Transcript anesthesia for orthopedic,ent and maxillofacial surgery

ANESTHESIA FOR
ORTHOPEDIC,ENT AND
MAXILLOFACIAL SURGERY
Presented by-DR.POOJA
Moderator-DR.GIRISH SHARMA
ANESTHESIA FOR ORTHO SURGERY
Patients range from elderly patient with multiple
co morbid conditions to a young apparentely
healthy patient
 All patient need a thorough pre-op evaluation
 Challenges include
- difficult airway
- large blood losses
- positioning
-significant post-op pain

ELDERLY PATIENT
Are more prone to cardiac, pulmonary complications and
dementia/delirium
cardiac complications because of
-Co morbid condition
-Limited functional capacity
-Significant blood loss and fluid shift
-Systemic inflammatory response
-Post op pain
All these trigger a stress response leading to
tachycardia, hypertension, increased O2 demand and
myocardial ischemia.
pulmonary complications due to
- Age related changes in lung mechanics
- Decrease in arterial O2 tension
- Decrease of 10% in FEV1 with each decade of life
-Increase in closing volume
Confusion or delirium-risk
factors include- advancing age
- alcohol use
- pre op cognitive impairment
- periop hypoxemia
- hypotension
- hyper volemia
- electrolyte imbalance
- infections
- sleep deprivation
- pain
- medications
Strategies to reduce incidence include
-identifying risk factors
-adequate pain control
-mobilization
-maintaining normal sleep
-avoiding psychotropic medications
SPECIAL CONSIDERATION
Fat Embolism Syndrome
 Pneumatic Tourniquets
 Deep Vein Thrombosis and PE
 Bone Cement Implantation Syndrome

FAT EMBOLISM SYNDROME
Fat embolization is a well known complication of
skeletal trauma and surgery involving femoral
medullary canal
 FES is a physiologic response to fat within systemic
circulation
 Embolization occurs in almost all patients with pelvic
or femoral fracture but FES in <1%

.
GURD,S DIAGNOSIS- major feature(at least one)
respiratory insufficiency,
cerebral involvement,
petechial rash
Minor features(at least four)
pyrexia,
tachycardia,
retinal changes,
jaundice,
renal changes
LAB featuresFat microglobulinemia (required)
anemia, thrombocytopenia, high ESR
SCHONFELD FES INDEX
Petechial rash
 Diffuse alveolar infiltrate
 Hypoxemia PaO2<70mmHgFiO2100%
 Confusion
 Fever>38C
 HR>120
 RR>30
Score >5 is diagnostic

5
4
3
1
1
1
1
It can be gradual over 12-72hrs or fulminant
leading to ARDS and even cardiac arrest
 Treatment includes –
-early stabilization of fracture
-O2 therapy
-early mechanical ventilation before
respiratory failure
-Steroid therapy may be benefecial

PNEUMATIC TOURNIQUETS
Used to create blood less field
 Inflation pressure is 100mm above systolic BP
 Prolonged inflation (>2hrs) leads to
-transient muscle dysfunction
- rhabdomyolysis,
-nerve injuries
 Exsanguination of extremity causes shift of blood
volume into central compartment , rise in CVP and
arterial BP that may not be well tolerated in pat.
with LV dysfunction.

.
Tourniquet pain –even during GA manifesting as
increasing MAP beginning about ¾-1hr of cuff
inflation
 Cuff deflation causes fall in CVP and arterial BP
Washout of metabolic wastes in ischemic extremity
increases PaCO2, ETCO2,lactate and potassium
levels
Can cause increase in minute ventilation and
rarely dysrythmias
DVT and PE may develop

DEEP VEIN THROMBOSIS AND THROMBO
EMBOLISM
Risk factors include
-obesity
-age >60
-lower extremity fracture
-tourniquet use
-immobilization >4days
 Prophylactic anticoagulation ,pneumatic leg
compressions ,early mobilization reduce the
incidence

BONE CEMENT IMPLANTATION SYNDROME
Manifesting as hypotension, hypoxia, FES or
even cardiac arrest
 Mech. Includes
-embolization of bone marrow debris during
pressurization of femoral canal
-toxic effect of methyl methacrylate
-release of cytokines
 Risk factors are
-revision surgery
-pathological fracture
-preexisting pulmonary hypertension
-quantity of cement used
Strategy to minimize - increasing FiO2 prior to cementing
- maintaining euvolemia
- high pressure lavage of femoral shaft
- creating vent in distal femur
- cement less prosthesis
SPECIAL CONDITIONS
RHEUMATOID ARTHRITIS –
-airway(limited TMJ movement, narrow glottic
opening)
-Cervical spine (atlanto axial instability)-pre op
flexion extension x-ray in limited neck movement
if instability exceeds 5mm awake fibroptic
intubation with neck stabilization
-Cardiac(pericarditis , tamponade)
-Pulmonary(interstitial fibrosis)
-Renal insufficiency




