Mod9: Otolaryngologic Surgery - Panendoscopy

Question 1

_{Otolaryngologic Surgery}

Surgical procedures

^{of which organs:}

Answer 1

Ears

Nose

Neck

Throat

Question 2

_{Otolaryngologic Surgery - Surgical procedures}

Ears

^{procedures include:}

Answer 2

Myringotomy & tubes

Tympanoplasty

Mastoidectom

Question 3

_{Otolaryngologic Surgery - Surgical procedures}

Nose

^{procedures include:}

Answer 3

Septoplasty

Rhinoplasty

FESS

Maxillary sinusotomy

Polypectomy

Question 4

_{Otolaryngologic Surgery - Surgical procedures}

Neck

^{procedures include:​}

Answer 4

Laryngectomy

Glossectomy

Pharyngectomy

Radical neck dissection

Question 5

_{Otolaryngologic Surgery - Surgical procedures}

Throat

^{procedures include:​}

Answer 5

Panendoscopy

T&A

UPPP

Question 6

_{Otolaryngologic Surgery}

Challenges of Anesthetic Management

^include:

Answer 6

Establishing, maintaining, & protecting an airway that may be altered

Shared airway & operative field

Surgical field avoidance

Selecting appropriate anesthetic drugs compatible with the procedure

Use of specialized equipment

Cooperation and communication between the surgeon and anesthesia provider is vital!!!!

Question 7

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Establishing, maintaining, & protecting an airway

that may be altered

^By:

Answer 7

Infection

Tumor

Trauma

Congenital defect

Question 8

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Shared airway & operative field

^Concerns:

Answer 8

Maintenance of adequate ventilation

Patency of the anesthesia circuit

Prevention of leaks

Question 9

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Surgical field avoidance

^why?

Answer 9

Table turned 90-180°

Question 10

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Selecting appropriate anesthetic drugs compatible with the procedure

^{Which should be considered in this selection?}

Answer 10

To paralyze or not to paralyze, that is the question??

Short procedure requiring relaxation

Long procedure not requiring muscle relaxation

Question 11

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Use of specialized equipment

^{may include:}

Answer 11

Jet ventilator (manual/high frequency)

Laser (YAG vs CO2)

Ventilating scope

Specialized ETT’s

Question 12

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Specialized ETT’s

^including:

Answer 12

Oral rae (T&A/Endoscopy)

Nasal rae (Oral/Maxillary)

MLT (microlaryngoscopy tube)

Anode (prevents kinking/tracheostomy)

Laser (metal)

Question 13

_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Determining appropriate time for extubation

^options:

Answer 13

Awake (pharyngeal reflexes intact) vs. Deep

Avoid coughing/bucking (bleeding)

Question 14

_{Otolaryngologic Surgery}

Four components of Panendoscopy

Answer 14

Direct laryngoscopy

Microlaryngoscopy

^{(DL with microscopic inspection of vocal cords)}

Bronchoscopy

Esophagoscopy (EGD)

^{(One patient may receive one or all four of these)}

Question 15

_{Otolaryngologic Surgery}

Indications for Panendoscopy

Answer 15

Diagnostic

^{Hoarseness, stridor, hemoptysis, dysphagia, trauma}

Operative

^{Papillomatosis, tracheal stenosis, obstructing tumors, VC dysfunction, foreign body removal}

Question 16

_{Panendoscopy - Preoperative Anesthetic Considerations}

Patient population

^include:

Answer 16

Elderly

Tobacco abuse

ETOH abuse

Pre-existing comorbidities (CAD, COPD/emphysema)

Question 17

_{Panendoscopy - Preoperative Anesthetic Considerations}

Potential airway complications!!!

^{Proper assessment should include:}

Answer 17

Thorough exam and medical history must precede any decision regarding plan

Prior indirect laryngoscopy results in clinic

Discuss findings/plan with surgeon

Question 18

_{Panendoscopy - Preoperative Anesthetic Considerations}

Potential airway complications

^{Questions to ask}

Answer 18

Will pt be easy to mask ventilate?

Will pt be easy to intubate by DL?

Question 19

_{Panendoscopy - Preoperative Anesthetic Considerations}

Potential airway complications

^{If suspected, what should you do?}

Answer 19

Secure airway prior to induction, with

=> AFOI

=> Awake tracheostomy

Question 20

_{<strong>Panendoscopy</strong> - Preoperative Anesthetic Considerations}

Premedication

Answer 20

Sedatives

^Cautious

^{<u>Avoid</u> if signs of <u>upper airway obstruction</u>}

Antisialalogue (Glycopyrrolate)

^{Minimizes secretions}

^{Facilitates airway visualization}

Question 21

_{Panendoscopy - Intraoperative Anesthetic Considerations}

Provide profound muscle relaxation

^{Benefits and challenges:}

Answer 21

Aid with suspension DL

^{(Doing a DL and having the pt suspended in that position for the surgical procedure - Use of a tool is necessary to maintain the position - Muscle relaxation essenetial)}

