ENT Procedures Flashcards
Special consideration for otolaryngology
Shared airway Surgical field avoidance Restricted use of N2O, muscle relaxant Specialized equipment, laser High % Peds cases
Compromised airway b4 surgery because
Edema
Infection
Tumor
Ear surgery considerations
Facial n Epinephrine use Effect of N2O in middle ear Extremes of head positioning Possibility of air emboli Control bleeding PONV
Nerves that provide sensory innervation to ear
- Auriculotemporal n
- Great auricular n (cervical plexus)
- Auricular branch of vagus
- Tympanic n ( glossopharyngeal n)
Incidence of facial n paralysis
.6-3%
Ear surgery best choice
- VA the best
- No muscle relaxants the best
- Requires maintenance of skeletal muscle activity
N2O considerations
-NO- middle ear/paranasal sinuses
-Consist of open no ventilated spaces
-Enters air filled cavities more rapidly than air can leave
Vented passively via the E-tube into nasopharynyx
-narrowing can prevent middle ear from venting passively
N2O don’t use
-previous middle ear reconstructive surgery
-serious otitis media
Dis articulation of stapes
Tympanoplasty and N2O
- can cause displacement & lifting of the tympanic membrane graft
- limit to <50% & d/c @ least 16 min b4 closure of the middle ear
Microsurgery of the ear requires
-Bloodless field
-10-15 head tilt
-Infiltration of local epin (10cc of 1:100000)
-Relative hypotension (sbp <100)
VA are good
Max dose of epinephrine w/VA
Iso 6.7mcq/kg
Des 4.5mcq/kg
Sevo 5 mcq/kg
Myringotomy facts
- 2nd most common Peds procedure
- GA w/o IV
- short
- Inhalation induction
- Abx & steroid gtts frequently
Myringotomy summary
What to use in anesthesia?
- All routine monitors
- NDMR maintain twitch 10-20% or avoid
- GA w/ETT Rae tube
- VA
Myringotomy nausea due to
- Labyrinth involvement which stimulates CTZ - vertigo, n/v, nystagmus
- ondansetron .05mg/kg
- dramamine
- decadron
- increase Fluids
Nasal/sinus surgery considerations
- inc airway reactivity
- topical cocaine
- posterior pharyngeal pack
- lg potential blood loss
- reflexive extubation: swallowed blood/secretions
- laser use by surgeon
- field avoidance
Topical cocaine
- HTN & tachycardia
- 1.5 mg/kg intranaslly safe dose
- no effect on duration/vasoconstriction
- can use w/VA
- use during GA or local/sedation
Septoplasty induction/maintance
- deep
- give narcotics IV & topical
- intubation
Maintance: VA, narcotics, NDMR, controlled respirations
Septoplasty summary of anesthesia
- shared airway w/surgeon
- long breathing circuit
- potential difficult airway
- nasal packing
- careful w/mask
- Nausea
Endoscopy areas of concerns
- Supraglottic-tumors, infection, laryngomalacia
- Glottic abn- vocal cord abn (palsy, edema, papillomas)
- Subglottic- tumor, stenosis, tracheomalacia
Endoscopy anesthesia goals
Suppression of cough & laryngeal reflexes
- superior laryngeal
- glossopharyngeal
- transtracheal n block
- LTA
- cetacaine spray
- aerosolized lidocaine 4cc of 4% for 5-7 min
Maxillary n block
- Interrupts sensory to nasal cavity
- Eliminates messeter m tone
- relaxes jaw
- minimizes biting
Laryngoscopy reason
- visualize inspect posterior oral pharynx
- posterior commisures
- Glotic opening
- vocal cords
If any questions about airway
Direct laryngoscopy or fiberoptic in the awake or
Ventilating bronchoscope sanders
- Provides high pressure insufflation of gases
- Requires muscle relaxation to permit adequate ventilation of the lungs
Bronchoscopy
Rigid bronchoscopy
- Pt paralyzed
- indications: massive hemoptysis, foreign body removal, placement of stents, lg biopsy specimen
- can cause tracheal tear &/or Ptx
- contraindicated if cervical spine pathology
Laser surgery
- CO2 laser energy absorbed by water in blood & tissue
- the heat vaporizes tissue & cauterizes capillaries
Anesthetic considerations for laser procedures
- cover pts eyes w/moist gauze pads or protective eyewear (cornea)
- staff eye protection
- muscle relaxant
- protect ETT w/saline soaked 4x4s
What gases support fire?
O2 & N2O Inhalation = chemical injury O2<30% Helium nonflammable Heliox O2+helium allows for lowerFiO2 & allows laminar flow
What equipment protection can be done?
