1
Q
what is otolaryngology
A
ENT (study of ear, nose, throat)
2
Q
- what is optimal management of airway
2. why is that so important with ENT cases
A
- reliable control of upper airway
2. patients may already have compromised airways d/t edema, infection or tumor
3
Q
what do you have to consider with head and neck procedures?
regarding airway, surgical field, nitrous, muscle relaxants, laser, and patient age
A
- airway may be shared with MD
- you may be away from sterile field because table is turned
- use nitrous only when warranted (limited use for ENT)
- restricted use of MRs
- specialized equipment like laser (can start fires)
- high percentage are pediatric patients
4
Q
ear surgery considerations 1. nerve issues to monitor? 2. Why would epi be used? 3. Effects of N2O on ear? 4 5. at risk for \_\_\_ d/t open venous sinus? 6.. Face very vascular so... 7.Face, throat, ear surgery=risk for what post op?
A
- facial nerve presentation
- surgeon using epi (helps to control bleeding)
- effect of N20 on middle ear (expansion of closed space)
- extremes of head positioning
- risk of air emboli
- bleeding control (face, mouth, nose are bleeders!)
- PONV
5
Q
ear surgery: facial nerve presentation:
- what percent incidence of facial nerve paralysis?
- what intraop test checks for this?
- what are 4 nerves that provide sensory innerv. to ear
A
- 0.6-3% incidence of facial nerve paralysis
- auditory evoked potentials test for this
3.– auriculotemporal nerve
great auricular nerve (branch of cervical plexus)
auricular branch of Vagus
tympanic nerve ( branch of glossopharyngeal nv.)
6
Q
what anesthetic technique is best for ear surgeries?
A
- volitile anesthesia-gives deep anesthesia but still allows ability to identify facial nerve
- because you want to maintain skeletal muscle activity with evoked potentials, muscle relaxant SHOULD be avoided (if you can).
7
Q
why not use Nitrous oxide for ear cases?
A
- middle ear, paranasal sinuses are air cavities that are open and non ventilated such that AIR ENTERS EASIER THAN IT LEAVES. this increases inner ear pressures which are slowly vented via eustachian tube into nasopharynx
- infalmmation or edema may compress eustachian tube and not allow n2o (which rapidly expands) to leave quick enough, causing pressure on inner ear and possible damage.
8
Q
what does nitrous do in the surgical middle ear (what can it cause)
A
- on reconstructive surgery can cause serious otitis media or disarticulate the stapes
- on tympanoplasty, N2O can cuase displacement and lifting of tympanic membrane graft.
9
Q
- if using nitrous, what percent and
- when should it be turned off?
- what can happen when nitrous is turned off?
- whats the best nitrous technique with inner ear procedures?
A
- use less than 50%
- turn off 15 minutes before closing
- however, when nitrous is turned off, it is reapidly reabsorbed and can create a negative ear pressure in the ear (bad as well)
- no N2O is best!!!
10
Q
at what pressure does passive venting occur?
A
200-300mmH2O
11
Q
microsurgery of middle ear
- what kind of conditions are needed?
- what type head position? what does this do?
- what type of local
A
- requires optimum operative conditions (bloodless field)
- 10-15 degrees head tilt (decreases venous bleeding d/t decreased venous blood pressure)
- –local: infiltration of local with epinephrine (10cc of 1:100,000)
- -relative hypotension (systolic BP< 90mmHg)
- -volatile anesthetic good
- -NDMR useful particularly if using microscope
12
Q
anesthesia: what doses for micro ear
1. epi:
2. Iso:
3. Des:
4. Sevo:
A
- epi: max doses???
- iso: 6.7 mcg/kg
- des: 4.5 mcg/kg
- sevo: 5 mcg/kg
13
Q
Myringotomy:
- what is it? how frequently done?
- what type anesthetic
- induction?
- do they need an IV?
- what other meds are used frequently
- post op pain relief?
- pediatric implications?
- anesthesia for adults
A
- Tubes in ears: second most frequently preformed pediatric surgeical procedure
- general anesthesia
- ihnalation induction (with nitrous and sevo) and head turn from side to side
- they dont need an IV, but have one ready (out of the package)
- antibiotic or steriod drops to ears
- liquid tylenol or motrin ; sometimes intranasal fentanyl pre op
- general anesthesia or mac for adults
14
Q
1 what would tou use for anesthesia in micro ear case?