Immobile surgical field

Challenging due to short duration of procedure (5-15mins)

Succinylcholine gtt*

^{(Helps with suspension DL)}

Intermittent boluses of intermediate NDMR*

^{(Helps with suspension DL)}

Question 22

_{Panendoscopy - Intraoperative - Provide profound muscle relaxation}

Succinylcholine gtt

^{Helps with suspension DL/Dosing:}

Answer 22

500mg in 500cc NS via micro gtt tubing

Titrate to twitch height

^{(PNS on wirst - Baseline - Place them on repeated single twitch - Titrate Sux gtt to an overall decrease in twitch height)}

^{TOF will not work}

Phase II block if prolonged case

Question 23

_{Panendoscopy - Intraoperative - Provide profound muscle relaxation}

Intermittent boluses of intermediate NDMR

^{Helps with suspension DL/Concerns:​}

Answer 23

Difficult to reverse

Delayed emergence

_{Welcome Suggamadex!!!}

Question 24

_{Panendoscopy - Intraoperative Anesthetic Considerations}

Cardiovascular stability

^Why?

Answer 24

Alternating periods of intense surgical stimulation (HTN/tachycardia) with

Periods of minimal surgical stimulation (Hypotension)

Question 25

_{Panendoscopy - Intraoperative Anesthetic Considerations}

Cardiovascular stability

^{Because of CV instability, what the appropriate management?}

Answer 25

Modest Baseline supplemented with

Shorter acting agents

^{Propofol - Remifentanil - Esmolol}

Question 26

_{Panendoscopy - Intraoperative Anesthetic Considerations}

Provide adequate oxygenation & ventilation

^Options:

Answer 26

Small standard ETT (4.0-6.0) with PPV

^{This size ETT designed for pediatrics}

^{Too short for adult - smaller diameter ETT are also shorter}

^{Low volume cuff → exert high pressure}

^{High PIP (Poiseuille’s)}

4.0-6.0 MLT (microlaryngoscopy tube)

^{Longer than standard adult ETT}

^{High volume, low pressure cuff}

^{Stiffer, less prone to compression/kinking}

^{Better for pt with tracheal stenosis}

Intermittent periods of apnea

^{Ventilate by mask/ETT followed by 2-3 min period of apnea during surgical procedure}

^{Hypoventilation/hypercarbia}

^{Pulmonary aspiration}

^{Anesthetic technique??}

^{TIVA best}

Manual jet ventilation

^{Connect to side port laryngoscope}

^Inspiration

^{Direct 30-50 psi of O2 source through glottis for 1-2 secs}

^{Venturi effect entrains room air into lungs}

^{Expiration is passive}

^{4-6 secs in duration}

^{Monitor chest wall motion to avoid air trapping/barotrauma}

High-frequency jet ventilation

^{Small canula or tube into trachea or side port of laryngoscopy}

^{Gas injected 80-300X’s/min}

Question 27

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation}

Small standard ETT (4.0-6.0) with PPV

Answer 27

This size ETT designed for pediatrics

Too short for adult

Low volume cuff → exert high pressure

High PIP (Poiseuille’s)

Question 28

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation}

4.0-6.0 MLT (microlaryngoscopy tube)

Answer 28

Longer than standard adult ETT

High volume, low pressure cuff

Stiffer, less prone to compression/kinking

Better for pt with tracheal stenosis

Question 29

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation}

Intermittent periods of apnea

Answer 29

Ventilate by mask/ETT followed by 2-3 min period of apnea during surgical procedure

Hypoventilation/hypercarbia

Pulmonary aspiration

Anesthetic technique??

^{TIVA best}

^{(long periods of apnea without anesthetic gases => just use TIVA)}

Question 30

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation}

Manual jet ventilation

^{Another way we can ventilate the pt during these periods of apnea without taking them out of the suspension}

^Technique:

Answer 30

Connect manual jet ventilation to side port laryngoscope

Inspiration

^{Direct 30-50 psi of O2 source through glottis for 1-2 secs}

^{Venturi effect entrains room air into lungs}

Expiration is passive

^{4-6 secs in duration}

^{May need longer expiratory period}

^{Monitor chest wall motion to avoid air trapping/barotrauma}

Question 31

_{Panendoscopy - Intraoperative}

Surgical Laryngoscope

^{Used to maintain suspended DL - what does it look like?}

Answer 31

see picture

Blade is like Miller blade

Jet ventilator attaches to “Venturi jet port”

Question 32

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation}

High-frequency jet ventilation

^{Characterisics:}

Answer 32

Small canula or tube into trachea or side port of laryngoscopy

Gas injected 80-300X’s/min

Controlled by a machine/not the anesthetist

Question 33

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation}

Both Manual & High-frequency jet ventilation require TIVA

^Why?

Answer 33

Inability to deliver INH agents