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Basics of Anesthesia > Week 10 - ENT Anesthesia > Flashcards

Week 10 - ENT Anesthesia Flashcards

1
Q

What is the correct positioning of a NIMS tube?

A

Blue section is between the vocal cords with the black lines facing lateral

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2
Q

What is the functions of the Larynx?

A

Involved in respiration and speech

Laryngeal reflexes protect the airway

False Cords: ventricular folds (act as muscular valve)
True Cords: act like one way valve, resist pressure from above, but not below)

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3
Q

What nerves innervate the larynx?

A

Vagus Nerve supplies the larynx:

  • Superior Laryngeal Nerve = SENSORY innervation (down to cords)
  • Recurrent Laryngeal Nerve = MOTOR innervation to all intrinsic laryngeal muscles except cricothyroid and external branch of superior laryngeal nerve (sensory below true cords as well)
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4
Q

What is the function of the Posterior Cricoarytenoid Muscle?

A

ABDUCTS the vocal cords
-widen glottic opening during respiration

*Posterior Pulls the cords apart

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5
Q

What is the function of the Thyroarytenoids and Lateral Cricoarytenoids Muscles?

A

ADDUCTs (relaxes) vocal fold (false cords)

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6
Q

What is the function of the Cricothyroids Muscles?

A

ADDUCT and TESNE (open) true vocal cords

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7
Q

What is the function of the vocalis muscle?

A

Shortens true cords

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8
Q

What are considerations with LASER ENT procedures?

A

– Specific protected tubes w/ dye and saline in balloon
– Warning sign on door
– Protective eyewear for all providers (Eyewear or wet gauze over patients eyes)
– Vacuum/suction for smoke removal
– Special particulate masks
– Low FiO2 < 0.3 - 0.4 - As low as patient will tolerate (Risk of FIRE)
– No N20 - Supports combustion

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9
Q

What are the steps in the case of airway fire?

A
  • STOP delivery of all gases, including O2
  • Extubate pt and ventilate with mask, O2 at 100% FiO2
  • Maintain anesthesia depth with narcotics, Propofol, muscle relaxants
  • Reintubate with smaller tube
  • Bronchoscopy/lavage with saline to assess for tracheobronchial damage
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10
Q

What are the anesthetic considerations for Tonsillectomy/Adenoidectomy?

A
  • Aim for smooth emergence to prevent bucking (lidocaine? sufficient opioid)
  • Laryngospasm is common
  • Suction the stomach (possible blood - PONV)
  • Remove throat pack
  • Transport in tonsillar position (lateral (semi-prone) with head down)
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11
Q

What is the most common complication and cause of mortality in Tonsillectomy/Adenoidectomy?

A

Bleeding Tonsil
-seen either immediately, 6-9 hrs post op or 5-10 days later

Symptoms: frequent swallowing, increased HR and respiratory rate, hypotension and pallor

*Consider fluid resuscitation vs blood before GA… awake intubation vs RSI? suction stomach

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12
Q

What are anesthetic considerations for Laryngoscopy/ Esophagoscopy/ Bronch?

A
  • Careful w/ sedation in compromised airways
  • Steroids useful after extensive manipulation
  • History of smoking and malignancy are common (watch for radiation changes, scarring, abnormal anatomy)

Anesthetic Goals: immobile pt, GA, prompt finish (reflexes return to baseline for extubation)

Ventilation Options: small ETT, adaptation to bronchoscope, jet ventilation

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13
Q

What are the components of Jet ventilation?

A

100% FiO2

35-75 L/min

At 50 psi

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14
Q

What is used for topical vasoconstriction in ENT procedures?

A

Cocaine 4% – max dose is 3 mg/kg (1.5 mg/kg preferred), hydrolyzed by pseudocholinesterase, treat toxicity with beta blockers

Epinephrine Solutions – 5 mcg/mL is optimal solution (1:200,000), 200-250 mcg max

  • incidence of arrhythmias not related to dose of inhaled agent
  • N2O doesn’t enhance epi induced irritability
  • increased risk of arrhythmias w/ cocaine, beta agonists, tricyclics, and MAOs
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15
Q

What are the anesthetic considerations for sinus surgery?

A
  • Sinus cavities are closed spaces (N2O diffuses rapidly into closed spaces – best to avoid)
  • Ensure full return of airway reflexes
  • Suction oropharynx carefully
  • Ensure removal of throat pack
  • Nose may be packed following surgery (Pt has to breathe through mouth)
  • Minimize post op N/V (Scop patch, decadron, zofran, droperidol???)
  • Occult bleeding
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16
Q

What is the most common complication with ear procedures?

A

PONV – be aggressive and communicate with the patient on what to expect

17
Q

What are the anesthetic considerations for ear procedures?

