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931: Advanced Principles of Anesthesia I > Anesthesia for ENT surgeries > Flashcards

Anesthesia for ENT surgeries Flashcards

1
Q

Unique challenges for ENT surgeries include

A

use of specialty equipment- lasers, endoscopes, special ET tubes
use of specialized anesthetic/ventilation techniques
often have a preexisting tenuous airway- tumors, abscesses, congenital disorders
increased risk of airway fire
share airway with surgeon- access to patient is limited or nonexistent

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2
Q

The four cranial nerves that supply sensory & motor function to the airway include

A

trigeminal, glossopharyngeal, facial, & vagus

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3
Q

The trigeminal nerve provides

A

sensory innervation to the face

Three divisions include: ophthalmic, maxillary & mandibular

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4
Q

The glossopharyngeal nerve provides sensory innervation to

A

posterior 1/3rd of the tongue
oropharynx
vallecular
anterior epiglottis

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5
Q

The glossopharyngeal nerve is responsible for the afferent limb of the

A

gag reflux

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6
Q

The facial nerve is located at the

A

tragus of the ear

-supplies motor and sensory function to the face for facial expressions

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7
Q

The six major branches of the facial nerve include:

A

“The zebra bit my cousin paul”

  • anterior: temporal, zygomatic, buccal, & mandibular
  • inferior: cervical
  • posterior: posterior auricular
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8
Q

The vagus includes the

A

superior laryngeal nerve (internal & external branch)

Recurrent laryngeal nerve

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9
Q

The internal branch vs. external branch of the superior laryngeal nerve.

A

internal branch- sensory innervation to posterior epiglottis to vocal cord folds
external branch- motor innervation below the vocal cords

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10
Q

The recurrent laryngeal nerve provides

A

sensory innervation below the vocal cords & trachea
motor innervation to all intrinsic laryngeal muscles
-Right RLN loops under subclavian artery
L RLN loops under aorta & susceptible to injury

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11
Q

There is increased ______ in the head & neck

A

vascularity

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12
Q

Facial, head, & neck arteries include:

A 
carotid (internal & external)
facial 
maxillary
superficial temporal
deep temporal
superior thyroid
buccal
middle meningeal
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13
Q

Facial, head & neck veins that are deep include

A

internal jugular
maxillary
vertebral

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14
Q

Facial head and neck veins that are superficial include

A

external jugular
superficial temporal
occipital
facial

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15
Q

Sharing of the airway requires

A

preparation
planning
communication

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16
Q

For ENT cases, preoperative airway assessment

A

is critical
a thorough history & extensive evaluation allows:
-deliberate approach to airway management
-need for additional equipment & assistance
-determine alternative approaches

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17
Q

Common considerations for ENT cases nclude:

A

true sharing of the airway with the surgeon- eye protection, tube placement must allow for surgical facilitation (down-sizing)
-head of bed often rotated 90 to 180 degrees- need for additional line & tubing length (HME device)
Arms tucked- second IV line, nerve monitoring
-precordial or esophageal stethoscope

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18
Q

Nerve monitoring requires

A

specialized ETT

short acting narcotics & lack of paralysis

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19
Q

ETT needs to be secured with

A

tape or suture to prevent extubation, disconnects & leaks

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20
Q

After turning the patient,

A

ALWAYS REASSESS
-oxygenation/anesthetic level- tube placement, breath sounds
IV access

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21
Q

Specialized ETT tubes include:

A

small diameter ETT- decreased ventilation & increased resistance; standard tubes may result limited cuff contact
Oral ring, Adair, & RAE tubes- allows for better surgical access
-armored and reinforced tubes- greater flexibility and resist kinking (not guaranteed)
-metal-impregnated- reduce occurrence of airway fire
-laryngeal mask airway (LMA)

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22
Q

Common drugs for ENT cases include

A 
vasoactive drugs
anticholinergics
corticosteroids
postoperative nausea & vomiting
deliberate controlled hypotension
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23
Q

Vasoactive drugs include

A

epinephrine- causes vasoconstriction 1:200,000
cocaine- naturally occurring ester of benzoic acid
Combination of these drugs can result in: headaches, hypertension, tachycardia, & dysrhythmias

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24
Q

Local anesthetics that might be used include

A

cocaine 4%
lidocaine 2%
bupivacaine 0.25%

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25
Q

Anticholinergics may be used for

A

antisialogogue effects

reduce vagal tone- glycoyrolate preferred

26
Q

Corticosteroids may be used to

A

reduce nausea & vomiting (given early)

inhibit production of prostaglandins reducing pain & edema

27
Q

ENT surgeries associated with increased incidence of

A

PONV

particularly middle ear

28
Q

Additional reasons for PONV with ENT surgery include

A

accumulation of blood in oropharynx & swallowed- throat pack, orogastric suctioning prior to extubation
multimodal approach to prevent/treat

29
Q

Select techniques commonly used in ENT surgery include:

A

laser surgery
endoscopy
jet ventilation
foreign body aspiration

30
Q

Deliberate controlled hypotension is a technique to

A

reduce blood loss in prolonged cases
reduce MAP to pre-determined limits of cerebral autoregulation (50-60 mmHg; within 20% of baseline)
-arterial line is required (not always)
-better operating conditions achieved when hypotension is achieved with B-blocker