A
- lidocaine mouth spray,
- lots of narcotic,
- higher MAC
- (no Muscle relaxant if testing nerves)
- may use MR (small amount) if not testing nerves
15
Q
what if the patient has hypotension with increased MAC, and moves with decreased MAC
A
- treat the blood pressure
2. you can sometimes use a sub-theraputic dose of MR (discuss with doctor) i.e. 15 mg of ROC
16
Q
no nitrous AT ALL if the patient has HISTORY of…
A
Tympanoplasty
17
Q
monitoring ear patients:
1.if face covered use…?
2. What to do with connections (ET tube)?
3 who ahould u consult regarding ET tube type?
4.what shiuld quantitative teitch heught be if using MRs?
5. WhaT 4 meds/ actions reduce PONV?
A
- use precordial if face is covered
- tape your connections to your circuits (tape endo to circuit)
- may use rae tube (GA with ETT) ask physician (problem with rae tube, they may be short once placed)
- if using MR, keep twitch height at 10-20%
- cover all N/V receptors (zofran .05mg/kg, dramamine, decadron) also replace NPO (will help decrease nausea). Iv fluid is a med too.
18
Q
what do you want to do prior to knife hitting skin?
A
have the patient breathed down so deep that you are breathing for them, the knife stimulation will get them back breathing
19
Q
nasal and sinus surgery:
Septoplasty:
1.how is it done?
2.why is airway reactive?
3. How is nose anesthetized?
4. What keeps blood from being aspirated or swallowed? If they ndont have this, what shoudl u do?
5. EBL for nasal septoplasty?
6.?
7. What might you have to prepare for flammability wise?
8 what is it called when the patient is turned from you (like with septoplasty)?
A
- hammer and chisel with alot of blood
- reactive airway d/t blood going down throat
- topical cocaine (anesthesia and vasoconstriction) with pledges, then epi is applied
- posterior pharyngeal pack (ONLY if intubated) if not suction stomach
- large blood loss (150-300 ml)
- reflexive extubation d/t swallowed blood and secretions
- doctor may use laser (be careful)
- field avoidance (patient turned)
20
Q
cocaine
- what is safe dose
- why not use epi with it?
- if someone has heart issues, they may be more prone to ?
- what should you “front load” with these patients?
- what is the caveat with VAs and cocaine?
- what else can be used with cocaine?
A
- 1.5 mg/kg intranasally of 4%
- epi does not prolong (cocaine already is a vasoconstrictor)
- HTN and tachycardia
- “front load” narcotics to decrease endogenous catecholamines which may increase tachycardia and arrhythmias with cocaine
- volitile agent is ok with cocaine, BUT they DO sensitize myocardium to arrhythmias
- sedation or local sedation
22
Q
nose surgery- what are issues with these?
- nasal packing
- pharyngeal packing
A
- patient cannot breathe thru nose post op
2. make sure to remove paryngeal pack prior to extubation
23
Q
- when do you extubate a nasal surgery nose
2. what is the process of extubating a rhinoplasty etc.
A
- when they are reflexic and purposeful (moving arms etc) (wait til they are putting the dressing and packing on before you get them back breathing)
- drop sevo to about 1% or so and let them breathe
- suction the stomach
- when they are moving arms and things, extubate
24
Q
what dont doctors want on patient
A
- no tape on eyes (distorts face)- use lacrilube
2. no oral airway until surgery done (distorts face)
25
Q
ENDOSCOPY:
rigid bronchoscopy, flexible bronchoscopy
A
- usually have co-existing airway pathology (may have tumors and masses or altered anatomy)
- usually sick people
26
goals with endoscopy:
1. suppression of cough and laryngeal reflexes
2. relaxed mandible
3. rapid awakening with return of protective airway reflexes
27
suppression of cough and laryngeal reflexes done how?
suppression of cough and laryngeal reflexes: with nerve blocks (superior laryngeal, glossoplyaryngeal, transtracheal), cetacaine spray, aerosolized lidocaine (4cc of 4% for 5-7 min)
28
relaxed mandible how?
relaxed mandible: bite block, maxillary nerve block (interrupts sensory to nasal cavity, decreases masseter muscle tone, relaxes jaw, minimizes biting).
29
rapid awakening with return of protective airway reflexes how?
rapid avakening with return of protective airway reflexes:
local with sedation or GA
propofol with short acting muscle relasant via bolus or continuous infusion
30
usual pathology for endoscopy:
1. supraglottic
2. glottic abnormalities
3. subglottic
1. supraglottic- tumors, infection, laryngomalacia
2. glottic abnormalities- vocal cord abnormalities (palsy, edema, papillomas)
3. subglottic- tumor, stenosis, tracheomalacia
31
EBL for nasal procedures:
1. can you always see it?
