Transcript ANESTHESIA for Dental & MAXILLOFACIAL SURGERY

ANESTHESIA
for
Dental
&
MAXILLOFACIAL SURGERY
SAAD A. SHETA
MBChB, MA, MD
Associate Professor, Anesthesia
Dental College
KSU
Dental Anesthesia
I. Out-Patient anesthesia
II. Day-Case anesthesia
III. In-Patient anesthesia
V. Emergency Surgery
Out-Patient Dental Anesthesia
Dental Chair Anesthesia
Out-Patient Dental Anesthesia
Dental Chair Anesthesia
 Out-Patient dental extraction
 Children (4-10 years): URTI
 Steadily decreased
Out-Patient Dental Anesthesia
Induction
 Inhalational (mask) induction
 Intravenous Induction
Out-Patient Dental Anesthesia
Maintenance
 Inhalational agents/N2O
 Maintain airway
Posture
(Supine Position)
 Less hypotension
 less bradycardia
However
 high risk of aspiration
 high risk of Airway obstruction
Out-Patient Dental Anesthesia
Recovery
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Left lateral position
100% O2
Suction Observation & monitoring
Discharge criteria
Instructions
Analgesia (NSAIDs)
Out-Patient Dental Anesthesia
Complications
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Respiratory Complications
Cardiovascular Complications
Syncope
Allergic Reaction
Respiratory Complications
 Airway Obstruction
 Respiratory Depression
Cardiovascular Complications
 Hypotension
 Bradycardia
 Dysrhythmias
Aetiology
(Tachy-arrhythmias)
(Tooth extraction)
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High preoperative catecholamines
Light anesthesia
Airway obstruction & hypoxia
Halothane & local anesthesia
Local anesthesia with vasopressors
Syncope
Causes
Previous factors (CV, allergic,..)
Emotional factors (more common)
Aetiology
limbic cortex-hypothalamus-reflex vasodilatation
Increase parasympathetic activity-bradycardia
Management
Head down-leg elevated
100% O2
Cessation of anesthesia
Allergic Reaction
Incidence
 Very rare
 More commonly (vaso-vagal, toxic reaction,
epinephrine)
Aetiology
 Ig E-mediated reaction
 Easter-linked: p-amino benzoic acid
 Amide-linked: preservatives (Paraben)
Manifestations
Management
Day-Case Dental Anesthesia
Minor Oral Surgery& Conservative Dentistry
Day-Case Dental Anesthesia
Concerns
Rapid Recovery
Minimal Postoperative Morbidity
Remote Location
Day-Case Dental Anesthesia
Minor oral surgery and conservative dentistry
 Limited surgery
 No significant risk of complications
 Standard criteria of patient selection (ASAI&II)
Day-Case Dental Anesthesia
Anesthetic Technique
Induction
• Inhalational (pediatrics) or Intravenous (propofol)
• Airway
Intubation
Nasal Endotracheal tube
Oral intubation
LMA
Nasal mask& Nasophryngeal airway
NDMR (short acting)
Suxamethonium (Postoperative Mylegia)
Deep Inhalational Anesthesia
Propofol & Alfentanil
• Moist Pharyngeal Pack
Day-Case Dental Anesthesia
Anesthetic Technique
Maintenance
• Inhalational
• Ventilation
Sevoflurane
Isoflurane
Halothane
(slow recovery & cardiac
arrhythmias)
Spontaneous (Short procedure)
Controlled ventilation
• Extubation
Throat pack removed
Very light anesthesia (recommended)
Patient turned to one side
Day-Case Dental Anesthesia
Anesthetic Technique
Recovery& PO
• Minimum 2 hrs
• Pain Control
NSAIDs (IM diclofenac)
Short acting opioids
Local analgesic block (2Quadrants only )
Preoperative Dexamethazone
• Discharge
Assessment (Morbidity)
Written instructions
Contact telephone number
Possible overnight admission
In-Patient Dental Anesthesia
Major Oral & Fasciomaxillary Surgery
