surgery

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25
Q

deliberate hypotension common drugs

A
  • nitroprusside
  • dexmedetomidine
  • esmolol
  • NTG
  • nicardipine
  • remifentanil
  • propofol

(can you see why you would need an art line??)

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26
Q

advantages to laser surgery (3)

A

precise excision
minimal edema
less blood loss

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27
Q

MOST ______ ______ during head/neck sx are r/t lasers

A

surgical fires

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28
Q

____ _____ (patient & staff), _______ ______, and _____ are biggest concerns

[Laser surgery]

A
  • eye protection
  • plume dispersion (done often for papillomas aersolizing the virus)
  • fires
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29
Q

laser sx and ETTs

A

large risk of losing tube

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30
Q

endoscopy procedures

A
  • panendoscopy
  • microlaryngoscopy
  • bronchoscopy
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31
Q

endoscopy complications:

A
  • eye trauma
  • epistaxis
  • laryngospasm
  • bronchospasm
  • adverse effects and epinephrine
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32
Q

bronchs require _______ _____ ______

A

vocal cord relaxation

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33
Q

airway sharing leads to potential ____ ___ ______, _______ complications, operative field ________ by ____

A

loss of airway, laser complications, operative field blocked by ETT

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34
Q

apneic techniques - unprotected ________, ________ ________

A

unprotected airway, hemodynamic liability

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35
Q

HFJV - no _____ involved

A

ETT

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36
Q

HFJV - manual:

A

hand valve connected to independent O2 source

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37
Q

HFJV - mechanical:

A

various devices for controlling rate and % O2

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38
Q

Use lowest O2 possible

A

less than or equal to 30%

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39
Q

difficult to maintain ____ and _____ in obese patients and with pulmonary disease

A

SaO2 and CO2

the bigger the patient the harder these techniques can be

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40
Q

air-trapping with HFJV can lead to _________ or _______

A

sub-cu emphysema or PTX

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41
Q

HFJV is contraindicated in

A

full stomach patients

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42
Q

with HFJV, to minimize OR contamination use

A

TIVA - gives a more steady level of anesthesia also

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43
Q

foreign body aspiration is common in _______ and usually in the _____ ______

A

children
right bronchus

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44
Q

FBA symptoms

A

wheezing, coughing, aphonia, cyanosis

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45
Q

FBA gold standard treatment

A

rigid bronch with GA

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46
Q

mortality of bronch

A

0.4% (CV arrest, bronchial rupture) in OTW healthy patients

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47
Q

FBA complications

A
  • severe laryngeal edema
  • pneumothorax
  • pneumomediastinum
  • hypoxic brain injury
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48
Q

________ induction with _______ ventilation is best for FBA

A

inhalation induction with spontaneous ventilation

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49
Q

use ______ O2, _______ ______, deep _____, sometimes _______

[Foreign Body Aspiration]

A

100% O2
ventilating scope
deep GA
sometimes TIVA

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50
Q

prefer to bring up on

A

mask

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51
Q

______ ______ with riskier airway

A

ETT wake-up

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52
Q

_____ and _____ ____ commonly given to help relax traumatized airways post sx

A

steroids and breathing tx

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53
Q

Intraop EMG of ______, _______, _______, _______ ______ nerves

A

facial, laryngeal, vagus, spinal accessory

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54
Q

most common

[Nerve preservation]

A

unilateral facial paresis

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55
Q

nerve preservation: avoid _____ ______ or use short acting for intubation

A

muscle relaxants

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56
Q

nerve preservation: avoid ______ and ______ (or turn off well before closing)

A

LAs and N2O

N2O can dislodge grafts, LAs can impede nerve reaction

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57
Q

nerve preservation - deep extubation

A

in healthy patient with no contraindication, it can be a nice technique that prevents coughing/bucking

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58
Q

common middle ear procedures

A

tympanoplasty, mastoidectomy

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59
Q

middle ear procedures require _______ ______

A

bloodless field

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60
Q

______ _______ common (no MRs after ______)

[ear procedures]