2. why so much or so little blood loss?
3. how much blood loss?
4. what should you always do?
1. can be concealed (swallowed)
2. oropharynx and nasopharynx are very vascular, can have 3.significant blood loss
4. always suction pharynx and stomach
32
anesthetic considerations with laser vocal cord surgery
1. cover patients eyes with moist gauze or protective eyewear, laser can damage cornea
2. staff should wear protective airway
3. some plastic surgeons do laser to whole face-wrap ETT in saline soaked 4x4s.
4. patient must be immobile (safest to use NDMR)
5. dont use more than 30% oxygen (may start fire); heliox is non flammable mixture of o2 and helium
6. use metal laser tubes (pvc tubes burn and produce hydrogen chloride)
7. metal laser tubes have sterile saline in cuff (laser shield II has methylene blue crystals in the cuff)
33
what to do for airway fire? (8 things)
1. turn off O2
2. put out fire
3. remove burnt tube (if difficult airway, use tube changer)
4. re-intubate
5. flush pharynx with cold saline (should be kept on field during procedure)
6. do rigid bronch to remove debris and assess for damage
7. humidified 100% o2, steroids, antibiotics, controlled ventilation
8. possible tracheostomy
34
1. to reduce risk of fire with laser surgery(6 things)
| 2. why silicone coated metal tubes?
1. 30% o2 in N2 or helium
- . protect ETT (metal tube or wrap with metal tape)
- . helps increase mean ignition time from 4 to 60 seconds
- . inflate cuff with saline
- . allows tube to absorb more energy before becoming hot
- . avoid paper drapes
2. metal absorbs more energy before igniting then PVC
35
how is cocaine applied?
with soaked pledgets or can be applied with cotton swab
35
what brand and dose of local anesthetic is used for septoplasty?
0.5-1% lidocaine for 45-60 minutes
36
1. pharyngeal pack- what does it do?
| 2. what should you remember to do?
1. absorbs blood in posterior pharynx
| 2. remember to remove packing PRIOR to extubation and document removal on anesthesia record
37
blood loss:
1. how can you tell how much blood loss?
2. what about the oropharynx and nasopharynx vascularity causes what?
3. what should you always do before emergence? why?
1. hard to know, blood can be concealed (by being swallowed)
2. oropharynx and nasopharynx are very vascular and will have significant blood loss
3. always suction the stomach or patient will vomit (and you wont have an accurate EBL).
37
Keys to induction of ENT case: (6 things)
1. get deep
2. give narcotics, IV and topical Lido
3. Intubation is best choice (LMA not so good, but can be done in some instances)
4. know the surgeon (what they want, how they work, do they want a rae or straight tube etc.)
5. use a long breathing circuit
6. may need muscle relaxant
38
Keys to maintainance with ENT cases:
1. volitile agent
2. narcotic
3. NDMR
4. control vent
39
what to do with extubation of ENT patient:
1. suction pharynx
2. suction stomach
3. remove throat pack
4. extubate when reflexive
5. be careful with edema & dressing which can occlude airway
6. turn table back to anesthetist
7. cannot apply face mask following intubation
39
ENT surgery-anesthetic considerations re:
1. airway & surgeon?
2. what about connections and length of circuit?
3. what does pathology cause?
1. airway is shared with surgeon
2. secure (tape) connections, use long breathing circuit
3. pathology may cause difficult airway
40
septoplasty:
1. what monitors?
2. is local sedation a good choice?
3. what should patient know about nose breathing before surgery?
4. how do you apply the facemask?
1. all monitors even precordial
2. general is good choice(local anesthesia with sedation is BAD choice)
3. patient will not be able to breathe thru nose
4. must be careful with facemask
41
endoscopy: issues
| - airway concerns:
a) co-existing airway pathology
b) shared airway (ET tube and scope)
c) oral secretions
41
endoscopy: pathologies-(3 regions)
supra glottic: tumors, infection, laryngomalacia
glottic: vocal cord abnormalities (palsy, edema, papilomas)
subglottic: tumor, stenosis, tracheomalacia
41
what should you always do with endoscopy in regards to secretions?
give antisialagogue
41
goals with endoscopy: (3)
a. suppression of cough and laryngeal reflexes
b. relaxed mandible
c. repid awakening with return of protective airway reflexes
d. adequate oxygenation
41
endoscopy goals:
suppression of cough and laryngeal reflexes:
how is it done?
