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

Question 1

_{Otolaryngologic Surgery - Laser Surgery}

LASER

^{stands for:}

Answer 1

Light

Amplification by

Simulated

Emission of

Radiation

Question 2

_{Otolaryngologic Surgery - Laser Surgery}

LASER

^{Characteristics:}

Answer 2

Monochromatic

^{One wave length}

Coherent

^{Oscillates in same phase}

Collimated

^{Narrow, parallel beam}

Question 3

_{Otolaryngologic Surgery - Laser Surgery}

Use of LASER in surgery

^Provides:

Answer 3

Surgical precision

Minimal bleeding/edema

Preservation surrounding tissue

Question 4

_{Otolaryngologic Surgery - Laser Surgery}

Lasers most commonly used

Answer 4

CO2 lasers

ND: YAG & KPT lasers

Question 5

_{Otolaryngologic Surgery - Laser Surgery}

CO2 lasers

^{characteristics:}

Answer 5

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)}

Question 6

_{Otolaryngologic Surgery - Laser Surgery}

ND: YAG & KPT lasers

^{characteristics:}

Answer 6

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!!!}

Question 7

_{Otolaryngologic Surgery - Laser Surgery}

Major Hazards

^{to take into consideration:}

Answer 7

Toxic fumes (laser plume) from tissue vaporization

Eye injury

Airway fire!!!

Question 8

_{Otolaryngologic Surgery - Laser Surgery - Major Hazards}

Toxic fumes (laser plume) from tissue vaporization

^{be careful if the pt has:}

Answer 8

HPV

HIV

Ensure adequate evacuation

Wear protective masks

Question 9

_{Otolaryngologic Surgery - Laser Surgery - Major Hazards}

Eye injury

^Precautions:

Answer 9

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)

Question 10

_{Otolaryngologic Surgery - Laser Surgery - Major Hazards}

Airway fire!!!

^{considerations and precautions:}

Answer 10

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!!!

Question 11

_{Otolaryngologic Surgery - Laser Surgery - Preventing <strong>Airway fire</strong>}

ETT resistant to laser ignition

^{How to use it?}

Answer 11

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}

Question 12

_{Otolaryngologic Surgery - Laser Surgery}

Airway fire!!!

^{Precautions to take:}

Answer 12

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}

Question 13

_{Otolaryngologic Surgery - Laser Surgery}

Airway-fire protocol

^{What do you do in case of fire?}

Answer 13

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}

Question 14

_{Otolaryngologic Surgery}

Tonsillectomy & Adenoidectomy

^{Preoperative considerations}

Answer 14

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**}

Question 15

_{Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy}

Intraoperative considerations

Answer 15

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)}

Question 16

_{Tonsillectomy & Adenoidectomy - Intraoperative considerations}

Inhalation induction with pediatrics

Answer 16

No muscle relaxants until ability to ventilate is established

Question 17

_{Tonsillectomy & Adenoidectomy - Intraoperative considerations}

Reinforced or oral RAE tube

^Benefits:

Answer 17

Decreases kinking with self-retaining mouth gag

Question 18

_{Tonsillectomy & Adenoidectomy - Intraoperative considerations}

Throat pack placed

Answer 18

Decrease amount blood in stomach

Document placement and removal

Question 19

_{Tonsillectomy & Adenoidectomy - Intraoperative considerations}

Fairly painful (tonsil> adenoidectomy)

Answer 19

Consider local anesthesia at surgical site

Decadron (↓ inflammation)

Question 20

_{Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy}

Emergence

considerations:

Answer 20

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}

Question 21

_{Tonsillectomy & Adenoidectomy - Emergence}

Smooth controlled!!

Answer 21

Bucking/coughing increased risk for postoperative bleeding

Question 22

_{Tonsillectomy & Adenoidectomy - Emergence}

Airway patent with pharyngeal reflexes intact to prevent aspiration and obstruction

^{How should you suction the pharynx prior to extubation?}

Answer 22

GENTLE yet meticulous suctioning of pharynx just prior to extubation

Avoid rigid suction catheters (e.g. Yankaeur)

Question 23

_{Tonsillectomy & Adenoidectomy - Emergence}

Transport to PACU in tonsillar position

^{Characteristics and benefits:}

Answer 23

Lateral with head down

=> allows you to qucikly ID any bleeding

Question 24

_{Otolaryngologic Surgery - Tonsillectomy & Adenoidectomy}

Postoperative considerations

Answer 24

PONV common (30-65%)

Postop bleeding

Post obstruction pulmonary edema

Question 25

_{Tonsillectomy & Adenoidectomy - Postoperative considerations}

PONV common (30-65%)

^Prevention:

Answer 25

Avoid by placement OGT and decompressing stomach prior to extubation

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

Question 26

_{Tonsillectomy & Adenoidectomy - Postoperative considerations}

Postop bleeding

^{characteristics:}

Answer 26

75% occurs within 6hrs

Hypotensive/tachycardic/pallor

Surgical Emergency!!

^{=> To Restore intravascular volume}

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

Question 27

_{Tonsillectomy & Adenoidectomy - Postoperative considerations}

Post obstruction pulmonary edema

^{Cause & Treatment:}

Answer 27

Occurs after acute pulmonary obstruction

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

Usually the result of airway edema!!!

Question 28

_{Otolaryngologic Surgery}

Uvulo-palato-pharyngo-plasty (UPPP)

^{characteristics:}

Answer 28

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

Question 29

_{Otolaryngologic Surgery}

Uvulo-palato-pharyngo-plasty (UPPP)

^{Indicated for:}

Answer 29

Significant OSA

Not corrected by CPAP