A

nerve stimulators
intubation

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61
Q

middle ear - ______ is a big problem

A

PONV

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62
Q

avoid ______ or turn off _______ before closing

A

avoid N2O or turn off > 15 mins before closing (moves into middle ear and causes displacement of graft)

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63
Q

N2O also increases risk of ________

A

PONV

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64
Q

myringotomy (minor sx)

A
  • usually doesnt require IV access (mask/gas only usually)
  • N2O ok d/t brevity of procedure
  • precedex/fent nasally can be nice for mild analgesia
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65
Q

tonsillectomy and adenoidectomy (T&A) - most common ______ ______

A

pediatric sx

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66
Q

T&A frequently have ______. Adult version: _________ (___)

A

OSA
UvuloPalatoPharyngoPlasty (UP3)

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67
Q

T&A - some centers using

A

LMAs

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68
Q

T&A deep extubation MUST have

A

dry field (usually dependent on surgeon)

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69
Q

ENTs want to avoid ______ d/t increased risk of bleeding. Studies show that _______ result in no difference in bleeding and actually less ________

A

NSAIDs
NSAIDs
PONV

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70
Q

T&A anesthesia implications:

A

airway obstruction (when lisa likes using dex)
shared airway
suspension
rapid awakening
pain management
PONV

71
Q

most common ER peds airway ER procedure

A

bleeding tonsil

72
Q

bleeding tonsils are usually in patients ___________, within ________, and usually ______

A

> 15 years old
6 hours
usually slow

73
Q

bleeding tonsils may ______ ______ _____ before discovery

A

swallow large amounts

74
Q

bleeding tonsil pts can present (3)

A

hypovolemic
tachycardic
hypotensive

75
Q

bleeding tonsils get ______ _____ pre-op (may need _______)

A

crystalloid bolus
transfusion

76
Q

ALL bleeding tonsils are _____ ______ and require _____

A

FULL STOMACHS
RSI

77
Q

propofol, _____, _____

A

ketamine, etomidate

78
Q

suction stomach _____ ______

A

before emergence

79
Q

bc all bleeding tonsils are full stomachs and have to have RSI, they would NEVER be candidates for a _____ ______

A

deep extubation

80
Q

thyroid mass may impinge on _______

A

airway - know how big the mass is before you get started

81
Q

thyroid procedure preop

A

neck CT and EKG

82
Q

large thyroids have increased incidence of _______ _______ (increased sensitivity to _______)

A

myasthenia gravis
increased sensitivity to MRs

83
Q

Pts should be ______ prior to sx and usual meds taken ( lowers risk of ____ _____)

A

euthyroid
thyroid storm

84
Q

_____ ____ dose if patient is on steroids preop

A

steroid stress dose

85
Q

motor innervation to vocal cords:

A

recurrent laryngeal and external branch of superior laryngeal

86
Q

inadvertent resection of nerves can result in:

A

unilateral or bilateral VC paralysis leading to airway emergency after extubation

87
Q

______ or short acting ____ for intubation

A

sux or short acting MR (will be gone before nerve monitoring begins)

88
Q

thyroid sx gold standard

A

intra-op nerve monitoring

89
Q

______ tube = ETT with 4 embedded electrodes. ______ = right, ______ = left

A

NIM
red = right
blue = left

90
Q

increasing core temp and/or hyperdynamics can mean an ______ _______

A

impending storm

ask scenario based questions to rule things out

91
Q

treat hypotension with direct acting drug:

A

phenylephrine

92
Q

caution with hypocalcemia 24-96 hrs post-op dt damaged ________ _______ (numbness/tingling) leading to ________, _______, ________, or even cardiac arrest