In-Patient Dental Anesthesia
Classifications:
 Major Orthognathic Surgery
 Tumor Surgery
 Palate Surgery
In-Patient Dental Anesthesia
Concerns:
 Altered Airway Anatomy
 Shared Operative Field
 Anesthetic Drugs Choice
 Appropriate Time for Tracheal
Extubation
 Airway Management
 Anesthetic Management
Airway Management
Airway Management
Choice of the technique depends on several factors:
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Patient safety
Experience of the anesthetist
Known difficult airway
Requirement: nasal or oral
Post operative jaw wiring
Airway Management
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History
Physical Examination
Further Evaluation
Difficult Airway & Algorism
Airway Strategies
History
 Documented History of Difficulties with general anesthesia
or, more specifically, mask ventilation or endotracheal
intubation
 Congenital Syndromes Associated With Difficult
Endotracheal Intubation
 Pathologic States That Influence Airway Management
Selected Congenital Syndromes Associated With Difficult
Endotracheal Intubation
SYNDROME
Down
DESCRIPTION
Large tongue, small mouth make laryngoscopy difficult;
small subglottic diameter possible
Laryngospasm frequent
Goldenhar
Mandibular hypoplasia and cervical spine abnormality
make laryngoscopy difficult
Klippel-Feil
Neck rigidity because of cervical vertebral fusion
Pierre Robin
Small mouth, large tongue, mandibular anomaly; awake
intubation essential in neonate
Treacher Collins
(mandibulofacial
dysostosis)
Laryngoscopy difficult
Turner
High likelihood of difficult intubation
Selected Pathologic States That Influence Airway Management
PATHOLOGIC STATE
DIFFICULTY
Infectious epiglottitis
Laryngoscopy may worsen obstruction
Abscess (submandibular,
retropharyngeal, Ludwig‘s
angina)
Distortion of airway renders mask ventilation or
intubation extremely difficult
Croup, bronchitis,
pneumonia
(current or recent)
Airway irritability with tendency for cough,
laryngospasm, bronchospasm
Maxillary/mandibular
injury
Airway obstruction, difficult mask ventilation, and
intubation; cricothyroidotomy may be necessary
with combined injuries
Laryngeal fracture
Airway obstruction may worsen during
instrumentation
Cervical spine injury
Neck manipulation may traumatize spinal cord
Selected Pathologic States That Influence Airway Management
PATHOLOGIC STATE
DIFFICULTY
Upper airway tumors
Inspiratory obstruction with spontaneous ventilation
Lower airway tumors
Airway obstruction not relieved by tracheal intubation
Radiation therapy
Fibrosis may distort airway or make manipulations
difficult
Inflammatory
rheumatoid arthritis
Mandibular hypoplasia, temporomandibular joint
arthritis, immobile cervical spine, laryngeal rotation,
cricoarytenoid arthritis all make intubation difficult
and hazardous
Ankylosing spondylitis
Direct laryngoscopy maybe impossible
Soft tissue, neck injury
(edema, bleeding,
emphysema)
Anatomic distortion of airway
Laryngeal edema
(postintubation)
Irritable airway, narrowed laryngeal inlet
Selected Pathologic States That Influence Airway
Management
PATHOLOGIC STATE
Angioedema
DIFFICULTY
Obstructive swelling renders ventilation and intubation
difficult
Endocrine/metabolic Large tongue, bony overgrowths
acromegaly
Diabetes mellitus
Reduced mobility of atlanto-occipital joint
Hypothyroidism
Large tongue, abnormal soft tissue (myxedema) make
ventilation and intubation difficult
