anesthesia for ENT, maxillofacial, ophthalmic, and plastic sx Flashcards
1
Q
goals for anesthetic management
selecting/preparing for:
A
specialized techniques
2
Q
goals for anesthetic management
prevention/management of:
A
airway complications
3
Q
goals for anesthetic management
balance _____ ______ with ______ _______
A
deep relaxation with rapid recovery
4
Q
goals for anesthetic management
maintaining _____ ______ during intense stimulation
A
CV stability
5
Q
goals for anesthetic management
muscle relaxation ________ ________
A
without paralytics
6
Q
goals for anesthetic management
preventing ______ ______
A
airway fire
7
Q
goals for anesthetic management
minimizing ______ ______
A
blood loss
8
Q
goals for anesthetic management
CV stability during _____ ______/ ______ stimulation
A
carotid body/vagal stimulation
9
Q
goals for anesthetic management
preventing/treating post-op ________ _______
A
airway obstruction
10
Q
goals for anesthetic management
minimizing use of ______
A
N2O
11
Q
RAE tubes
A
oral and nasal
cuffed, uncuffed, sometimes difficult to fit d/t bend
(keeps circuit out of the surgeons way)
12
Q
anode tubes
A
armored, reinforced
flexible, resists kinking but can be occluded with biting
13
Q
laser tubes
A
metal impregnated - reduces risk of fire
14
Q
most LAs used are _____-______
A
amide-based
15
Q
varying concentrations of ________ added
A
epinephrine (almost always see some tachycardia with how vascular the face is where injected)
16
Q
______ still used in some centers - caution when combined with ______
A
cocaine
epinephrine
17
Q
__________ for secretions
A
anticholinergics
18
Q
steroids to ____ _____, ______, and prolong ____ _____
A
reduce edema, PONV, and prolong LA effects
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)
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)
21
Q
Deliberate hypotension: Maintain MAP greater than or equal to
A
60 mmHg (pts with HTN may need higher)
22
Q
deliberate hypotension - ________ required*
A
arterial line (best practice)
23
Q
deliberate hypotension is common for ______ _______ and ______ cases
A
extensive dissections and FESS
24
Q
FESS
A
functional endoscopic sinus surgery
25
deliberate hypotension common drugs
- nitroprusside
- dexmedetomidine
- esmolol
- NTG
- nicardipine
- remifentanil
- propofol
(can you see why you would need an art line??)
26
advantages to laser surgery (3)
precise excision
minimal edema
less blood loss
27
MOST ______ ______ during head/neck sx are r/t lasers
surgical fires
28
____ _____ (patient & staff), _______ ______, and _____ are biggest concerns
[Laser surgery]
- eye protection
- plume dispersion (done often for papillomas aersolizing the virus)
- fires
29
laser sx and ETTs
large risk of losing tube
30
endoscopy procedures
- panendoscopy
- microlaryngoscopy
- bronchoscopy
31
endoscopy complications:
- eye trauma
- epistaxis
- laryngospasm
- bronchospasm
- adverse effects and epinephrine
32
bronchs require _______ _____ ______
vocal cord relaxation
33
airway sharing leads to potential ____ ___ ______, _______ complications, operative field ________ by ____
loss of airway, laser complications, operative field blocked by ETT
34
apneic techniques - unprotected ________, ________ ________
unprotected airway, hemodynamic liability
35
HFJV - no _____ involved
ETT
36
HFJV - manual:
hand valve connected to independent O2 source
37
HFJV - mechanical:
various devices for controlling rate and % O2
38
Use lowest O2 possible
less than or equal to 30%
39
difficult to maintain ____ and _____ in obese patients and with pulmonary disease
SaO2 and CO2
the bigger the patient the harder these techniques can be
40
air-trapping with HFJV can lead to _________ or _______
sub-cu emphysema or PTX
41
HFJV is contraindicated in
full stomach patients
42
with HFJV, to minimize OR contamination use
