Mod9: Otolaryngologic Surgery - Laser surgery - Tonsillectomy & Adenoidectomy - UPPP Flashcards

1
Q

Otolaryngologic Surgery - Laser Surgery

LASER

stands for:

A

Light

Amplification by

Simulated

Emission of

Radiation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Otolaryngologic Surgery - Laser Surgery

LASER

Characteristics:

A

Monochromatic

One wave length

Coherent

Oscillates in same phase

Collimated

Narrow, parallel beam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Otolaryngologic Surgery - Laser Surgery

Use of LASER in surgery

Provides:

A

Surgical precision

Minimal bleeding/edema

Preservation surrounding tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Otolaryngologic Surgery - Laser Surgery

Lasers most commonly used

A

CO2 lasers

ND: YAG & KPT lasers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Otolaryngologic Surgery - Laser Surgery

CO2 lasers

characteristics:

A

Produces a beam with a long wavelength of 10,600-nm

Absorption by H20 increased decreasing tissue penetration

More superficial/localized (High Heat)

May produce Cornea damage, not retinal

(b/c the beam is not as strong as the YAG lasers)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Otolaryngologic Surgery - Laser Surgery

ND: YAG & KPT lasers

characteristics:

A

Produces a shorter wavelength of 1064-1320-nm,

Nearly 10 x the ability to penetrate tissue

Deeper tissue penetration (retinal damage)

Exert more precautions and use specialized eye protection with these lasers!!!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Otolaryngologic Surgery - Laser Surgery

Major Hazards

to take into consideration:

A

Toxic fumes (laser plume) from tissue vaporization

Eye injury

Airway fire!!!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Otolaryngologic Surgery - Laser Surgery - Major Hazards

Toxic fumes (laser plume) from tissue vaporization

be careful if the pt has:

A

HPV

HIV

Ensure adequate evacuation

Wear protective masks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Otolaryngologic Surgery - Laser Surgery - Major Hazards

Eye injury

Precautions:

A

Protective goggles for both patient and OR personnel

(Protect pt’s eyes with goggles even if they are taped!!!)

CO2: <u>clear</u> glasses

Nd-YAg: <strong><em>green</em></strong> tint glasses

KTP-dYAG: <strong>red/amber/orange</strong>

Wet soaked gauze to eyes in anesthetized patient

(because of the potential for fire)

Avoid Lacri-Lube ointment (flammable)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Otolaryngologic Surgery - Laser Surgery - Major Hazards

Airway fire!!!

considerations and precautions:

A

Greatest fear

Prevention best plan!

Consider alternatives to tracheal intubation

(Intermittent apnea or jet ventilation)

ETT resistant to laser ignition

No cuffed ET or currently available ETT is completely laser proof!!!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Otolaryngologic Surgery - Laser Surgery - Preventing <strong>Airway fire</strong>

ETT resistant to laser ignition

How to use it?

A

Wrap PVC with metallic tape

No cuff protection

Not an FDA approved device

Adhesive may ignite

Reflective/damage non targeted tissue

Specialized laser tube

Stainless steel reflects laser beam

Defocuses beam, decrease tissue damage

Double cuffed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Otolaryngologic Surgery - Laser Surgery

Airway fire!!!

Precautions to take:

A

Deliver lowest possible FiO2

(<30% any time fire is possible)

Avoid N20

Replace with helium/air (Heliox)

Fill cuff with saline dyed methylene blue

saline will help Dissipate heat/ID cuff rupture

Limit laser intensity and duration

Combustibility depends on fraction of FiO2 and laser energy

Keep FiO2 below 30% limit laser exposure

N20 can fuel a fire although not flammable

Helix rationale:

Nonflammable

Posses a lower density than nitrogen and oxygen (main constituents of air)

Improving flow dynamics

Laminar flow is described by a lower calculated Reynold’s number

Reynolds number = vpd/n

v: linear velocity of fluid

p: density of fluid

d: diameter of tube

n: viscosity

The lower the Reynold’s number the greater degree of laminar flow (decreased resistance to flow) Reynolds > 2000 = predominantly turbulent flow

Reynolds < 2000 = reflects predominantly laminar flow

allows use of lower oxygen levels during laser thus lowering the risk of combustion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Otolaryngologic Surgery - Laser Surgery

Airway-fire protocol

What do you do in case of fire?

A

1) . Stop ventilation & Turn off O2 & disconnect anesthesia circuit from ETT
2) . Remove ETT and flood surgical field if flame persists
3) . Extinguish fire by placing removed ETT in H20
4) . Ventilate with 100% O2 by face mask

5). Reintubate with regular ETT

6) . Assess airway damage with bronchoscopy and flush with saline to remove debris & dissipate heat
7) . Obtain CXR
8) . Consider bronchial lavage and steroids

Great board exam technique to put in correct order.

The first action in an airway fire is to stop ventilation and remove the endotracheal tube, followed immediately by turning off/ disconnecting the oxygen. The sequence of subsequent actions varies (different references give slightly different orders) but includes: mask ventilation and reintubation; diagnose the injury, treat by bronchoscopy and laryngoscopy; administer short-term steroids; monitor the patient for at least 24 hours; and, administer antibiotics and provide ventilatory support as necessary.