Thyromegaly
Extrinsic airway compression or deviation
Obesity
Upper with loss of consciousness airway obstruction
Tissue mass makes successful mask ventilation unlikely
Physical Examination
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Inspection (Obvious Problems)
Mouth Opening (3 – 4cm)
Oral Cavity Examination
Mallampati Score
Thyromental Distance (3 large fingers = 5 cm)
Neck Movement
Further Evaluation
PRE-OPERATIVE ASSESSMENT OF THE
AIRWAY
» Indirect or Fiberoptic Laryngoscopy
» X ray: Chest , Cervical Spine
» CT or MRI
» Flow- Volume Loops
» Pulmonary Function Tests
Cormack-Lehane Laryngeal View Scoring
Difficult Airway
 Difficult airway
The clinical situation in which a conventionally trained
anesthesiologist experiences difficulty with mask
ventilation, difficulty with tracheal intubation, or both
 Difficult mask ventilation
1) inability of unassisted anesthesiologist to maintain
SpO2 > 90% using 100% oxygen and positive
pressure mask ventilation in a patient whose SpO2
was 90% before anesthetic intervention;
Or
2) inability of the unassisted anesthesiologist to prevent
or reverse signs of inadequate ventilation during
positive pressure mask ventilation
Difficult Airway
 Difficult Laryngoscopy
Not being able to see any part of the vocal cords
with conventional laryngoscopy
 Difficult Intubation
Proper insertion with conventional laryngoscopy
requires either :
a) > 3 attempts
b) > 10min
Airway Management
Normal Airway Difficult Airway
Awake or Sedated
Under GA
Difficult Airway
Awake
Under GA/Sedation
Awake Laryngoscopy
Different Laryngoscopes,
Stylets
Awake Fiberoptic
LMA/ I LMA/FO
Tracheostomy
Fiberoptic
Retrograde Intubation
Tracheostomy
Blind Nasal Intubation
AWAKE TECHNIQUES
Difficult Airway
Awake
Awake Laryngoscopy
Awake Fiberoptic
Tracheostomy
Retrograde Intubation
AWAKE TECHNIQUES
Glosso-Pharyngeal Nerve IX Nerve
Posterior pharyngeal fold at its midpoint, 1 cm deep to the
mucosa of the lateral pharyngeal wall
AWAKE TECHNIQUES
Superior Laryngeal Nerve
Pyriform Fossa
External :1 cm medial to the superior cornu of the Hyoid
Bone to pierce the thyrohyoid membrane
AWAKE TECHNIQUES
Trachea & Vocal Cord
 Atomizer
 Injection
AWAKE TECHNIQUES
Laryngoscope Blades
AWAKE TECHNIQUES
McCoy
AWAKE TECHNIQUES
AWAKE TECHNIQUES
FIBER OPTIC INTUBATION
AWAKE TECHNIQUES
SURGICAL AIRWAY
Under General Anesthesia
Chidren / Uncoaperative Adults / Sepsis
Assess / Anticholinergic / Anxiolytic ( if any)
1) Inhalational / asses: Ventilation / Veiw
2) Stillete / Different Laryngeoscopes
(=/- short acting MR)
3) LMA / LMA + F.O.
Face Mask + F.O. + Modified Oral AW
4) F.O using Sedation Or light GA
5) Tracheosyomy under light GA
6) Blind Nasal Technique
GA TECHNIQUES
Laryngoscope Blades
GA TECHNIQUES
McCoy
GA TECHNIQUES
Laryngeal Mask Airway (LMA)
GA TECHNIQUES
LIGHTED STYLETS/LIGHTWAND
Well Circumscribed Glow
GA TECHNIQUES
Unconventional LMA
F.O. + LMA
Fast Track LMA
GA TECHNIQUES
Blind Nasal Intubation
 90% successful but may need several attempts
 Contraindicated in fractured base of skull
 Cervical collar in situ
GA TECHNIQUES
FIBER OPTIC INTUBATION
GA TECHNIQUES
Rigid Fiberoptic
laryngoscope
Retromolar
Fiberscope
GA TECHNIQUES
BULLARD LARYNGOSCOPE
GA TECHNIQUES
SURGICAL AIRWAY
Classification According to Mouth Opening
Awake or Sedated
Normal mouth opening
SLN block +Transtracheal LA
Limited
Retrograde Intubation
Extremely limited
Awake Intubation with F.O.
