EENT Flashcards
HOW MANY CATARACT OPERATIONS ARE PREFORMED EACH YEAR
> 2 MILLION
WHICH ANESTHETIC TECHNIQUE IS USED FOR MOST EYE PROCEDURES
USING MAC AND SOME SORT OF REGIONAL EYE ANESTHETIC
WHO DO WE USE GENERAL ANESTHESIA FOR IN OPHTHALMOLOGY
PROLONGED DURATION
MORE INVASIVE ORBITAL PROCEDURES
THOSE PATIENTS WHO CANNOT STAY STILL.
NORMAL EYE PRESSURE
10-22MMHG
WHAT DOES SUSTAINED INCREASED IOP DURING ANESTHESIA HAS THE POTENTIAL TO PRODUCE (4)
ACUTE GLAUCOMA
RETINAL ISCHEMIA
HEMORRHAGE
PERMANENT VISUAL LOSS.
OPHTHALMOLOGY FACTORS OF INCREASED IOP VENOUS CONGESTION:
OBSTRUCTION FROM EPISCLERAL VEINS TO THE RIGHT ATRIUM MAY CAUSE INCREASED IOP
BODY POSITION THAT INCREASE IOP
TRENDELENBURG/TIGHT CERVICAL COLLAR
HOW MUCH DOES STRAINING. RETCHING/COUGHING CAN INCREASE IOP UP TO
STRAINING/RETCHING/COUGHING UPON INDUCTION CAN INCREASE IOP UP TO 40 mm Hg OR MORE
OPHTHALMOLOGY FACTORS OF INCREASED IOP
HIGH PRESSURE DURING GLOBAL SURGERY CAN CAUSE VITREOUS HEMORRHAGE AND EXPULSION OF EYE CONTENTS WHICH MAY LEAD TO PERMANENT DAMAGE
ARTERIAL HPTN
COMPRESSION OF GLOBE FROM FACE MASK TO TIGHT
LARYNGOSCOPY AND TRACHEAL INTUBATION
SUPRAGLOTTIC AIRWAY HAS MINIMAL EFFECT
HYPOXEMIA AND HYPOVENTILATION
WHAT DECREASES IOP
HYPERVENTILATION AND HYPOTHERMIA
OCULOCARDIAC REFLEX:
SUDDEN PROFOUND DECREASE IN HR IN RESPONSE TO TRACTION ON THE EXTRAOCULAR MUSCLES OR EXTERNAL PRESSURE ON THE GLOBE.
OCULOCARDIAC REFLEX: MORE COMMON IN WHAT TYPE OF PATIENTS
YOUNG PATIENTS
OCULOCARDIAC REFLEX: MOST OFTEN ENCOUNTERED DURING WHAT SURGERY
MOST OFTEN ENCOUNTERED IN STRABISMUS SURGERY BUT CAN OCCUR DURING ANY TYPE OF OPHTHALMIC SURGERY.
REFLEX ARC
TRIGEMINAL NERVE AFFERENT LIMB - GENERATES AN EFFERENT VAGAL RESPONSE
RESULTING IN…
VARIETY OF DYSRHYTHMIAS: JUNCTIONAL; SINUS BRADY; ATRIOVENTRICULAR BLOCK; BIGEMINY; PVC; V-TACH; ASYSTOLE
efferentneuron
can bring
the response from the CNS.
afferentneuron
must
bring the stimulus to the CNS
OCULOCARDIAC REFLEX - WHAT HAPPENS WHEN YOU REMOVE THE SURGICAL STIMULUS
PROMPT REMOVAL OF THE INSTIGATING SURGICAL STIMULUS FREQUENTLY RESULTS IN RAPID RECOVERY
WHAT MEDICATION CAN ABATE THE OCULOCARDIAC REFLEX
WITH ADMINISTRATION OF PARASYMPATHOLYTIC SUCH AS ATROPINE OR GLYCOPYRROLATE.
HOW CAN THE OCULOCARDIAC REFLEX BE STOPPED WITH ANESTHESIA?