a. superior laryngeal block
b. glossopharyngeal block
c. trahstracheal nerve block
d. LTA
e. cetacaine spray
f. aerosalized lidocaine 4cc of 4% for 5-7 min
42
endoscopy: goals
relaxed mandible:
how is it achieved?
a. usually use a bit block
| 2. maxillary nerve block (eliminates masseter muscle tone, relaxes the jaw and minimizes biting)
42
endoscopy goals:
rapid awakening with the return of protective airway reflexes:
how?
a. local with sedation or general
| b. propofol via bolus or continuous infusion with short-acting muscle relaxant
43
endo
adequate oxygen during the procedure:
how?
nasal canula with panendo
44
1. why is a laryngoscopy done?
2. what if airway is a question
3. how should you anesthetize the person with questionable airway?
1. to inspect, assess and investigate the posterior oral pharynx, posterior comisures, glottic opening, vocal cords for polyps, tumors, friable tissue, lesions.
2. direct laryngoscope fiberoptic should be done in awake patient to assess airway
3. regionally: using superior laryngeal nerve block, glossopharyngeal block or topical
45
laryngoscopy:
1. if you need a small ETT, what brand makes 4s& 5s for adults. 2. what is different from a regular 4 or 5?
3. why would you need a smaller ETT?
1. Mallinkrodt makes 4 &5 mm tubes adult tubes
2. 4 & 5 tubes are for children and are typically shorter and non cuffed. the Mallinkrodt is longer (it is an adult tube) and is cuffed.
3. the smaller tubes allow for the surgeon to visualize the glottis, epiglottis etc.
46
bornchoscopy:
1. if you use a ventilation bronchoscope, who makes it?
2. how does it work?
3. what does it require (regarding anesthesia)?
4. what patient population doesnt tolerate the ventilation bronchoscope?
1. Sanders
2. provides a high pressure insufflation of gas
3. requires muscle relaxation to permit adequate ventilation of the lungs
4. not tolerated in small children or adults with bullous lung disease.
47
laryngoscopy:
1. what are the benifits of the mallinkrodt tube?
2. what drugs will you be using (dont forget the basics)
3. how do you scope someone on the vent, what about breathing?
1a) protects against aspiration and helps with oxygenation
b) facilitates ventilation of the lungs
2. a)small doses of short acting muscle relaxants
b) remifentanil infusion
c) always use an antisialagogue
3. apneic techniques (the patient will not be breathing while the scope is in).
48
bronchoscopy:
1. what for?
2. 2 types of bronchoscope?
1. to visualize the lungs, trachea, perform biopsy, obtain bronchial washings
2. flexible and rigid
49
bronchoscopy:
1. what drugs, oxygen settings and patient ventilation are good for bronchoscopy?
2. why that type of ventilation for foreign body?
volatile anesthetic agents with 100% oxygen and SPONTANEOUS ventilations (especially for foreign body removal) is best
2. pressure ventilation would push a foreign body down further, spontaneous ventilations does have as much pull as the vent would push.
50
flexible bronch
1. what size ETT do you need to accomodate the scope for adults; children
2. what adapter will you need? why?
3. if the patient is awake, what technique will you use? how will you pre-treat them (anesthesia wise)?
4. what type of patients get this scope?
1. 8.5 tube or larger to accomodate scope, 7.0 tube for children
2. will need SWIVEL adapter to allow for ventilation during bronch
3. through the nose; good airway block or aerosolized lidocaine
4. usually sick patients
51
rigid bronchoscope
1. indications:
2. anesthesia type?
3. what are risks?
4. contraindications:
5. what is the swivel adapter that allows for ventilation?
1. indicated for massive hemoptysis, foreign body removal, placement of stents, large biopsy specimens
2. patient is motionless GA with muscle relaxers
3. can cause tracheal tear or pneumothorax
4. contraindicated in cervical spine pathology (head must be hyperflexed)
5. racine adapter
52
what is a triple endoscopy?
1. laryngoscopy
2. bronchoscopy
3. esophagoscopy
53
laser surgery for vocal cord polyps
1. indications:
2. shared airway considerations?
3. pros?
1. used for precise controlled coagulation, incision or vaporization of tissues
2. can be done with ETT tube in or without a tube
3. minimal edema, rapid healing
54
anesthetic considerations of laser vocal cord surgery:
1. anesthetic?
2. protection?
3. what type of ET tube?
4. how much oxygen can be used? what is a good to have mixed with oxygen to increase flow?
5. air in cuff or what?.
