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Premium member Presentation Transcript Anesthesia for Airway Surgery Part 2: Anesthesia for Airway Surgery Part 2 Advanced Principles of Anesthesia University of New England School of Nurse Anesthesia Adenotonsillectomy: Adenotonsillectomy Both adenoids and tonsils are often removed at the same operation, although separate procedures may be indicated, especially in children less than 4-5 years of age. Most common indications for both T + A are adenotonsillar hyperplasia with OSA, malignant disease, hemorrhagic tonsillitis, abnormal maxillofacial growth, and failure to thrive. Tonsillectomy and Adenoidectomy: Tonsillectomy and Adenoidectomy Indications for tonsillectomy without adenoidectomy include recurrent or chronic tonsillitis, peritonsillar abscess,and streptococcal carriage. Indications for adenoidectomy without tonsillectomy include adenoiditis, recurrent or chronic rhinosinusitis and otitis media. Special Indications in Adults: Special Indications in Adults Pickwickian syndrome and OSA. Pickwickian syndrome is also called obesity hypoventilation syndrome, a combination of severe obesity, OSA and marked daytime somnolence. Uvulopalatopharyngoplasty (UPPP) to address redundant pharyngeal tissue. Preoperative Considerations: Preoperative Considerations Assess upper airway obstruction: Patent nasal airway Dysphagia Sleep apnea Restless sleeping patterns Snoring Encroachment of tonsils on the airway Preoperative Considerations: Preoperative Considerations Assess for presence of congestive heart failure: Jugular vein distension Pretibial edema Hepatojugular reflux Assess for presence of cor pulmonale: Right ventricular hypertrophy Preoperative Considerations: Preoperative Considerations Assess for bleeding diathesis: Coagulation history Use of aspirin, ibuprofen, parenteral ketorolac Measurement of hematocrit and coagulation parameters controversial. Sickle cell workup when appropriate. Preoperative Considerations: Preoperative Considerations Preoperative Considerations Assess for loose teeth: Primary teeth in children are exfoliating (especially age 4-7) risking dental evulsion. Dental trauma can be caused by oropharyngeal airway placement, laryngoscopy, or the mouth gag used to maintain adequate surgical exposure. Preoperative Considerations: Preoperative Considerations Chest X-ray and EKG not normally indicated unless a history consistent with cor pulmonale or recent infectious process would indicate reason to pursue these tests. Premedication: Premedication Goals are anxiolysis, analgesia and drying of secretions. Antisialogogues assist in assessment and manipulation of the airway. Oral midazolam can significantly compromise airway dynamics in OSA. Patients with OSA should be premedicated with great caution. Anesthetic Management: Anesthetic Management GA indicated with standard monitors. Depending on patient’s age or preference, induction by inhalation or IV drugs. Airway depends on provider and surgeon preference. May be done with flexible LMAs, oral RAE tubes, or standard ETT. Anesthetic Management: Anesthetic Management Younger children usually require inhalational induction. In all cases, primary concern is airway patency after induction as pharyngeal muscles and soft tissues become lax, exacerbating preexisting obstruction. In adults, awake intubation with topical anesthesia may be indicated when difficult mask airway or difficult intubation anticipated. Anesthetic Management: Anesthetic Management Balanced technique used, taking care not to overmedicate patients with narcotics in order to allow for rapid recovery of reflexes and extubation. Muscle relaxation is commonly used to allow placement of the mouth gag and to prevent bucking, coughing and gagging. Anesthetic Management: Anesthetic Management OR table usually turned, so plan placement of monitors, IV access and anesthetic circuit accordingly. Monitor closely for kinking of the tube by the tongue blade in the hypopharynx or for dislogdement or movement of the ETT as the mouth gag is placed. Anesthetic Management: Anesthetic Management Head and neck positioning precautions. It is important not to be overly aggressive in hyperextending the patient’s neck under anesthesia, especially with neuromuscular blockade. Case report of postoperative paralysis in a child with an undiagnosed Arnold-Chiari Type I malformation during tonsillectomy. Anesthetic Management: Anesthetic Management Use the lowest inspired oxygen concentration (FiO2) to safely oxygenate the patient to prevent airway fires. Close