Mod9: Otolaryngologic Surgery - Panendoscopy Flashcards by Olivier Mba

_{Otolaryngologic Surgery}

Surgical procedures

^{of which organs:}

Ears

Nose

Neck

Throat

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_{Otolaryngologic Surgery - Surgical procedures}

Ears

^{procedures include:}

Myringotomy & tubes

Tympanoplasty

Mastoidectom

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_{Otolaryngologic Surgery - Surgical procedures}

Nose

^{procedures include:}

Septoplasty

Rhinoplasty

FESS

Maxillary sinusotomy

Polypectomy

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_{Otolaryngologic Surgery - Surgical procedures}

Neck

^{procedures include:}

Laryngectomy

Glossectomy

Pharyngectomy

Radical neck dissection

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_{Otolaryngologic Surgery - Surgical procedures}

Throat

^{procedures include:}

Panendoscopy

T&A

UPPP

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_{Otolaryngologic Surgery}

Challenges of Anesthetic Management

^include:

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!!!!

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Establishing, maintaining, & protecting an airway

that may be altered

^By:

Infection

Tumor

Trauma

Congenital defect

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Shared airway & operative field

^Concerns:

Maintenance of adequate ventilation

Patency of the anesthesia circuit

Prevention of leaks

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Surgical field avoidance

^why?

Table turned 90-180°

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Selecting appropriate anesthetic drugs compatible with the procedure

^{Which should be considered in this selection?}

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

Short procedure requiring relaxation

Long procedure not requiring muscle relaxation

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Use of specialized equipment

^{may include:}

Jet ventilator (manual/high frequency)

Laser (YAG vs CO2)

Ventilating scope

Specialized ETT’s

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Specialized ETT’s

^including:

Oral rae (T&A/Endoscopy)

Nasal rae (Oral/Maxillary)

MLT (microlaryngoscopy tube)

Anode (prevents kinking/tracheostomy)

Laser (metal)

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_{Otolaryngologic Surgery - Challenges of Anesthetic Management}

Determining appropriate time for extubation

^options:

Awake (pharyngeal reflexes intact) vs. Deep

Avoid coughing/bucking (bleeding)

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_{Otolaryngologic Surgery}

Four components of Panendoscopy

Direct laryngoscopy

Microlaryngoscopy

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

Bronchoscopy

Esophagoscopy (EGD)

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

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_{Otolaryngologic Surgery}

Indications for Panendoscopy

Diagnostic

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

Operative

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

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_{Panendoscopy - Preoperative Anesthetic Considerations}

Patient population

^include:

Elderly

Tobacco abuse

ETOH abuse

Pre-existing comorbidities (CAD, COPD/emphysema)

_{Panendoscopy - Preoperative Anesthetic Considerations}

Potential airway complications!!!

^{Proper assessment should include:}

Thorough exam and medical history must precede any decision regarding plan

Prior indirect laryngoscopy results in clinic

Discuss findings/plan with surgeon

_{Panendoscopy - Preoperative Anesthetic Considerations}

Potential airway complications

^{Questions to ask}

Will pt be easy to mask ventilate?

Will pt be easy to intubate by DL?

_{Panendoscopy - Preoperative Anesthetic Considerations}

Potential airway complications

^{If suspected, what should you do?}

Secure airway prior to induction, with

=> AFOI

=> Awake tracheostomy

_{Panendoscopy - Preoperative Anesthetic Considerations}

Premedication

Sedatives

^Cautious

^{Avoid if signs of upper airway obstruction}

Antisialalogue (Glycopyrrolate)

^{Minimizes secretions}

^{Facilitates airway visualization}

_{Panendoscopy - Intraoperative Anesthetic Considerations}

Provide profound muscle relaxation

^{Benefits and challenges:}

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)}

_{Panendoscopy - Intraoperative - Provide profound muscle relaxation}

Succinylcholine gtt

^{Helps with suspension DL/Dosing:}

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

_{Panendoscopy - Intraoperative - Provide profound muscle relaxation}

Intermittent boluses of intermediate NDMR

^{Helps with suspension DL/Concerns:}

Difficult to reverse

Delayed emergence

_{Welcome Suggamadex!!!}

_{Panendoscopy - Intraoperative Anesthetic Considerations}

Cardiovascular stability

^Why?

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

Periods of minimal surgical stimulation (Hypotension)

_{Panendoscopy - Intraoperative Anesthetic Considerations} **Cardiovascular stability** ^{Because of CV instability, what the appropriate management?}

Modest B**aseline** supplemented with **Shorter acting agents** ^{Propofol - Remifentanil - Esmolol}

_{Panendoscopy - Intraoperative Anesthetic Considerations} **Provide adequate oxygenation & ventilation** ^Options:

**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}

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation} ## Footnote **Small standard ETT (4.0-6.0) with PPV**

This size ETT designed for pediatrics Too short for adult Low volume cuff → exert high pressure High PIP (Poiseuille's)

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation} ## Footnote **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

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation} ## Footnote **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}** **^{(long periods of apnea without anesthetic gases => just use TIVA)}**

_{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:

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}

_{Panendoscopy - Intraoperative} **Surgical Laryngoscope** ^{Used to maintain suspended DL - what does it look like?}

see picture Blade is like Miller blade Jet ventilator attaches to "Venturi jet port"

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation} **High-frequency jet ventilation** ^{Characterisics:}

Small canula or tube into trachea or side port of laryngoscopy Gas injected **80-300X’s/min** Controlled by a machine/not the anesthetist

_{Panendoscopy - Intraoperative - Provide adequate oxygenation & ventilation} **Both Manual & High-frequency jet ventilation** **require TIVA** ^Why?

Inability to deliver INH agents