TIVA - gives a more steady level of anesthesia also
43
foreign body aspiration is common in _______ and usually in the _____ ______
children
right bronchus
44
FBA symptoms
wheezing, coughing, aphonia, cyanosis
45
FBA gold standard treatment
rigid bronch with GA
46
mortality of bronch
0.4% (CV arrest, bronchial rupture) in OTW healthy patients
47
FBA complications
- severe laryngeal edema
- pneumothorax
- pneumomediastinum
- hypoxic brain injury
48
________ induction with _______ ventilation is best for FBA
inhalation induction with spontaneous ventilation
49
use ______ O2, _______ ______, deep _____, sometimes _______
[Foreign Body Aspiration]
100% O2
ventilating scope
deep GA
sometimes TIVA
50
prefer to bring up on
mask
51
______ ______ with riskier airway
ETT wake-up
52
_____ and _____ ____ commonly given to help relax traumatized airways post sx
steroids and breathing tx
53
Intraop EMG of ______, _______, _______, _______ ______ nerves
facial, laryngeal, vagus, spinal accessory
54
most common
[Nerve preservation]
unilateral facial paresis
55
nerve preservation: avoid _____ ______ or use short acting for intubation
muscle relaxants
56
nerve preservation: avoid ______ and ______ (or turn off well before closing)
LAs and N2O
N2O can dislodge grafts, LAs can impede nerve reaction
57
nerve preservation - deep extubation
in healthy patient with no contraindication, it can be a nice technique that prevents coughing/bucking
58
common middle ear procedures
tympanoplasty, mastoidectomy
59
middle ear procedures require _______ ______
bloodless field
60
______ _______ common (no MRs after ______)
[ear procedures]
nerve stimulators
intubation
61
middle ear - ______ is a big problem
PONV
62
avoid ______ or turn off _______ before closing
avoid N2O or turn off > 15 mins before closing (moves into middle ear and causes displacement of graft)
63
N2O also increases risk of ________
PONV
64
myringotomy (minor sx)
- 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
65
tonsillectomy and adenoidectomy (T&A) - most common ______ ______
pediatric sx
66
T&A frequently have ______. Adult version: _________ (___)
OSA
UvuloPalatoPharyngoPlasty (UP3)
67
T&A - some centers using
LMAs
68
T&A deep extubation MUST have
dry field (usually dependent on surgeon)
69
ENTs want to avoid ______ d/t increased risk of bleeding. Studies show that _______ result in no difference in bleeding and actually less ________
NSAIDs
NSAIDs
PONV
70
T&A anesthesia implications:
airway obstruction (when lisa likes using dex)
shared airway
suspension
rapid awakening
pain management
PONV
71
most common ER peds airway ER procedure
bleeding tonsil
72
bleeding tonsils are usually in patients ___________, within ________, and usually ______
> 15 years old
6 hours
usually slow
73
bleeding tonsils may ______ ______ _____ before discovery
swallow large amounts
74
bleeding tonsil pts can present (3)
hypovolemic
tachycardic
hypotensive
75
bleeding tonsils get ______ _____ pre-op (may need _______)
crystalloid bolus
transfusion
76
ALL bleeding tonsils are _____ ______ and require _____
FULL STOMACHS
RSI
77
propofol, _____, _____
ketamine, etomidate
78
suction stomach _____ ______
before emergence
79
bc all bleeding tonsils are full stomachs and have to have RSI, they would NEVER be candidates for a _____ ______
deep extubation
80
thyroid mass may impinge on _______
airway - know how big the mass is before you get started
81
thyroid procedure preop
neck CT and EKG
82
large thyroids have increased incidence of _______ _______ (increased sensitivity to _______)
myasthenia gravis
increased sensitivity to MRs
83
Pts should be ______ prior to sx and usual meds taken ( lowers risk of ____ _____)
euthyroid
thyroid storm
84
_____ ____ dose if patient is on steroids preop
steroid stress dose
85
motor innervation to vocal cords:
recurrent laryngeal and external branch of superior laryngeal