ANKYLOSING SPODYLITIS-chronic inflammatory
arthritic disease resulting in axial skeleton fusion
airway management difficult due to reduced movement of
cervical spine and TM joint
Neuraxial anesthesia difficult because ossification of
spinal ligament closes inter vertebral spaces which may
block acces to epidural and spinal space In some cases
caudal may be feasible
ACHONDROPLASIA-dwarfism ,kyphoscoliosis and
fo ramen magnum stenosis Chronic hypoxemia
hypercarbia due to airway obstruction leads to
pulmonary hypertension
-awake fibroptic intubation is safe
- Echo should be obtained to asses pulmonary
hypertension and intracardiac shunts
-aggravating pulmonary hypertension is to be avoided

OSTEOGENESIS IMPERFECTA
-fragility of tissues and bones require extreme
care in positioning and padding during
anesthesia
-Intubation with minimal neck manipulation
-Sch avoided because fasiculations can cause
fractures
-Bleeding status should be evaluated because of
platelet abnormality
-Aggressive hydration because of risk of
hyperthermia and MH
REGIONAL VERSUS GA
Reduced incidence of DVT and PE
 Less blood loss
 Less respiratory complications
 Superior post op analgesia
 Conscious pat aid in comfortable positioning
 Manipulation of airway avoided
Full anticoagulation is a contraindication
Interval of 12hrs bw LMW and neuraxial block
Epidural catheter removal 8-12hrs of LMW
Admn and 1-2hrs before next admn

SPINAL SURGERIES
Problems include related to positioning-airway
management difficult
Eyes pressure CRAO, CRVO, corneal abrasion
Neck rotation –compromized blood flow to brain
Large blood losses-controlled hypotensive
anesthesia is used. adequacy of end organ
perfusion to be maintained with invasive BP,UO
and ABG analysis

ANESTHESIA FOR ENT SURGERIES
Clear, free, unobstructed airway is the principal
concern of these procedures
 Pt. may present with airway obstruction or
distorted anatomy
 During surgery anesthetist is away from airway
making adjustment difficult
 Significant head extension and lateral rotation
may be required
 During intraoral procedures ,instruments to open
mouth obstruct airway
 Airway requires protection from blood and
secretions in intraoral and nasal procedures

EAR SURGERY
Op. range from short procedures to more long and
complex procedures Anesthetic factors are-Choice of airway
-Use of nitrous oxide
-Head and body position
-Facial nerve monitoring
-Adequate surgical field
-Nausea and vomiting
-DVT prophylaxis
-Temp. control
For long procedures tracheal tubes are used to
secure the airway. Reinforced tubes may be used
to prevent kinking with head rotation
 Nitrous diffuses to airspaces in body it can
diffuse into middle ear cavity increasing
pressure and upon discontinuation rapid
absorption leading to negative pressure resulting
in graft displacement so avoided during graft
procedures

Head up tilt of 15 degree is useful to reduce
venous pressure and improve operating field
 Lat. tilt of OT table helps prevent extreme
rotation of neck
 For facial nerve monitoring it may be required to
reverse the NM block
 High incidence of PONV so adequate hydration
and prophylactic anti emetics

NASAL SURGERY
Potential to contaminate lower airway with blood and
secretions
Airway is secured with tracheal tube and throat pack is
inserted
Extubation is done awake or deep
Awake involves removal of tube when pt. responds to
commands and make attempts to remove the tube
advantages is airway control in awake pt. with
return of laryngeal reflexes
Disadvantages include high incidence of coughing,
bucking,de saturation , laryngo spasm
deep extubation leaves unprotected airway pt. is
dependent on oro pharyngeal airflow due to nasal
packing
recovery with a LMA
At end of surgery pack should be carefully
removed
 Laryngo scopy followed by neck flexion to
encourage any clot to fall past soft palate and
direct visualization of suction catheter going
behind soft palate
 Any clot left behind can be aspirated after tube
removal causing total airway obstruction and
death called coroners clot

Endoscopic procedures
for vocal cord pathology including polyp, nodules,
tumours ,tracheal stenosis
 Preoperative airway assesment
 information about sub glottic ,tracheal lesions by
CXR,CT,MRI

sedative premedication avoided in airway
obstruction
 profound muscle paralysis to provide masseter
muscle relaxation for introduction of scope and
immobile surgical field