1. NDMRs, patient must be still
2. cover patients eyes with moist gauze or protective eyewear (laser can damage cornea); staff should wear eyewear as well.
3. cover ETT with saline soaked gauze in some cases. Metal laser tubes (inpregnated with silicone) are best
4. no more than 30% oxygen, Heliox is a helium and o2 mixture
5. sterile saline in cuff, laser shield II has methylene blue crystals in the cuff
55
treatment for airway fire
1. discontinue O2
2. place boogie
3. remove burning tube
4. re-intubate
5. flush pharynx with cold saline (keep on field at all times)
6. rigid bronch to remove particles and asess for damage
7. assess for damage
8. humidified osygen, steroids, antibiotics, controlled ventilation
9. possible tracheostomy
56
reducing fire hazard; what steps can be taken?
| 6 things
1. use no more or no less than 30% oxygen (30% is the lowest you can go).
2. protect ETT- wrap with metalic tape (increases ignition time from 4 seconds to 1 minute).
3. inflate cuff with saine (tube absorbs more energy-doesnt get hot as fast)
4. avoid paper drapes
5. use silicone coated metal tube (requires more energy to burn than pvc or red rubber tubes).
6. have a 60cc syringe filled with water
57
laryngotomy/ neck dissection
| indication:
1. To contain cancer: to remove as much cancer as possible, this will involve much of the local lymphatic system, some muscles, arteries veins and glands. NOT to be performed if cancer has spread beyond head and neck, or cervical vertabra or skull.
58
laryngectomy/ neck dissection
1. reason?
2. what is removed with a radical neck?
1. to remove as much cancer as possible (only if the cancer has not spread beyond the neck).
2. some of the lymphatics, veins, arteries, muscles and glands are removed
59
1. what is included under term: larygectomy/neck dissection?
| 2. what is EBL and surgery time for these procedures?
1. -laryngectomy
- radical neck
- hemimandibulectomy
- radical sinus surgery
- pharyngectomy
- glossectomy
2. large EBL and 3-8 hour surgery
60
1. patient population for radical neck:
2. intubation issues?
3. pre op testing that would be benificial?
1a. heavy smokers and or drinkers
b. bronchitis, emphysema
c. CV disease
d. malnourished with electrolyte imbalances (tumor may interfere with eating)
2. may have masses, often heavy smokers hx, copd, CV disease
3. pulmonary function tests, cxr, EKG, coags, type and cross for at least 2-4 units (bloody surgery)
61
monitors for laryngectomy/neck dissection:
1. Lines?
2. monitoring lines?
3. monitors?
4. temperature?
5. urine output?
6. can you use a esophageal stethoscope? what can you use? for what?
7. what will you need for your IV?( why?)
8. positioning to comfort, what do you need? why?
1. large bore IV or central line for CVP
2. arterial line
3. routine monitors
4. bair hugger, HME, fluid warmers
5. foley cath
6. you may not be able to; use precordial doppler, monitor for venous air embolus
7. iv extension x2 (both arms will be tucked)
8. padding for extremities; long procedure
62
induction for laryngectomy/ neck dissection:
Induction:
1. what methods may be needed for intubation?
2. what type tube?
3. what type induction for CAD? CHF?
4. what should you always have near by?
5. if heavy smoker use what med?
6. before intubation or trach
7. because the bed will be turned from you, you need...?
1. may have to do awake, awake fiberoptic or trach prior to induction
2. reinforced (Anode) tube
3. slow induction for:
a) CAD =more narcotic than gas, less induction agent
b) chf=primarily narcotic, avoid high doses of IV induction meds and inhaled agent
4. always have emergency airway equipment (fiber optic, different blades, smaller tubes, trach equipment)
5. use lidocaine 1.5 mg/kg
6. protect (tape) eyes
7. extension or flex adaptor
63
emergence from laryngectomy/ neck dissection:
1. when to extubate?why?
2. what should be done with the tube?
3. what is sometimes performed for airway at end of case?
1. some patients will remain intubated post op (h/r airway and neck edema)
2. secure tube well, accidental extubation can be deadly d/t edema and bleeding into airway
3. tracheostomy may be performed at end if severe enough
64
1. what is a parotidectomy?
2. what are anesthesia implications?
3. why?
4. radical parotidectomy-what happens to facial nerve?
1. usually removal of parotid gland from cancer
2. no muscle relaxer
3. facial nerve will be tested;
4. facial nerve may be reconstructed with facuak nerve graft, mastoid may be drilled for healthy proximal end of nerve.
65
1. what is a UPP?