86
inadvertent resection of nerves can result in:
unilateral or bilateral VC paralysis leading to airway emergency after extubation
87
______ or short acting ____ for intubation
sux or short acting MR (will be gone before nerve monitoring begins)
88
thyroid sx gold standard
intra-op nerve monitoring
89
______ tube = ETT with 4 embedded electrodes. ______ = right, ______ = left
NIM
red = right
blue = left
90
increasing core temp and/or hyperdynamics can mean an ______ _______
impending storm
ask scenario based questions to rule things out
91
treat hypotension with direct acting drug:
phenylephrine
92
caution with hypocalcemia 24-96 hrs post-op dt damaged ________ _______ (numbness/tingling) leading to ________, _______, ________, or even cardiac arrest
parathyroid glands
laryngospasm
seizures
dysrhythmias
93
hypocalcemia treatment
Ca++ gluconate or chloride bolus (slow) or infusion until Ca++ is normalized
94
EMERGENCY complication for thyroid sx
post-op hematoma leading to airway obstruction
95
________ of cleft palate pts also have other anomalies (downs, pierre robin, treacher collins)
30%
96
CPs are usually repaired around ___ _____ _____
3 months old
97
CPs can make ______ ______
intubation difficult
98
with CPs, beware of sudden, severe ______ when mouth gag is removed
edema
99
_____ _____ post-op (no oral or nasal airway)
tongue suture
100
cleft lip can be difficult ________ and/or _______
mask and/or intubation
101
cleft lip - must protect repair post - op, can use ____ ____
elbow restraints
102
dental surgery patients
frequently developmentally delayed
103
dental sx common practices
nasal ETTs
throat pack (make sure its out)
104
facial trauma - prepare for what airway techniques
F/O
retrograde
VL
HFJV
cricothyrotomy
trach
105
facial trauma - assume
c-spine injury and maintain in line stabilization
106
smoke inhalation should be
intubated stat
107
le fort fracture I
horizontal, nose/palate, septum, posterior pteygoids
usually no AIs, oral or nasal ETT ok
108
le fort fracture II
triangular, nose, orbit, below zygoma, lateral maxilla and pterygoids
may need nasal intubation
109
le fort fracture III
complete separation of midface from the cranial base across nose, ethmoid, orbit, sphenopalatine fossa
110
le fort fracture III - avoid ____ _____ without F/O guidance if _____ _____ _____ is suspected
nasal ETT
basilar skull fx
(CSF from nose or ears, blood behind tympanic membrane, "raccoon eyes")
111
its usually easy to differentiate _______ ______ from the _____ _____
raccoon eyes
black eye
112
raccoon eyes are always ________
bilateral
113
raccoon eyes develop ___ to ____ ____ after a closed head injury that results in basilar skull fx
2 to 3 days
114
facial fxs are usually
not emergent
115
all facial fxs are
full stomach
116
_____ ______ used for mandibular or maxillary fxs d/t wiring
nasal ETTs
117
facial fxs possible significant _____ _____
blood loss
118
______ ______ MUST BE AVAILABLE AT BEDSIDE
WIRE CUTTERS
119
facial traumas may need post-op _____/_______/______
ETT/ventilation/ICU
120
facial fxs can have significant ______ and must be extubated ______ _____
edema
FULLY awake
121
radical neck dissection (RND) - highly vascular tumors may be invading airway. History of radiation leads to _______ ________
difficult intubation (r/t tissue trauma)
122
RND frequent age-related _______
comorbidities
123
RND extremely ______ procedures
LONG
(trach, flaps, bowel harvest, invasive monitoring, foley, nerve stimulator)
124
RND procedures can have significant blood loss but ______ ______ should be avoided
fluid overload
125
RND head up position and open neck veins
risk for VAE - may need doppler, TEE
126
most common ophthalmic surgeries
cataract extraction, vitreoretinal
127
local anesthesia can have _______ ______ in effects
wide variations
128