CAN BE ERADICATED BY INSERTING A REGIONAL ANESTHETIC EYE BLOCK THEREBY ABOLISHING ITS AFFERENT ARC.
IN ELDERLY WHAT ARE WE CONCERNED WITH USING PARASYMPATHOLYTICS
WATCH HEART RATE IN ELDERLY IF USING THE PARASYMPATHOLYTICS
TELL ME ABOUT CHILDREN AND THEIR DEPENDENCE ON HR. HOW DO WE TREAT THIS
CHILDREN ARE MORE DEPENDENT ON HR TO MAINTAIN C.O., PROPHYLACTIC IV ADMINISTRATION OF ATROPINE (0.01-0.02 MG/KG) MAY BE PRUDENT.
WHAT IS THE MOST COMMON CAUSE OF POST OP EYE PAIN AFTER GENERAL ANESTHESIA
CORNEAL ABRASIONS
EXPLAIN THE REASONS FOR CORNEAL ABRASIONS (3)
AND TREATMENT?
TAPE INCORRECTLY
TAKING TAPE OFF TO EARLY
STETHOSCOPE/NAME BADGE
HITTING EYE;
ABX OINTMENT AND EYE PATCH USUALLY RESULTS IN CORNEAL HEALING WITHIN A DAY OR TWO
ACUTE GLAUCOMA
PAINFUL. PRESENCE OF MYDRIATIC (DILATED)PUPIL MAY BE DIAGNOSTIC. URGENT MATTER NEEDING OPHTHALMOLOGIST. IV MANNITOL OR ACETAZOLAMIDE CAN DECREASE IOP AND RELIEVE PAIN
POST-OP VISION LOSS- painless loss of vision (2)(rare)
more frequent risk
ISCHEMIC OPTIC NEUROPATHY
BRAIN INJURY
THE PRONE POSITION
CARDIAC SURGERY
(ISCHEMIC OPTIC NEUROPATHY). OPHTHALMOLOGY CONSULT IS NECESSARY
OTOLARYNGOLOGY- WHEN SHOULD NITROUS NOT BE USED?
NOT IF SURGERY IS IN THE MIDDLE EAR
MYRINGOTOMY AND TUBE INSERTION INDICATION FOR SURGERY?
CHRONIC OTITIS MEDIA: DRAINS MIDDLE EAR OF FLUID. MYRINGOTOMY CREATES THE OPENING IN TM THEN TUBE PLACED TO HELP DRAIN FLUID.
WHAT TYPE OF ANESTHESIA IS USED WITH OTOLARYNGOLOGY
USUALLY MASK CASE/ NO IV/SUCC DART IS NEEDED (WHAT IS IT?)
WHAT ARE THE TWO MOST COMMON PROCEDURES PERFORMED ON THE MIDDLE EAR AND ACCESSORY STRUCTURES
TYMPANOPLASTY AND MASTOIDECTOMY
TYMPANOPLASTY AND MASTOIDECTOMY - TELL ME ABOUT THE POSITION PROBLEMS
SOMETIMES REQUIRES EXTREME DEGREES OF LATERAL ROTATION. EXTREME TENSION ON THE HEAD OF THE STERNOCLEIDOMASTOID MUSCLES MUST BE AVOIDED.
CAN CAUSE C1 AND C2 SUBLUXATION (MISALIGNMENT) OF WHICH CHILDREN ARE ESPECIALLY PRONE DUE TO LAXITY OF LIGAMENTS OF THE CERVICAL SPINE AND THE IMMATURITY OF ODONTOID PROCESS
HOW DO YOU DELIVER NITROUS IF YOU MUST DELIVER IT FOR EENT CASES
MIDDLE EAR AND SINUSES ARE AIR-FILLED, NONDISTENSIBLE CAVITIES. NITROUS SHOULD NOT BE USED. IF HAVE TO USE IT CUT 50% WHEN TYMPANIC GRAPH TO AVOID PRESSURE DISPLACEMENT.