- Laser shield ETT w/silicon
- Metal laser tubes
- Cuff inflated with sterile saline/methylene blue
Airway fire ETT
- 6 sec to recognize & remove intraluminal fire
- proximal O2 source (ETT)
- tube exchanger for difficult airway
- ventilate w air/O2
Treatment of airway fire
- D/c O2
- remove burning tube
- reintubate
- flush pharynx w/cold saline
- rigid bronchoscopy to remove tube particles and assess for damage
- humidified O2, steroids, Abx, controlled ventilation, possible trach
Reduce fire hazards
- Low O2 concentration
- laser suitable ETT
- inflate cuff w/saline
- avoid paper drapes
- H2O on field at all times
- H2O soluble lubricant on beards
- sx O2 source if sedation
What 3 nonlymphatic structures that are preserved during radical neck dissection
SAN
IJV
sCM
What is modified radical neck dissection?
Excision of the LN routinely removed in a radical neck dissection with preservation of one or more nonlymphatic structures
Monitoring for extensive neck surgeries
- IV, Art line, EtCO2, foley cath, Precordial to monitor for venous air embolus
- table turned: padding, long breathing circuit/IV tubing
- all warming modalities
Intubation for neck surgery
- awake intubation
- reinforced Anode tube
- Resp hx (smoker, copd)
- always have emergency equipment available
Cardiac considerations for neck surgeries
- CAD: slow controlled induction-high doses of narcotics, decrease induction agent
- CHF: primary narcotic technique- AVOID high doses of IV induction meds & inhalation agent
Maintenance of anesthesia:
Big neck surgery
- VA best choice: bronchodilates, depresses airway reflexes, permits high O2 concentration, mod hypotension
- muscle relaxants depends on surgeon/surgery
Complications during maintenance of big neck surgeries
- Open neck veins increase the possibility of venous air embolism (low incidence)
- trauma to the right stellate ganglion & cervical ANS
- prolong QT interval & lower the threshold for V-Fib
- watch manipulation of carotid sinus
- brady, hypot, cardiac arrest
Usually remains intubated after surgery
Mandibulectomy
Acoustic neuroma
-NO NDMR ( stimulation & location of the facial nerve)
- field avoidance
- shared airway
- high fire risk
Indications for tonsillectomy
- Tonsillar hyperplasia
- chronic bronchitis
- OSA: right heart failure, pul HTN, cor pulmonale
Sickle cell patients
- higher risk for pneumonia, atelectasis, vaso-occlusive crisis
- may be given transfusion to decrease Hgb S ratio to less than 40%
- inpatient
Down syndrome
- C-SPINE clearance
- lg tongue & unstable atlanto-occipital joints
- preop antisialagogue & narcotics
- maintain spontaneous respiration
Tonsillectomy maintenance
- fluid 3-5ml/kg
- dexamethasone .5-1 mg/kg
- VA are good Sevo has decreased airway irritability
- O2 low,
- Can supplement w/local on the tonsil area: decreases postop laryngospasm, stridor
- can cause arrhythmia a by endogenous epinephrine
Tonsillectomy emergence
- sx pharynx & stomach for blood & secretions
- make sure pharynx is “ VERY DRY
- awake, reflexive ( safest)
- deep is common in peds
Post to tonsillectomy bleeding
- .1-3 require surgery
- us occurs 3-6 hrs postop or up to 6 days
- 75% can have lg blood loss
- rapid sequence induction w/cricoid pressure since they coming back with n/v, full stomach, blood
- awake extubation
Narcotics doses
Fentanyl 3-5 mcq/kg
Morphine for Peds 0.1-0.2 mg/kg
Dilaudid adults 1mg
What is UPPP and why we do it?
- severe sleep apnea, usually adults
- removal of uvula, tonsils, & redundant tissue in the pharynx
- simar consideration for tonsillectomy
- extubate in high fowlers
What are the vasoconstrictors and what dose?
Used for mandibular osteotomy
- 4%cocaine or Afrim
- apply above on a cotton tipped swab to each nare 30 min b4 instrumentation , usually 15 min
Sedation for nasal intubation for mandible surgery
- Versed & narcotics prior to insertion of cotton swabs
- narcotics to decrease release of catecholamines: important in young healthy adults
Preop meds for mandibular surgery
- Vasoconstrictors
- sedation
- antiemetic
- steroids (decadron 8-12 mg edema)
- equipment
Mandibular osteotomy
- induction
- maintenance
-propofol best choice, not ketamine
- front load narcotics b4
- LTA or IV lidocaine
MAINTENANCE:
-VA: mod hypotension
- beta blockers
- NDMR not necessary
Mandibular osteotomy
- Fluids
- emergence
6-10ml/kg/hr blood loss 3:1 crystalloid - reach blood near the end of blood loss - carefully watch/chart blood loss EMERGENCE - sx stomach prior to - absolutely awake extubation - PACU/ICU over night