Awake Intubation
Under Anesthesia
Spontaneously
Risk of apnea with
breathing awake
difficulty mask
patient without the risk ventilation
of apnea
Suitable for patients
Suitable for patients
with no obstructive
with obstructive
symptoms
symptoms
Needs patient’s
cooperation
Success rate in good
experienced hands
Risk of complications
from nerve block
Incase of failure , can
be postponed for
reconsideration
Failure to intubate may
result in fatal outcome
Multiple attempts may
lead to bleeding and/or
aspiration
Blind Technique
Blind technique such
as BNI, Light wand,
Retrograde wire
intubation, LMA, and
Combi tube are C/I in
tumor patients
because of the risk of
bleeding and tumor
dislodgement.
Techniques
Under Vision
Awake
Laryngoscopic
Fiberoptic
Intubation
Under GA
Tracheostomy
Blind
Techniques
Retrograde Wire
Intubation
Lighted Stylet/
Light wand
Combi-Tube
Blind Nasal
Intubation
Modified
Techniques
Wu Scope
Bullard
Laryngoscope
 NEVER PARALYSE UNTILL POSSIBLE VENTILATION
HAS BEEN ESTABLISHED
 RECENT SUCCESSFUL INTUBATION DOESNOT MEAN
FUTURE POSSIBLE INTUBATION
 FULL RANGE OF DIFICULT INTUBATION EQUIPMENT
MUST BE AVAILABLE
 ALL PHYSICIANS RESPONSIBLE FOR AIRWAY
MANAGEMENT SHOULD BE PRACTICED IN AT LEAST
ONE ALTERNATE TO BAG & MASK VENTILATION.
THESE ALTERNATIVE INCLUDES THE FOLLOWING:
 LARYNGEAL MASK AIRWAY
 COMBI TUBE
 TRANSTRACHEAL TECHNIQUES
 LMA PROVIDE RESCUE VENTILATION IN 94% OF
CASES OF UNANTICIPATED DIFFICULT INTUBATION
 HAVING DISCUSSED ALL THE MANAGEMENT
STRATEGIES AWAKE TECHNIQUE IN GENERAL &
AWAKE FIBER OPTIC TECHNIQUE ESPECIALLY, IS
THE MOST COMMONLY USED & SAFE TECHNIQUE
ANESTHESIA MANAGEMENT
Special Consideration
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Preoperative Management
 Intraoperative Management
 Post operative Management
PRE-OPERATIVE PROBLEMS
 Elderly, Chronically Debilitated Patients
 Malnourished
 H/O Heavy Smoking with Resultant COPD
 H/O Alcoholism
 Co-existing disease such as HTN,D.M, IHD,
etc.
PRE-OPERATIVE
MANAGEMENT
Adequate pre-operative work-up of Cardiac Status &
Pulmonary Functions should be carried out using
various diagnostic modalities with the objective of
optimizing patient’s condition
RECONSTRUCTIVE MAXILLOFACIAL
SURGERY
Problems:
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Major problem: Airway Management
Extensive, long operation
Significant blood loss
Poor nutritional status
Micro-vascular surgery
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Caution with Vasoconstrictors
Caution with Transfusion
Caution with Diurresis
Blood Rheology (Hct:25-27)
INTRA-OPERATIVE
 Routine
 Monitoring
 NIBP
 ECG
 SPO2
 ETCO2
 TEMPERATURE
 Choice of Volatile Agent
 Choice of Anesthesia
INTRA-OPERATIVE MANAGEMENT
SPECIAL CONSIDERATIONS
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Two large bore canulae
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Invasive blood pressure monitoring
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Central venous pressure monitoring
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Use of muscle relaxants
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Induced hypotension
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Blood loss & transfusion
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Haemodynamic changes
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Venous air embolism
INTRA-OPERATIVE MANAGEMENT
Two Large Bore Canulae
 After induction of anesthesia, two large bore
canulae can be put in large veins so that rapid fluid
replacement can be carried out in case need arises.