communication with the surgeon may allow lowering the FiO2 only during periods when electrocautery –an ignition source– is being used. Anesthetic Management: Anesthetic Management Local anesthetic and epinephrine may be used for analgesia and to reduce blood loss. Monitor for systemic effects and toxicity, which can be exacerbated in hypoxia and hypercarbia. Anesthetic Management: Anesthetic Management Intraoperative blood loss can be difficult to assess due to drainage into the stomach. Blood loss has been estimated to reach 5% of blood volume in tonsillectomies (or 4 ml/kg). Anesthetic Management: Anesthetic Management Replacement of blood loss for less than 10% of the calculated volume may be accomplished with the administration of 3 mL of crystalloid solution for each mL of blood loss. Consider transfusion if loss > 10%. New cautery devices have been developed to help minimize blood loss. Emergence: Emergence Stomach should be emptied prior to ending anesthesia, as swallowed blood frequently culminates in nausea and vomiting and places the patient at risk for aspiration, laryngospasm and rebleeding. Surgeon can assist in this, placing an orogastic tube while he or she is observing for hemostasis of the operative area. Emergence: Emergence Postoperative pain can be severe. A small dose of narcotics toward the end of surgery will allow for a more comfortable awakening: Morphine(0.05mg/kg) Fentanyl(0.5 mcg/kg). Prophylaxis for PONV should be given prior to awakening. Emergence: Emergence Should be rapid with the patient awake and able to clear blood and secretions from airway before transfer to the recovery area. Deep extubation is sometimes chosen to prevent violent coughing, straining or bronchospasm during emergence. Lidocaine IV can reduce the risk of laryngospasm, although it may impair emergence. Emergence: Emergence Patients who are extubated deep should be placed in the lateral decubitus position, with the bed slightly head down = “tonsil position”. Attendance of personnel trained in advanced airway management should be present with these patients in the PACU until they awaken. Postoperative Problems: Postoperative Problems Postoperative apnea or obstruction Bleeding or hemorrhage Nausea and vomiting Laryngospasm Aspiration Dehydration Pain Postoperative Management: Postoperative Management Blood loss may be unquantifiable due to swallowing, so monitor for signs of significant hemorrhage: tachycardia, diaphoresis, orthostatic hypotension, hypotension, pallor, hematemesis. Insure hydration in the postoperative period even in the absence of significant rebleeding. Postoperative Management: Postoperative Management For most patients undergoing ambulatory adenotonsillectomy, 4-8 hours of observation are recommended before discharge. Patients with OSA are at risk for respiratory compromise following T+A and should be monitored closely in special care unit for at least 24 hours. Reoperation for Postoperative Hemorrhage: Reoperation for Postoperative Hemorrhage Majority of postoperative hemorrhage is biphasic: Most common bleeding within 8 hours of surgery. Next significant risk period is 7-10 days postop when eschar falls away from surgical site. Usually results from significant emesis, retching or straining. Prevention is key.Anesthetic Considerations for Reoperation: Anesthetic Considerations for Reoperation Replenish intravascular volume. HCT, coagulation profile and blood products may be indicated. Avoid inhalation induction in children. Considered full stomach Anesthetic Considerations: Anesthetic Considerations RSI with cricoid pressure indicated. Surgeon should be present for induction in the event of an inability to intubate due to excessive bleeding or surgical edema. Anesthetic Considerations: Anesthetic Considerations Empty stomach of contents after securing airway and before awakening patient. Awake extubation preferred and may be facilitated by narcotic-based technique which can limit coughing and bucking on tube. Endoscopies of the Airway: Endoscopies of the Airway Endoscopies of the airways include: Laryngoscopy(diagnostic and operative) Microlaryngoscopy Bronchoscopy Endoscopic procedures may be accompanied by laser surgery. Airway Surgery: Airway Surgery Requires diagnostic or therapeutic manipulation of the conducting airways despite ongoing ventilation. Anesthesia provider and surgeon must share the airway. The anesthetic technique is influenced by the choice mode of ventilation.Continue to Part 3………………..: Continue to Part 3……………….. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.