2. why is it done?
3. what is anesthesia goal and challenges?
4. what patient conditions and medications can complicate the surgery?
1. uvulopalatopharyngoplasty (removal of uvula, tonsils and redundant tissue of pharynx).
2. recurrent tonsilitis, mouth breathing, snoring, obstructive sleep apnea
3. goal is to provide deep general anesthesia that prevents reflex HTN, tachycardia and arrhythmias;
- large tonsils may obstruct airway make for tough intubation
- airway shared with surgeon
4. -loose teeth (kids 4-7 yrs old)
- nsaid ingestion
- coagulation issues
- sickle cell-(see later cards)
- down sndrome (see card)
- obstructive sleep apnea (see card)
66
UPPP
1. what should be given pre op
2. what post op risk is really high with uppp
3. what conditions should postpone this surgery?
1. antisialogogue and possibly narcotic
2. PONV
3. recent upper respiratory infection
67
uppp and sickle cell anemia
1. what test should be done?
2. what should be done if it is over __%?
3. what are they at risk for post op?
1. Hgb S
2. if greater than 40% may need blood preop (you want S ratio less than 40%)
3. high risk for post op pneumonia, atalectasis and vaso occlusive crisis
68
UPPP & down syndrome:
| what is the issue?
large tongue and unstable allanto-occipital joints
69
UPPP and obstructive sleep apnea
patient may have chronic adenotonsillar hypertrophy
70
tonsilectomy
| 1. 2 types of techniques
1. cold- just cut them out
| hot- cut them out and cauterize them
71
what is a the airway challenge with tonsils
they will obstruct when they go to sleep
72
patient assessment:
1. loose teeth (d/t age 4-7 y/o)
2. watch for recent ASA or nsaid ingestion
3. check coagulation (very bloody procedure)
4. give pre op antisialogogue possible narcotic
5. history of sleep apnea
6. upper respiratory infection (increases irritability) postpone surgery
73
induction of tonsilectomy/UPPP:
1. iv bore
2. ebl (estimated)
3. monitors
4. pre treat throat?
5. positioning
6. what should you do to make sure tube stays in place?
7. what is inserted in the mouth?
1. large bore IV
2. estimated ebl 4 ml/kg
3. all monitors/ precordial too
4. pre treat with LTA
5. supine with towel roll under shoulders
6. flag tube at the lip and hold it there during procedure
7. mough gag (Crowe-Davis) is inserted with ET in midle of the gag; you may tape it down.
74
why should you try to pick the best size tube for a pediatric tonsilectomy?
1. tube is UNCUFFED, too much waste gas blowing into surgeon face
2. too much oxygen coming around tube, can cause fire
3. too much blood will leak into the trachea
75
extubating a tonsilectomy
1. best choice (safest)
2. what is the technique used most?
1. awake, reflexive (safest)
| 2. extubate deep (especially children), but only if meet criteria
76
how do you extubate a UPPP
high fowlers
77
when a patient is intubated asleep nasally, how should they be extubated?
WIDE AWAKE!!! (they will have an NGT and a nasal rae with mouth wired shut).
78
induction:
1. what type of airway (easy or difficult) will this usually be
2. what type of tube is best to use
3. what diseases goes hand in hand with this patient
4. if poor cardiac function, how would you induce?
1.
| 2.
79
1. why will a surgeon ask the nurse to or the tech to do (with the right tube)
2. what type of tube is used for this
1. the recurrent laryngeal nerves are very clost to the lobes of the thyroid near the trachea; damage to these can cause vocal cord paralysis
2. NIM tube (has electrodes that touch vocal cords)
80
maintainance for neck dissection:
1. what is the best anestheti choice?
2. why?
3. what does 10-15 degree head tilt cause?
4. what happens with manipulation of carotid sins/ stellate ganglion/ cervical autonomic system (s/s)
5. open neck veins increase incidence of what?
6. should you use MRs?
7. positioning? should be done how?
8. EBL (high or low)?
1. inhaled anesthetic is best;
2. bronchodilaes, depresses airway reflexes, permits high O2 concentration and causes moderate hypotension
3. 10-15 degree head tilt helps to cause moderate hypotension and decreases blood loss.
4. manipulation of carotid sinus can cause bradycardia, hypotension, cardiac arrest; damage to right stellate ganglion and cervical autonomic nerve system can prolong QT and low v-fib threshold.
5. air embolism
6. muscle relaxant depending upon surgery
7. position carefully
8. increased vascularity in head and neck region=greater blood loss
81
maintainance for tonsilectomy/UPPP:
1. how much fluid?