most common and effective technique for analgesia/akinesia of eye and lids:
ocular local anesthesia (retrobulbar or peribulbar)
129
anesthetize
III, IV, V, VI, VII
130
injected into ______-______ space
orbital-epidural space
131
locals cause less ______ than _____
PONV
GA
132
other ocular blocks
sub-tenon
infraorbital
supraorbital
133
peds: ATTN to _______, _______, and _______ history
congenital, metabolic, and MH history
134
adults: ATTN to ________ and ________
comorbidities and drug interactions
135
regional techniques with _______ to avoid increased risks with GA
elderly
136
NPO if ________ to be used before block, OTW some allow light breakfast
propofol
137
NPO for
moderate sedation
138
D/C of _________ drugs and _________ generally not needed
antiplatelet drugs and anticoagulants
139
_______ _______ and trained ________ must be available
resuscitative equipment and trained personnel
140
______ causes transient increased IOP, but safe
Sux
141
advantages of non-depolarizers:
decreased IOP
maintain akinesis
142
beware of
oculocardiac reflex
143
LMAs require _____ _______ and have less risk of _______ at emergence
deep anesthesia
coughing
144
eye muscles - increased risk of
MH, PONV
145
for intraocular gas, avoid ______ or turn off ________ before injection
N2O
15 mins
146
consider
deep extubation
147
prolonged ______ may be sign of increased IOP
PONV
148
the sux debate (with open eye injury)
aspiration risk vs increased IOP with possible expulsion of intraocular fluid
149
oculocardiac reflex "the five and dime reflex" afferent and efferent nerves
afferent - trigeminal (V)
efferent - vagal (X)
150
stimulus
[oculocardiac reflex]
globe, optic nerve, conjuctival pressure, muscle traction
151
oculocardiac reflex usually in
children
152
oculocardiac reflex - sudden, profound ________
bradycardia (can cause other dysrhythmias)
153
oculocardiac treatment
- stop stimulus
- if unresolved, atropine or glyco
- "fatigues" with continued manipulation
*consider pretreating with anticholinergic*
154
complications from ophthalmic sx:
- 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
most common cause of death from PE
office based abdominoplasty
156
in 2019 only _____ states have guidelines, policies, or position statements regarding office-based surgery and anesthesia
33
157
OBA safe with careful ______ _____, adequate _____ _____, and practice ________
patient selection, adequate safety protocols, and practice standardization
158
OBA disadvantages
- absent/inconsistent regulations (state controlled)
- lack of peer review/credentialing
- lack of emergency support/additional anesthesia help
159
OBA heavy _______ and _____ ______ techniques
MAC and deep sedation
160
breast augmentation
usually local and sedation
161
liposuction tumescent solution with _______ and _______
lidocaine and epi
162
max sub cu lidocaine
35 mg/kg
163
max sub cu epi
70 mcg/kg
164
1L sub cu = ________ absorbed. max 5L
700 mL
165
major cause of mortality
VTE
166
other liposuction risks
- abdominal wall perforation
- sepsis
- fluid overload
- pulm edema
- hypothermia
- LA/epi toxicity
167
________ highest risk of death with VTE and increased risk when combined with _________
abdominoplasty
liposuction
168
factors contributing to VTE:
surgical positioning, surgical abdominal tightening, post-op abdominal binders
169
common facial procedures
rhinoplasty, blepharoplasty, rhytidectomy (face lift)
170
cocaine can cause a ____ ______
SNS response
171
with facial procedures, prevent ________, _______, and ________
hypertension, swelling, bleeding
172
to decrease risk of fire:
- minimize FiO2
- avoid flammable preps
- avoid O2 accumulation under drapes
- communicate with surgeon (cautery)
173
increased risk of VTE with
- 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
risk stratification used to determine need for perioperative ______ ______
VTE prophylaxis