A
  • Field avoidance
  • Facial nerve preservation (No muscle relaxation - Acoustic neuroma surgery)
  • Stapedectomy w/ Dr. Ganz (MAC ??? Complicated- Keep pt still)
  • Nitrous oxide? – Diffuses into closed spaces very rapidly (middle ear), Passive venting by eustachian tube unless blocked, Space open during tympanoplasty, closed after graft inserted
18
Q

What are the anesthetic considerations for orthognathic (jaw) procedures?

A
  • Airway/nasal obstruction can be extreme
  • Limited jaw motion (airway assessment very difficult/impossible)
  • Head Trauma? – neuro evaluation, c-spine precautions/clearance
  • Nasal Intubation – use afrin preoperatively (provides better surgical access)
  • contraindicated in LeFort II and III
19
Q

What are the anesthetic considerations for radical neck dissection/free flap?

A
  • Pt usually has hx of smoking/COPD
  • Lengthy procedures – skin grafting and muscular free flap placement vs rotational flap
  • Not recommended to avoid pressors anymore (Dopamine preferred but do what you need to to keep BP up)
  • Airway manipulation may be impossible (distortion of anatomy – awake tracheostomy by surgeon under MAC may be necessary)
20
Q

What are intraop considerations for neck dissection procedures?

A
  • Field avoidance – rectal temp probe place
  • Nerve preservation??
  • Blood loss usually well controlled
  • Monitor volume status (foley)
21
Q

What are complications of neck dissection procedures?

A

Vagal Reflexes: surgical manipulation of carotid sinus – manipulation of stellate ganglion

  • BP swings, bradycardia, dysrhythmias, sinus arrest, prolonged QT interval
  • treat with IV atropine, surgeon can infiltrate w/ lidocaine

Venous Air Embolus: head elevated, large open veins in neck, have surgeon flood field, support hemodynamically

22
Q

What are post op complications of thyroid and parathyroid surgery?

A

Airway compressing hematoma

Hypocalcemia (usually a 24 hr admit to assess Ca)

Recurrent laryngeal nerve injury

*stridor postop may be due to hypocalcemia or recurrent laryngeal nerve injury so important to figure out what is the cause

23
Q

What are the two types of recurrent laryngeal nerve injury?

A

Unilateral: causes cord on injured side to assume midline position = hoarseness

Bilateral: causes both cords to close to midline (adducted) position = aphonia and airway obstruction occurs (airway emergency!!)

*can occur with intubation, neck surgery, or stretching of neck, thyroid or cervical spine surgery

24
Q

If airway obstruction occurs after thyroid surgery, what could be the cause?

A

Hypocalcemia or Bilateral Recurrent Laryngeal Nerve Injury

25
Q

What nerve mediates a laryngospasm?

A

Superior laryngeal Nerve

-reflex closure of upper airway from spasm of glottic muscles

26
Q

What is the treatment for laryngospasm?

A
  • IV lidocaine (1-2 mg/kg) 30-45 min prior to emergence
  • Sustained positive pressure along with increasing depth of anesthesia (IV propofol, volatile, succinylcholine 10-50mg IV)
  • Pressure to the postcondylar notch (really hard pressure)
27
Q

What is the treatment of Stridor?

A
  • O2 via facemask and head in midline position with HOB up at 45-90 degrees
  • Nebulized racemic epi
  • Heliox (70% helium 30% O2) – decreases in airway resistance and improves ventilation
28
Q

What are the effects of anesthetic agents on IOP?

A

inhaled anesthetics = decrease

IV anesthetics = decrease

Muscle relaxants = non-depolarizers decrease and SUX increases

29
Q

What is the nerve impulse pathway for the oculocardiac reflex?

A

Ophthalmic division of trigeminal nerve (CN V) carries impulse to
the brain via grasserian ganglion –> continues to the sensory nucleus of CN V in brainstem –> fibers in reticular formation synapse w/ nucleus of vagus nerve –> efferent fibers from vagus terminate in the heart

*causes bradycardia, nodal rhythm, V-fib, and even cardiac arrest

30
Q

How do you treat oculocardiac reflex?

A
  • Removal of surgical stimulus until HR increases
  • Confirmation of adequate ventilation/oxygenation/depth of anesthesia
  • IV atropine 0.01-0.02 mg/kg
  • If repeatedly happens have surgeon inject rectus muscles w/ local anesthetic
31
Q

What is the most common cause of postop eye pain after GETA?

A

Corneal Abrasion

  • manifests w/ conjunctivitis, tearing, and foreign body sensation
  • can occur mechanically via scratching from ID tags, mask, drapes, inappropriate taping, pt rubbing eyes

Preventative measures: gently taping, ointments are not often used, protective goggles

Basics of Anesthesia (35 decks)

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