2. for swelling concerns, what medication is given?
3. what VA is the best?
4. what narcotics are good for adults? children?
5. what else helps with airway issues (cough etc).
6. how can adult tonsillectomy be done?
7. what heart issues can arise during tonsillectomy, and from what?
1. hydration important d/t 3-5 ml/kg blood loss is difficult to estimate.
2. decadron
3. sevoflurane; least irritating to airway.
4. narcotic (dilaudid for adults, fentanyl for children), also N20
5. lidocaine 4% to area-helps to decrease post op laryngospasm & stridor
6. adults can be done under local sedation
7. arrhythmias can be caused by endogenous epi release under too light of anesthesia
83
post op tonsilectomy/ UPPP bleeding
1. how many require going back to surgery
2a) . when does it happen most cases(%), why so long?
2b) .how much later can it happen (days) why?
3. what should be done when bleeding is noted?
4. how should they be re-intubaed if going back to surgery?
5. why?
6. why might the re-intubation/ induction be difficult?
7. what else should be placed?
8. what type of extubation?
1. 1-3% require surgery
2a) . usually occurs 3-6 hours post op (75% of cases), usually concealed (swallowed);
2b) can occur up to 6 days post op. when scabs from laser fall off may start bleeding.
3. type and cross, re-check coags, hydrate
4. rapid sequence induction with selleck manuver
5. full stomach from swallowing blood
6. d/t full stomach, airway obstruction and blood pressure from hypovolemia
7. place NGT post induction (to decompress stomach)
8. awake extubation (full stomach)
85
tracheostomy:
1. indications:
2. best done under what situations?
- edema
- large supraglottic tumors
- laryngeal trauma
- muscle weakness
- prolonged intubation
- foreign body presence
- airway trauma
2. elective and in the OR
86
tracheostomy:
1. if patient is a difficult airway, what is anesthesia?
2. it patient is already intubated?
1. local anesthesia without sedation
| 2. general anesthesia
87
crna role in placing the trach etc.
1. disconnect ett form hollister or tape
2. pull back slightly so that surgeon can insert trach (surgeon will pop ett cuff with knife)
3. when surgeon inserts trach, hand him circuit, turn 100% o2
4. give a breath or 2, if good (& ETCO2 good), suction pharyns and pull ETT.
93
maintainance for oral/maxillofacial;
1. what type anesthesia; why?
2. what else might they need to maintain moderate hypotension (especially if healthy)?
1. genreral, volatie agents help control BP (moderate hypotension) <100 mmHg
2. may require beta blockers d/t healthy autonomic nervous system
94
emergence for UPPP/ tonsil
1. what should be done as far as blood and secretions?
2. what is the best extubation in adults? what MAY be done differently in children?
3. what position is a tonsil extubated vs. UPPP?
4. what will happen that is common, does it affect surgical closure?
5. what may happen d/t blood secretions? what should you carry with you?
6. what narcotics? how about for pediatrics?
1. suction out pharynx and stomach for blood and secretions. make sure pharynx is dry.
2. extubate when patient is awake and reflexive (SAFEST) many will extubate children deep.
3. position tonils in tonsil (SIMS) position: patient on side with head slightly down (this prevents secretions from dripping down onto vocal cords) UPP is extubated in high fowlers.
4. some coughing is common but should not interfere with surgical closure
5. high incidence of laryngospasm due to blood, secreations, increased stimulation. carry succ and atropine to pacu
6. fentanyl for adults, morphine for peds (0.1-0.2 mg/kg)
95
1. what is a big side effect post tonsil/UPPP?
2. how does this factor into patient discharge?
3. what is the incidence?
4. treatment
5. what dont you want to do?
1. persistant post op vomiting
2. poor oral intake and vomiting most common reason for hospital admission post tonsil/UPPP
3. 70% approx.
4. treat with decadron 1 mg/kg (mas 25 mg) works especially well with children
5. do not force fluids (orally)
96
What are oral and maxillofacial procedures indicated for?
surgery of oral cavity, frequently performed under general. involves removal of impacted teeth, multiple dental extractions, pre-prosthetic (denture) surgery, surgical modification of gingival mucosa, insertion of osteointegrated implants.
97
oral-maxillofacial procedures:
preoperative considerations:
Airway issues:
1. may have TMJ or facial trauma which will limit mouth opening
- may have difficult airway due to anatomical deformaties
- may have braces or hardware
2. must do thorough airway assessment including nares, also have a back up plan (possible awake fiberoptic etc.).