HOW SOON IS NITROUS REABSORED AFTER D.C
WHY IS THIS A PROBLEM FOR THE MIDDLE EAR?
HOW LONG WILL THE EFFECTS LAST?
QUICKLY REABSORBED
NEGATIVE PRESSURE RESULTING IN SEROUS OTITIS, DISARTICULATION OF THE OSSICLES IN THE MIDDLE EAR, AND HEARING IMPAIRMENT
LAST UP TO 6 WEEKS AFTER SURGERY.
PRESERVATION OF FACIAL NERVE IS IMPERATIVE
SURGEON ISOLATES THE NERVE AND VERIFIES ITS FUNCTION BY ELECTRICAL STIMULATION. THIS IS DONE BY BRAINSTEM AUDITORY-EVOKED POTENTIAL AND ELECTROCOCHLEOGRAM MONITORING. COMPLETE MUSCLE RELAXANT NEED TO BE AVOIDED.
USING AN OPIOID RELAXANT DURING OTOLARYNGOLOGY CASE-
IF AN OPIOID RELAXANT TECHNIQUE IS CHOSEN AT LEAST 30% OF THE MUSCLE RESPONSE AS DETERMINED BY A TWITCH MONITOR SHOULD BE PRESERVED. THIS MAY SUGGEST THAT IT IS NOT NECESSARY TO AVOID NMB, HOWEVER, YOU MAY NOTICE MOST SURGEON MAY NOT WANT THEM USED.
Nitrous Oxide:
SOLUBLE?
DIFFUSE?
PRESSURE?
More soluble than nitrogen in the blood
Diffuses into air-filled cavities quicker than nitrogen diffuses out
This increases middle ear pressure and can dislodge tympanoplasty grafts
Acute d/c of high concentrations of nitrous oxide markedly decreases cavity pressure and may cause serous otitis
Should be avoided or if used, use in moderate concentration < 50% and d/c 15-30 minutes prior to graft application
Epinephrine
Frequently injected during EAR microsurgery to decrease bleeding and improve visual field.
Systemic uptake may precipitate tachydysrhythmias
Epi in concentration limited to 1:200,000 solution should be used
Reverse Trendelenburg decreases venous congestion and the use of volatile anesthetics to decrease systolic arterial blood pressure help with bleeding as well
Use of vasoactive drugs and controlled hypotension is controversial
Emergence: OTOLARYNGOLOGY
Coughing and bucking increase venous pressure, which can lead to graft disruption or acute bleeding
Deep extubation may be beneficial. Why would you not want to deep extubate?
PONV: OTOLARYNGOLOGY
Manipulation of vestibular apparatus often causes PONV after middle ear surgery
What factors exacerbate this PONV? Page 532
Difficult Airway: LARYNGOSPASM- what mediates it
Laryngospasm:
Mediated through vagal stimulation of the superior laryngeal nerve
Abrupt intense, prolonged closure of the larynx with compromise of ventilation can occur upon:
Instrumentation of the endolarynx
Blood or foreign body presence
Inadequate depth of anesthesia
Laryngospasm: CHILDREN- what happens with a brief laryngospasm
In children even brief laryngospasm is particularly perilous as a peripheral oxygen saturation decreases precipitously as a result of a small FRC and relative high CO.
Laryngospasm- what ensues?
temporal reduction in brain stem firing to what nerve makes the cords relax
If airway is completely obstructed, the anesthesia provider may be unable to ventilate despite an adequate mask fit
Ensuing hypercarbia, hypoxia, and acidosis elicit an automatic sympathetic response producing hypertension and tachycardia
Temporal reduction in brainstem firing to the superior laryngeal nerve eventually causes relaxation of the vocal cords.