31
Q

Laser light beams are used for their

A

thermal effect- lasers have only one wavelength

32
Q

Commonly used lasers in ENT are:

A

CO2- longer wavelength- shallow depth & precise
Nd:YAG (neodymium-doped yttrium aluminum garnett)- shorter wavelength- pass through superficial structures
Argon

33
Q

Laser safety includes

A

warning signs outside the OR
eye protection- provider & patient, lens depends on laser being used
use lowest oxygen concentration possible (goal of <30%)
avoid nitrous oxide
fill ETT cuff with saline and/or methylene blue
laser “plume”

34
Q

Most surgical fires occur during

A

head & neck surgery
due to combination of oxygen & laser use
laser penetrates ETT into oxygen rich environment- creates blowtorch effect

35
Q

When an airway fire occurs, remove

A

ETT immediately and replace with a new tube

perform bronchoscopy

36
Q

Prevention of airway fires includes

A 
metal impregnated ETT
saline filled ETT cuff
use lowest FiO2 possible
avoid nitrous oxide
avoid paper drapes
use water-based lubricants
37
Q

Endoscopy procedures may include

A

panendoscopy, laryngoscopy, bronchoscopy, esophagoscopy (flexible or rigid scope), sinus surgery

38
Q

Common pathology with endoscopy includes

A

foreign body aspiration
tumors/lesions
vocal cord dysfunction

39
Q

Anesthetic considerations for endoscopy include:

A

manage brief periods of extreme stimulation- avoid patient movement- consider lidocaine, remifentanil, and esmolol to block sympathetic stimulation
short procedures- careful muscle relaxation
constantly sharing airway with surgeon- small cuffed ETT 5.0-6.0 mm for adult, intermittent apnea

40
Q

Jet ventilation is

A

manual ventilation using hand valve or mechanical device

  • inspiration is high velocity jet stream (60 psi)
  • expiration is passive
41
Q

With jet ventilation, if an airway mass lies above the level of gas delivery, there is an increased risk of

A

air trapping resulting in subcutaneous emphysema or pneumothorax

42
Q

Jet ventilation may require

A

TIVA anesthesia

43
Q

Jet ventilation is contraindicated in

A

full stomach, hiatal hernia, trauma

44
Q

High frequency jet ventilation is used when

A

limited access to the airway

- done through a small needle, ETT, catheter or side port to a rigid bronchoscope

45
Q

High frequency jet ventilation uses

A

low tidal volumes & high respiratory rates

46
Q

Maintaining________ can be difficult in certain patient populations with high frequency jet ventilation.

A

oxygenation

47
Q

Indications for sinus surgery includes

A 
sinus obstruction (infection, polyps, or tumors)
sinustomies
48
Q

Surgical options for sinus surgery includes

A

endoscopic (FESS)
external
flouro
brain lab

49
Q

Sinus surgery can be performed under

A

general anesthesia vs. MAC

-ETT vs. LMA (decreased risk of blood flowing in oropharynx)

50
Q

Polyps associated with asthma & cystic fibrosis can result in

A

allergies

reactive airway

51
Q

Goals with sinus surgery include to

A

decrease bleeding through mild hypotension, vasoconstrictor use, & deep anesthesia

52
Q

Complications of sinus surgery include

A

dural puncture

53
Q

Treatment for dural puncture includes

A 
discontinue nitrous oxide (if using)
ETCO2 25-30 mmHg
mild hypotension
place foley catheter
consider mannitol 25-50 g/IV
patch by surgeon
54
Q

Sinus surgery can possibly indicate

A

deep extubation

would want to prevent coughing, bucking, and worsening of dural puncture if patient has one

55
Q

The leading cause of accidental death among children <4 years is

A

foreign body aspiration

56
Q

Most aspirated items are

A

food particles but can include beads, coins, pins, or parts of small toys

57
Q

Signs & symptoms of foreign body aspiration includes

A

wheezing, coughing, aphonia, & cyanosis

58
Q

The anesthetic management for foreign body aspiration depends on

A

size & location of object

59
Q

If a foreign body is aspirated in the larynx, then use

A

laryngoscopy & removal with Magill forceps

60
Q

If a foreign body is aspirated in the distal larynx or trachea, then use

A

rigid bronchoscopy with mouth guard to avoid injury

tracheal tears, & inadequate ventilation

61
Q

Anesthetic considerations for foreign body aspiration includes:

A

inhalational induction with 100% oxygen- maintain spontaneous respiration
administer antisialagogue, H2 blocker, & prokinetic
coughing, bucking or straining must be avoided
be cognizant of full stomach- RSI- full airway obstruction- surgeon must be prepared to perform cricothyrotomy or tracheotomy
observe for vagal stimulation during procedure

62
Q

Postoperative considerations for foreign body aspiration include

A

return of airway reflexes
edema possible for up to 24 hours post procedure–> Cuff leak?
supportive measures- racemic epinephrine, bronchodilators, steroids

931: Advanced Principles of Anesthesia I (22 decks)

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