OXYGENATION AND VENTILATION Most commonly pt. is intubated with small diameter
tracheal tube
 If intubation interfering with procedure ,there are
various non intubation techniques
Spontaneous ventilation and insufflation tech.useful in FB aspiration,glottic and sub glottic lesions
removal
 O2 admn by facemask with inhalation induction and
spontaneous ventilation
 Small catheter introduced into nasopharynx
 Tracheal tube cut short ,placed in nasopharynx just
beyond soft palate
 Nasopharyngeal airway
 Side-arm of laryngoscope or bronchoscope
JET VENTILATION TECH.
 attachment of jetting needle to laryngoscope for
supra glotic insufflation
 Trans tracheal jet ventilation through
percutaneous catheters
 sub glottic ventilation through catheter or tube
placed in glottis
LOCAL ANESTHESIA OF AIRWAY
If awake intubation is needed , local anesthesia
of airway can be used
 Block of superior laryngeal nerve b/l with trans
laryngeal injection of LA provides anesthesia
from infra glottic area to epiglottis
 SUPERIOR LARYNGEAL NERVE BLOCKhyoid bone displaced laterally to the side to be
blocked 25G 2.5cm needle walked of greater
cornu of hyoid bone inferiorly and advanced 23mm As it passes through thyro hyoid
membrane LOR is felt 3ml LA injected

TRANSLARYNGEAL BLOCK-cricothyroid
membrane is located 20G or smaller catheter
over needle is introduced into midline .Inner
cannula is withdrawn ,catheter held firmly in
place,air is aspirated 3-5ml of 4%lignocaine is
injected
 Vigorous cough results which aid in spread of
LA
GLOSSOPHARYNGEA NERVE BLOCK-22G
spinal needle is used to inject LA into post.
Tonsillar pillar

INTRAORAL SURGERIES Tonsillectomy is frequentely performed
procedure
pre op evaluation to identify OSA, active
infection, bleeding tendency ,anemia
 Surgery be postponed for RTI
 Sedation to be avoided in OSA
 Adequate depth of anesthesia to be maintained
EXTUBATION After careful inspection and laryngoscopy to
ensure no blood clots are present
 child placed in left lat. or semiprone head down
position
 pillow is placed under chest to drain secretions
 chances of laryngospasm are greater –topical
airway ,increasing depth of anesthesia,
subhypnotic doses of propofol or lidocaine can be
used
Chances of rebleeding are greater in first six
hours
 Problem because of hypovolemia,aspiration risk
and difficult laryngoscopy
 Senior’s help should be requested
 O2 started, adequate resuscitation, hematocrit
and coagulation checked ,blood cross matched
 Large bore iv asses established

RSI is preffered tech.
 Difficult laryngoscopy intubation anticipated
 Small tracheal tube should be available
 Tracheostomy set with surgeon should be there
 Gastric tube should be inserted to decompress
stomach
 Extubation should be done fully awake

ANESTHESIA FOR MAXILLOFACIAL
SURGEY
Priority is to clear and secure the airway
 Severe bleeding can occur and there is risk of
aspiration of blood, bone,loose teeth ,soft tissue
fragments
 Detailed preop airway evaluation focussing on
jaw opening , mask fit , neck mobility , maxillary
protrusion , nasal patency , intraoral lesions,
micrognathia , macroglossia

If problem with mask ventilation or
intubation,airway should be secured prior to
induction
This may involve-fibroptic nasal intubation
-fibroptic oral intubation
-tracheostomy
 Nasal intubation should be avoided in maxillary
fractures because of associated basillar skull
fracture and CSF rhinorrea

Intra op head up position , controlled
hypotension , local infiltration with epinephrine
soln.
 Two iv lines should be established oropharyngeal
pack should be inserted
 Anesthetist is remote from airway as surgical
field is near airway. Airway monitoring of end
tidal CO2,peak inspiratory pressures ,
esophageal stethoscope breath sounds are
important

At end pack to be removed with proper
suctioning
 Extubation is to be done once patient is fully
awake
 If chance of post-op edema of structures
interfering with airway, patient is to be left
intubated

DIFFICULT
AIRWAY ALGORITHM
1.ASSES BASIC MANAGEMENT PROBLEM
A .Difficult ventilation
B. Difficult intubation
C. Difficult patient co operation
D. Difficult tracheostomy
2.ACTIVELY DELIVER SUPPLEMENT O2
THROUGHOUT DIFFICULT AIRWAY
MANAGEMENT
3.CONSIDER BASIC MANAGEMENT CHOICES
A.Awake vs intubation after GA
B.Noninvasive vs invasive technique for initial
approach to intubation
C.Preservation of spontaneous ventilation vs ablation
a-surgery with facemask or LMA, local infiltration,
regional nerve block
b-cricothyrotomy or tracheostomy
c-use of different laryngoscope blades, stylets, tube
changers, lightwand, fibroptic,retrograde, blind
technique
d-cancel surgery
e-noninvasive ventilation-rigid
bronchoscopy,transtracheal jet ventilation
,combitube

THANK YOU