INTRA-OPERATIVE MANAGEMENT
Invasive Blood Pressure Monitoring
 is indicated due to following reasons :
 Blood loss may be rapid secondary to
 Neck dissection
 Pre operative radiotherapy
 Surgery close to big vessels of neck
 Frequent fluctuations in the blood pressure due to
manipulation in the area of carotid body and sinus.
INTRA-OPERATIVE MANAGEMENT
Central Venous Pressure Monitoring
 Risk of venous air embolism during neck
dissection
 As a guide to the management of fluid therapy
 The site of insertion is either:
 Antecubital vein
 Femoral vein
INTRAOPERATIVE MANAGEMENT
Use of Muscle Relaxants
During surgery IPPV is carried out without muscle
relaxant as surgeons need to identify the nerves
during surgery
INTRAOPERATIVE MANAGEMENT
Induced Hypotension
Mild degree of hypotension is required during
surgery to reduce the blood loss. This can be
achieved by following:
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15-30 degree head up tilt
Increasing the conc. of volatile anesthetics
Use of peripheral vasodilators
Use of beta blockers
INTRAOPERATIVE MANAGEMENT
Blood Transfusion
Before the decision of blood transfusion the following
points should be considered
 Patient’s underlying medical condition
 Possibility of risks of transfusion hazards
 Increased risk of post-transfusion cancer recurrence as a
result of immune suppression
INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes
During radical neck dissection, the traction or
pressure on the carotid sinus and / or stellate
ganglion can cause following:» Brady-dysrhythmias
» Sinus arrest leading to asystole
» Wide swings in blood pressure
» Prolonged QT Interval
INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes “Treatment”
 Immediate cessation of the stimulus
 Blockage of the sinus with local anesthetic by the
surgeon
 Vagolysis by atropine
INTRAOPERATIVE MANAGEMENT
Venous Air Embolism
 When the venous pressure in neck veins is low and
these veins are open to atmosphere, air is sucked in
causing air embolism.
 Diagnosis
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Early Detection
Hypoxia
Hypotension
Hypocarbia
INTRAOPERATIVE MANAGEMENT
Venous Air Embolism
Treatment
 Compression of neck veins
 Positive pressure ventilation
 Place the patient in the left lateral position
 Aspiration of air through the central venous
catheter
 Ionotropes
POST-OPERATIVE CARE
I.
ROUTINE CARE
II. SPECIAL CONSIDRATIONS
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ICU care & Possible mechanical Ventilation
Hemodynamic Instability
Analgesia
Tracheostomy
POST-OPERATIVE CARE
ICU Care & Possible Mechanical Ventilation
 Patient should be kept in the intensive care unit for
24-48 hours
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Prolonged Surgery
Airway Oedema
Co-existing diseases
Risk of bleeding and/or neck hematoma
POST-OPERATIVE CARE
Haemodynamic Instability
As bilateral neck dissection may result in post-operative
hypertension and hypoxic drive because of the denervation
of the carotid sinus and carotid body
POST-OPERATIVE CARE
Analgesia
 Non Steroidal Anti-inflammatory Agents should be
used as opioids cause respiratory depression in
spontaneously breathing patients
 When patient is on ventilator opioid analgesia can
be given
POST-OPERATIVE CARE
Tracheostomy Care
 Humidified Oxygen
 Intermittent Suction
 Sterile Precautions
 Adjustment of cuff pressure to15-20
mmHg
 Complications
THANK
YOU