LARYNGOSPASM Treatment Modality:
100% O2 vial positive-pressure face mask ventilation
Placement of an oral/nasal airway
Deepening of anesthesia with IV anesthetics
Small doses of succinylcholine (0.25 – 0.5 mg/kg)
Tracheal intubation may be necessary in refractory cases
To reduce encountering laryngospasm, the use of IV or topical lidocaine (4% lidocaine spray) prior to laryngoscopy and endotracheal intubation
TONSILLECTOMY & ADENOIDECTOMY (T&A) ISSUES (4)
what is very important in these cases
AIRWAY OBSTRUCTION
BLEEDING
CARDIAC ARRHYTHMIAS
CROUP (POST-EXTUBATION AIRWAY EDEMA).
PRE-OP ASSESSMENT IMPORTANT
TONSILLECTOMY & ADENOIDECTOMY (T&A)- HOW DO WE DELIVER ANESTHESIA
MASK A CHILD UNLESS WILL TOLERATE AND IV START. IF GOING TO BE A TRAUMATIC EXPERIENCE MASK ANESTHESIA IS PREFERRED.
TONSILLECTOMY & ADENOIDECTOMY (T&A)- WHAT TYPE OF TUBE IF THEY NEED TO BE INTUBATED
ORAL RAE TUBE TO KEEP OUT OF WAY OF SURGEON
(T&A) AIRLEAK
AN AIR LEAK OF 20 cm H2O PEAK AIRWAY ASSURES REDUCTION OF TISSUE EDEMA, A CRITICAL FACTOR FOR PEDS WHO HAVE A NARROWER AIRWAY DIAMETER THAN ADULTS. (WHAT IS THE MAX PRESSURE FOR ADULTS?)
(T&A) TYPE OF PATIENTS
YOUNG AND HEALTHY
(T&A) PONV/pain
IV DECADRON < EDEMA
POSTOP PAIN
PONV.
T&A AIRWAY OBSTRUCTION REASONS
SECRETIONS OR BLOOD ON THE VOCAL CORDS
RETAINED PHARYNGEAL PACK (always chart it was removed)
airway obstruction after T&A sometimes may create what
SOMETIMES MAY CREATE NEGATIVE-PRESSURE PULMONARY EDEMA. THIS PRESSURE IS TRANSMITTED TO INTERSTITIAL TISSUE AND PROMOTES FLOW OF FLUID FROM THE PULMONARY CIRCULATION INTO THE ALVEOLI.
T&A- CHILDREN LESS THAN 4 SUSCEPTIBLIITY
YOUNG CHILDREN < 4 YEARS ARE SUSCEPTIBLE TO AIRWAY OBSTRUCTION AS LATE AS 24 HOURS POSTOP AND MAY BENEFIT FROM PROLONGED POST OP MONITORING.
Tonsils & Adenoids. Sevo 8%,
Tonsils & Adenoids. Sevo 8%, IV start once down. Induction drugs: Specific body weight- Fent, Propofol may or may not give atropine . Intubation or oral airway, tape tube down, turn bed around: Iv to remain patent, keep circuit and airway secured, no kinks, clamped . May want a 20 mm leak for a pediatric tube = to decrease barotrauma and other pulmonary trauma, assess for laryngeal edema by deflating cuff and assess for leak. Decadron sometimes given.
WHEN DOES BLEEDING AFTER T&A OCCUR
OCCURS WITHIN A FEW HOURS AFTER SURGERY
EBL AFTER T&A
EBL IS UNDERESTIMATED B/C OF SWALLOWING AND ARE CONSIDERED A FULL STOMACH
WHAT ADMINISTRATION FOR T&A IS CRITICAL
FLUIDS
RSI IS NEEDED- WHAT WILL YOU HAVE READY?
PROBABLY SUCTION?
EPIGLOTTITIS- caused by what
affecting children between what ages
ACUTE EPIGLOTTITIS IS AN INFECTIOUS DISEASE CAUSED BY Haemophilus influenza TYPE B. OFTEN AFFECTING CHILDREN BETWEEN 2 & 7 YEARS OLD
EPIGLOTTITIS HX
OFTEN A HISTORY OF SUDDEN ONSET OF FEVER AND DYSPHAGIA
EPIGLOTTITIS SYMPTOMS
PHARYNGITIS TO AIRWAY OBSTRUCTION
RESPIRATORY FAILURE CAN BE RAPID (WITHIN HOURS).