98
Oral-maxillary-facial :respiratory assessment:
1. must be what?
2. what symptoms would cause postponement of surgery?
3. patient population?
1. must be THOROUGH!
2. symptoms of acute respiratory infection
3. many patients are pediatrics or teenagers
99
oral/maxillaryfacial surgery:
cardiovascular assessment:
1. again should be..:
2. if patient has dysrhythmias, may be sensitive to what?
3. Prophylactic abx if hx of what? What med (pain and abx) is usually given pre-op?
4. most patients are ASA__?
4.
1. thorough CV history
2. epinephrine in the local anesthetic
3. Hx of valvular disease; most patients are given PCN and mu2 (fentanyl).
4. most are ASA 1 with no cardiac hx.
100
oral/ maxillofacial surgery:
neurological assessment:
-why do neuro assessment?
-some surgical procedures can cause temporary or even permanent nerve damage.
101
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oral-maxillofacial surgery:
pre-opertive medications:
1. to decrease bleeding:
--b. what meds are given?
--c. calculate what?
2. for patient comfort:
3. to decrease infection:
4. to decrease swelling:
```
1. vasoconstrictors are given to shrink mucous membranes and decrease bleeding associated with nasal intubation and decrease surgical blood loss
--b. 4% cocaine or oxymetazoline (afrin) with cotton tipped swabs to each nare 30 min prior to insturmentation
2.a.-sedation: titrate benzos and narcotic prior to insertion of swabs (can be very stimulating)
b--narcotics titrated for pain releif and to blunt release of catecholamines (especially in young healthy persons)
c--antiemetics (inapsine, zofran) to decrease PONV, patients will swallow large amount of blood which can increase nausea.
3. antibiotics-usualy PCN given pre-op
4. steriods: decadron 4-8 mg preopertively and 2 hours into case, decrease swelling and inflammation.
---local anesthetic with epinephrine per surgeon prior to and during surgery
--c. carefully caluculate toxic doses of all local anesthetic and epi prior to start of all cases
102
oral-craniomaxillary surgery: pre-op:
1. equipment:
2. laboratory tests:
1. equipment:
- nasal rae -predict size, and have one size smaller available
- foam pads for tucking arms
- head donut
- foam tape to secure ETT
- blue towels
- ABD pads to secure tube
- blood warmers
- forced air warmer (bear hugger)
- NGT
2. Lab tests:
- dependent on patient history
- cbc with diff
- type and cross (may donate autologous blood)
- UCG (female)
104
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oral and maxillofacial procedures: induction:
1. induction
2. antibiotic
3. intubation technique
4. what else is good for induction
5.
```
1. asleep nasal
2. uaually ampicillin (more specific to mouth/nose flora)
3. propofol induction (avoid ketamine d/t catecholamine release)
4. front load narcotic prior to laryngoscopy, LTA or IV lidocaine
5.
104
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oral-maxillofacial procedures:
induction:
1. what induction medication is best? which is worst?
2. what other meds (2)
3. what type intubation?
```
1. propofol is best d/t antiemetic properties; ketamine is worst d/t causing catecholamine release (increased bp=increased bleeding).
2. front load narcotic prior to laryngoscopy/intubation; use lidocaine IV or LTA to depress airway irritability
3. asleep nasal intubation is first choice
105
oral-maxillofacial: fluids and blood replacement:
1. what is maintainance in cc/kg on this surgery?
2. blood replacement formula?
3. blood loss be treated based on what?
4. when should blood be replaced?
5. how do you know how much blood has been lost (what should you be looking at)?
6. what is usual blood loss for these patients?
1. 6-10cc/kg depending on procedure
2. 3cc crystaloid for every 1 cc blood loss
3. symptomatically
4. replace blood near the end of the procedure
5. watch the suction container and irrigator; doccument both
6. large amount of blood loss
106
oral-maxillo-facial:
emergence:
1. what question should you ask the surgeon? why?
2. what will be done to the patients jaw?
3. what should you do prior to emergence/extubation
4. how should patiens be extubated?
5. when are some patients extubated?
6. what will this patient have x 24 hours?
1. time to closure so that emergence can be planned
2. patients jaws will be wired or rubber banded shut; will have edema around face and lips
3. empty stomach via ngt prior to emergence (alot of blood in stomach)
4. ABSOLUTELY AWAKE EXTUBATION
5. some patients are even extubated in pacu or even the next morning
6. patient will have NGT x 24 hours
b. princip. exam 2 (w13)
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