A

parathyroid glands
laryngospasm
seizures
dysrhythmias

93
Q

hypocalcemia treatment

A

Ca++ gluconate or chloride bolus (slow) or infusion until Ca++ is normalized

94
Q

EMERGENCY complication for thyroid sx

A

post-op hematoma leading to airway obstruction

95
Q

________ of cleft palate pts also have other anomalies (downs, pierre robin, treacher collins)

A

30%

96
Q

CPs are usually repaired around ___ _____ _____

A

3 months old

97
Q

CPs can make ______ ______

A

intubation difficult

98
Q

with CPs, beware of sudden, severe ______ when mouth gag is removed

A

edema

99
Q

_____ _____ post-op (no oral or nasal airway)

A

tongue suture

100
Q

cleft lip can be difficult ________ and/or _______

A

mask and/or intubation

101
Q

cleft lip - must protect repair post - op, can use ____ ____

A

elbow restraints

102
Q

dental surgery patients

A

frequently developmentally delayed

103
Q

dental sx common practices

A

nasal ETTs
throat pack (make sure its out)

104
Q

facial trauma - prepare for what airway techniques

A

F/O
retrograde
VL
HFJV
cricothyrotomy
trach

105
Q

facial trauma - assume

A

c-spine injury and maintain in line stabilization

106
Q

smoke inhalation should be

A

intubated stat

107
Q

le fort fracture I

A

horizontal, nose/palate, septum, posterior pteygoids

usually no AIs, oral or nasal ETT ok

108
Q

le fort fracture II

A

triangular, nose, orbit, below zygoma, lateral maxilla and pterygoids

may need nasal intubation

109
Q

le fort fracture III

A

complete separation of midface from the cranial base across nose, ethmoid, orbit, sphenopalatine fossa

110
Q

le fort fracture III - avoid ____ _____ without F/O guidance if _____ _____ _____ is suspected

A

nasal ETT
basilar skull fx
(CSF from nose or ears, blood behind tympanic membrane, “raccoon eyes”)

111
Q

its usually easy to differentiate _______ ______ from the _____ _____

A

raccoon eyes
black eye

112
Q

raccoon eyes are always ________

A

bilateral

113
Q

raccoon eyes develop ___ to ____ ____ after a closed head injury that results in basilar skull fx

A

2 to 3 days

114
Q

facial fxs are usually

A

not emergent

115
Q

all facial fxs are

A

full stomach

116
Q

_____ ______ used for mandibular or maxillary fxs d/t wiring

A

nasal ETTs

117
Q

facial fxs possible significant _____ _____

A

blood loss

118
Q

______ ______ MUST BE AVAILABLE AT BEDSIDE

A

WIRE CUTTERS

119
Q

facial traumas may need post-op _____/_______/______

A

ETT/ventilation/ICU

120
Q

facial fxs can have significant ______ and must be extubated ______ _____

A

edema
FULLY awake

121
Q

radical neck dissection (RND) - highly vascular tumors may be invading airway. History of radiation leads to _______ ________

A

difficult intubation (r/t tissue trauma)

122
Q

RND frequent age-related _______

A

comorbidities

123
Q

RND extremely ______ procedures

A

LONG

(trach, flaps, bowel harvest, invasive monitoring, foley, nerve stimulator)

124
Q

RND procedures can have significant blood loss but ______ ______ should be avoided

A

fluid overload

125
Q

RND head up position and open neck veins

A

risk for VAE - may need doppler, TEE

126
Q

most common ophthalmic surgeries

A

cataract extraction, vitreoretinal

127
Q

local anesthesia can have _______ ______ in effects

A

wide variations

128
Q

most common and effective technique for analgesia/akinesia of eye and lids:

A

ocular local anesthesia (retrobulbar or peribulbar)

129
Q

anesthetize

A

III, IV, V, VI, VII

130
Q

injected into ______-______ space

A

orbital-epidural space

131
Q

locals cause less ______ than _____

A

PONV
GA

132
Q

other ocular blocks

A

sub-tenon
infraorbital
supraorbital

133
Q

peds: ATTN to _______, _______, and _______ history

A

congenital, metabolic, and MH history

134
Q

adults: ATTN to ________ and ________

A

comorbidities and drug interactions

135
Q

regional techniques with _______ to avoid increased risks with GA

A

elderly

136
Q

NPO if ________ to be used before block, OTW some allow light breakfast

A

propofol

137
Q

NPO for

A

moderate sedation

138
Q

D/C of _________ drugs and _________ generally not needed

A

antiplatelet drugs and anticoagulants

139
Q

_______ _______ and trained ________ must be available

A

resuscitative equipment and trained personnel

140
Q

______ causes transient increased IOP, but safe

A

Sux

141
Q

advantages of non-depolarizers:

A

decreased IOP
maintain akinesis

142
Q

beware of

A

oculocardiac reflex

143
Q

LMAs require _____ _______ and have less risk of _______ at emergence

A

deep anesthesia
coughing

144
Q

eye muscles - increased risk of

A

MH, PONV

145
Q

for intraocular gas, avoid ______ or turn off ________ before injection

A

N2O
15 mins

146
Q

consider

A

deep extubation

147
Q

prolonged ______ may be sign of increased IOP

A

PONV

148
Q

the sux debate (with open eye injury)

A

aspiration risk vs increased IOP with possible expulsion of intraocular fluid

149
Q

oculocardiac reflex “the five and dime reflex” afferent and efferent nerves

A

afferent - trigeminal (V)
efferent - vagal (X)

150
Q

stimulus

[oculocardiac reflex]

A

globe, optic nerve, conjuctival pressure, muscle traction

151
Q

oculocardiac reflex usually in

A

children

152
Q

oculocardiac reflex - sudden, profound ________

A

bradycardia (can cause other dysrhythmias)

153
Q

oculocardiac treatment

A
  • stop stimulus
  • if unresolved, atropine or glyco
  • “fatigues” with continued manipulation

consider pretreating with anticholinergic

154
Q

complications from ophthalmic sx:

A
  • retrobulbar hemorrhage
  • intravascular injection
  • globe puncture
  • optic nerve sheath damage
  • ocular ischemia
  • extraocular muscle palsy or ptosis
  • CN VII block (bell’s palsy)
  • corneal abrasion
  • central retinal artery occlusion
155
Q

most common cause of death from PE

A

office based abdominoplasty

156
Q

in 2019 only _____ states have guidelines, policies, or position statements regarding office-based surgery and anesthesia

A

33

157
Q

OBA safe with careful ______ _____, adequate _____ _____, and practice ________

A

patient selection, adequate safety protocols, and practice standardization

158
Q

OBA disadvantages

A
  • absent/inconsistent regulations (state controlled)
  • lack of peer review/credentialing
  • lack of emergency support/additional anesthesia help
159
Q

OBA heavy _______ and _____ ______ techniques

A

MAC and deep sedation

160
Q

breast augmentation

A

usually local and sedation

161
Q

liposuction tumescent solution with _______ and _______

A

lidocaine and epi

162
Q

max sub cu lidocaine

A

35 mg/kg

163
Q

max sub cu epi

A

70 mcg/kg

164
Q

1L sub cu = ________ absorbed. max 5L

A

700 mL

165
Q

major cause of mortality

A

VTE

166
Q

other liposuction risks

A
  • abdominal wall perforation
  • sepsis
  • fluid overload
  • pulm edema
  • hypothermia
  • LA/epi toxicity
167
Q

________ highest risk of death with VTE and increased risk when combined with _________

A

abdominoplasty
liposuction

168
Q

factors contributing to VTE:

A

surgical positioning, surgical abdominal tightening, post-op abdominal binders

169
Q

common facial procedures

A

rhinoplasty, blepharoplasty, rhytidectomy (face lift)

170
Q

cocaine can cause a ____ ______

A

SNS response

171
Q

with facial procedures, prevent ________, _______, and ________

A

hypertension, swelling, bleeding

172
Q

to decrease risk of fire:

A
  • minimize FiO2
  • avoid flammable preps
  • avoid O2 accumulation under drapes
  • communicate with surgeon (cautery)
173
Q

increased risk of VTE with

A
  • hx of VTE
  • hormone replacement therapy
  • oral contraceptives
  • older
  • recent travel
  • pregnancy
  • immobility
  • obesity
  • smoking
  • cancer
  • hypercoagulability
  • recent MI
  • CHF
  • longer procedures > 1 hour GA, or > hour sedation, or combined procedures (especially abdominoplasty)
174
Q

risk stratification used to determine need for perioperative ______ ______

A

VTE prophylaxis

NUNA 692 Principles III (20 decks)

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