[Longnecker, Tinker, and Morgan, PPA, 2nd ed., 1998, p1793; Morgan, et al., Clin. A nesthesiol., 3rd ed., 2002, p774; Miller, Anesthesia, 5th ed., 2000, p2 1871-0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Otolaryngologic Surgery

Tonsillectomy & Adenoidectomy

Preoperative considerations

A

Increased risk for airway complications

Chronic airway obstruction

(OSA - CO2 retention - Cor Pulmonale)

Increased risk for bacterial endocarditis

Postpone if acute infection present/clotting dysfunction (recent ASA ingestion)

Premedicate with antisialagogue

Procedures often performed separately or together

Adenoidectomy is less painful than Tonsillectomy**

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy

Intraoperative considerations

A

Inhalation induction with pediatrics

No muscle relaxants until ability to ventilate is established

Reinforced or oral RAE tube

Reinforced tube Decreases kinking with self-retaining mouth gag

Throat pack placed

Decrease amount blood in stomach

Document placement and removal

Fairly painful (Tonsil> adenoidectomy)

Consider local anesthesia at surgical site

Decadron (↓ inflammation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Tonsillectomy & Adenoidectomy - Intraoperative considerations

Inhalation induction with pediatrics

A

No muscle relaxants until ability to ventilate is established

17
Q

Tonsillectomy & Adenoidectomy - Intraoperative considerations

Reinforced or oral RAE tube

Benefits:

A

Decreases kinking with self-retaining mouth gag

18
Q

Tonsillectomy & Adenoidectomy - Intraoperative considerations

Throat pack placed

A

Decrease amount blood in stomach

Document placement and removal

19
Q

Tonsillectomy & Adenoidectomy - Intraoperative considerations

Fairly painful (tonsil> adenoidectomy)

A

Consider local anesthesia at surgical site

Decadron (↓ inflammation)

20
Q

Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy

Emergence

considerations:

A

Smooth controlled!!

Bucking/coughing increased risk for postoperative bleeding

Awake vs. Deep extubation

Each has advantages and disadvantages

Airway patent with pharyngeal reflexes intact to prevent aspiration and obstruction

GENTLE yet meticulous suctioning of pharynx just prior to extubation - Avoid rigid suction catheters (e.g. Yankaeur)

Transport to PACU in tonsillar position

Lateral with head down => allows you to qucikly ID any bleeding

21
Q

Tonsillectomy & Adenoidectomy - Emergence

Smooth controlled!!

A

Bucking/coughing increased risk for postoperative bleeding

22
Q

Tonsillectomy & Adenoidectomy - Emergence

Airway patent with pharyngeal reflexes intact to prevent aspiration and obstruction

How should you suction the pharynx prior to extubation?

A

GENTLE yet meticulous suctioning of pharynx just prior to extubation

Avoid rigid suction catheters (e.g. Yankaeur)

23
Q

Tonsillectomy & Adenoidectomy - Emergence

Transport to PACU in tonsillar position

Characteristics and benefits:

A

Lateral with head down

=> allows you to qucikly ID any bleeding

24
Q

Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy

Postoperative considerations

A

PONV common (30-65%)

Postop bleeding

Post obstruction pulmonary edema

25
Q

Tonsillectomy & Adenoidectomy - Postoperative considerations

PONV common (30-65%)

Prevention:

A

Avoid by placement OGT and decompressing stomach prior to extubation

Decadron preoperatively followed with Zofran 20” prior to end of surgery

26
Q

Tonsillectomy & Adenoidectomy - Postoperative considerations

Postop bleeding

characteristics:

A

75% occurs within 6hrs

Hypotensive/tachycardic/pallor

Surgical Emergency!!

=> To Restore intravascular volume

=> <u>Full stomach </u>(RSI with CCP)

27
Q

Tonsillectomy & Adenoidectomy - Postoperative considerations

Post obstruction pulmonary edema

Cause & Treatment:

A

Occurs after acute pulmonary obstruction

Supplemental O2, diuretics, CPAP, possible reintubation with mechanical ventilation

Usually the result of airway edema!!!

28
Q

Otolaryngologic Surgery

Uvulo-palato-pharyngo-plasty (UPPP)

characteristics:

A

UPPP can be a complex procedure for the CRNA

Bad airway to start with, usually obese with OSA, high incidence of CHF

Routine IV induction vs. inhalation vs. awake intubation

Surgery is to remove any redondant tissue in the airway

(could be uvula, portions of the palate, tonsils, addenoids, tongue may be shortenned through shortening of the muscle under it)

Indicated for pts with significant OSA that isn’t corrected with CPAP

HURTS post-op!!!

Management similar to T&A

29
Q

Otolaryngologic Surgery

Uvulo-palato-pharyngo-plasty (UPPP)

Indicated for:

A

Significant OSA

Not corrected by CPAP