Laryngectomy Flashcards
A 56-year-old male patient is undergoing an elective laryngectomy for
malignancy.
What added information would you like prior to proceeding with this case?
Patient factors:
* An anaesthetic history focusing on known cardiovascular and respiratory comorbidities, previous anaesthetics and the airway.
- Patients with laryngeal cancer often have a history of smoking or alcohol excess, which will cause perioperative anaesthetic and surgical challenges.
- The patient may be malnourished due to a decreased appetite or pain
in the oropharyngeal area, necessitating dietician involvement.
- Anaemia may be present due to blood loss, chronic disease or secondary to the patient’s comorbidities and should be treated prior to surgery.
- Information should be sought about completed treatment (chemotherapy/radiotherapy), which may have implications for airway manipulation and management. Intubation of a patient who has undergone radiotherapy to the airway necessitates a precise airway plan, discussed with the surgical team.
- Specific information about the tumour: patient symptoms and progression, and investigations (CT/MRI/nasendoscopy) suggesting encroachment on local structures:
- Changes in voice/hoarseness.
- Stridor/dyspnoea.
- Shortness of breath when lying flat.
Surgical factors:
* Details about the extent of malignant spread and the expected procedure: whether it is a partial or total laryngectomy, including the possibility of neck dissection or free fap reconstruction.
What is a stridor?
- A stridor is a harsh inspiratory breath sound produced due to partial upper airway obstruction.
What is your plan for induction of anaesthesia in this patient?
- Ensure patient consent, a completed WHO checklist, AAGBI monitoring, the difficult airway trolley present, a consultant anaesthetist and trained anaesthetic assistant, and emergency drugs drawn up. Further monitoring may include an arterial line, a central line and a catheter to monitor urine output.
- This patient should be anaesthetised in theatre with the surgeons present and scrubbed, if the anaesthetic assessment deems that the patient may be difficult to intubate or ventilate.
- The airway plan should be discussed with the multidisciplinary team at the team brief, with preparation for what will be done in the event of a failed intubation.
- The plan for induction will depend on the specific patient history, examination and investigations. If very high risk for a difficult intubation, a preoperative awake tracheostomy should be done. However, the usual technique in this patient involves:
- Preoperative assessment of the neck and landmark identification (ultrasound can be used to mark the cricothyroid membrane).
- Preoxygenation with high flow nasal oxygen.
- An intravenous induction with a sufficient dose of a muscle relaxant (rocuronium can be used with the correct dose of sugammadex drawn up if considered necessary).
What is THRIVE?
- “THRIVE” stands for transnasal humidified rapid insufflation ventilatory exchange.
- It is a technique that involves high flow humidified oxygen delivered via nasal specs (up to 70 L/minute).
- It uses apnoeic oxygenation. Maintenance of a patent airway allows gas exchange at a cellular level.
- The high flow of oxygen prevents entrainment of room air and generates a positive end expiratory pressure (PEEP) that prevents atelectasis and airway collapse.
The surgery is completed successfully and the patient is discharged home. Three months later, he presents to the emergency department with shortness of breath and difficulty breathing. What is your initial management?
- This is an anaesthetic emergency.
- Call for urgent senior anaesthetic and ENT help.
- Conduct a rapid assessment of the airway to assess the effort and efficacy of breathing via the stoma.
- Apply 100% oxygen using a Water’s circuit and an appropriately sized mask for the patient’s stoma.
- Assess the stoma to determine its patency by passing a suction catheter through.
- Ventilate the patient via his stoma while awaiting expert help.