AGITATED, DROOLING, LEANS FORWARD HOLDING THE HEAD IN AN EXTENDED POSITION.
EPIGLOTTITIS- WHY ARE THEY FATIGUED?
FATIGUE FROM BREATHING AGAINST A NEARLY CLOSED AIRWARY
EPIGLOTTITIS - WHEN DOES ANESTHESIA COMMENCE
ANESTHESIA COMMENCES ONLY WHEN ALL EMERGENCY AIRWAY EQUIPMENT IS OPEN AND READY AND SURGEON ADEPT AT RIGID BRONCHOSCOPY AND TRACHEOSTOMY PRESENT
WHY IS INHALED INDUCTION OF ANESTHESIA PREFERRED in epiglottis
AND INHALED INDUCTION OF ANESTHESIA MAINTAINING SPONTANEOUS VENTILATION IS PREFERRED
IS EPIGLOTTITIS DIRECT VISUALIZATION PREFERRED
DIRECT VISUALIZATION OF THE GLOTTIS SHOULD NOT BE ATTEMPTED B/C STIMULATION OF THE PATIENT AND STRUGGLING MAY RESULT IN COMPLETE AIRWAY OBSTRUCTION.
EPIGLOTTITIS-MEDICATION PRIOR TO INDUCTION
ATROPINE TO AVOID BRADY AND DRY SECRETIONS
EPIGLOTTITIS- ETT SIZES?
SMALL ETT WITH RANGE OF SIZES
EPIGLOTTITIS- ANY DIFFICULTY-
IF ANY DIFFICULTY, THE SURGEON SHOULD INTERVENE AND SECURE THE AIRWAY WITH A RIGID BRONCHOSCOPE OR ESTABLISH A SURGICAL AIRWAY
THYROID AND PARATHYROID
HYPERTHYROID MANIFESTS WITH SIGNS OF MASSIVE CATECHOLAMINE RELEASE INCLUDING TACHYCARDIA, HPTN, DIAPHORESIS
THYROID- SURGICAL MANIPULATION ANESTHETIC CONSIDERATIONS
SURGICAL MANIPULATION OF HEAD AND NECK CAN OCCLUDE A STANDARD ETT. AN ARMORED ETT MAY BE BENEFICIAL
POST OP THYROID AND PARATHYROID
POST OP BE WARE OF AIRWAY OBSTRUCTION AND VOCAL CORD DAMAGE
HOW DO WE MONITOR RECURRENT LARYNGEAL NERVE INTEGRITY DURING THYROID AND PARATHYROID SURGERY
AN ELECTROMYOGRAPHY (EMG) TO MONITOR RECURRENT LARYNGEAL NERVE INTEGRITY USING A SPECIAL ETT AND EMG MONITOR MAY BE USED
ELECTROLYTE ISSUES
PARATHYROID INJURY OR REMOVAL MAY CAUSE HYPOCALCEMIA WITH CLINICAL SIGNS OF TETANY CARDIAC DYSRHYTHMIAS AND LARYNGOSPASM
LEFORT 2
a triangle fracture- running from the bridge of the nose, through the medial and inferior wall of the orbit beneath the zygoma through the lateral wall of the maxilla and pterygoid plates.
LEFORT 3
separates the midfacial skeleton from the cranial base traversing the root of the nose, the ethmoid bone the eye orbits and the sphenopalatine fossa.
LEFORT 1
horizontal fracture of the maxilla extending from the floor of the nose and hard palate through the nasal septum and through the pterygoid plates posteriorly .
which lefort classification causes little difficulty for anethesia
before 1 fracture can be intubated orally or nasally.
can you nasally intubate lefort 2 or 3?
nasal intubation may aid the surgeon but great concern is given as the patient may have basilar skull fracture- inadvertent etc placement in the intracranial space may cause meningitis and could inflict damage on the brain itself.
will blood loss be a concern with major facial trauma
yes- these patients MUST be typed and crossmatched.
