anesthesia for maxillofacial procedure

7/27/2019 Anesthesia for Maxillofacial Procedure

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ANESTHESIAfor

Dental&MAXILLOFACIAL SURGERYSAAD A. SHETA

MBChB, MA, MDAssociate Professor, Anesthesia

Dental College

KSU


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Dental Anesthesia

I. Out-Patient anesthesiaII. Day-Case anesthesiaIII. In-Patient anesthesiaV. Emergency Surgery


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Out-Patient Dental AnesthesiaDental Chair Anesthesia


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Out-Patient Dental AnesthesiaDental Chair Anesthesia

Out-Patient dental extraction Children (4-10 years): URTI Steadily decreased


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Out-Patient Dental AnesthesiaInduction

Inhalational (mask) induction

Intravenous Induction


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Out-Patient Dental AnesthesiaMaintenance

Inhalational agents/N2O Maintain airwayPosture (Supine Position) Less hypotension less bradycardia

However high risk of aspiration high risk of Airway obstruction


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Out-Patient Dental AnesthesiaRecovery

Left lateral position 100% O2

Suction Observation & monitoring

Discharge criteria

Instructions

Analgesia (NSAIDs)


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Out-Patient Dental AnesthesiaComplications

Respiratory Complications Cardiovascular Complications Syncope Allergic Reaction


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Respiratory Complications

Airway Obstruction

Respiratory Depression


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Cardiovascular Complications Hypotension Bradycardia Dysrhythmias (Tachy-arrhythmias)

Aetiology (Tooth extraction) High preoperative catecholamines Light anesthesia Airway obstruction & hypoxia Halothane & local anesthesia Local anesthesia with vasopressors


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Syncope

Causes Previous factors (CV, allergic,..)Emotional factors (more common)

Aetiologylimbic cortex-hypothalamus-reflex vasodilatation

Increase parasympathetic activity-bradycardiaManagement

Head down-leg elevated100% O2Cessation of anesthesia


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Allergic ReactionIncidence

Very rare More commonly (vaso-vagal, toxic reaction,epinephrine)

Aetiology Ig E-mediated reaction Easter-linked: p-amino benzoic acid Amide-linked: preservatives (Paraben)

ManifestationsManagement


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Day-Case Dental AnesthesiaMinor Oral Surgery& Conservative Dentistry


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Day-Case Dental AnesthesiaConcerns

Rapid RecoveryMinimal Postoperative Morbidity

Remote Location


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Day-Case Dental Anesthesia

Minor oral surgery and conservative dentistry

Limited surgery

No significant risk of complications

Standard criteria of patient selection (ASAI&II)


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Day-Case Dental AnesthesiaAnesthetic Technique

Induction

Inhalational (pediatrics) or Intravenous (propofol)

Airway Nasal Endotracheal tube

Oral intubation

LMA

Nasal mask& Nasophryngeal airway

Intubation NDMR (short acting)

Suxamethonium (Postoperative Mylegia)Deep Inhalational Anesthesia

Propofol & Alfentanil

Moist Pharyngeal Pack


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Maintenance Inhalational Sevoflurane

Isoflurane

Halothane (slow recovery & cardiacarrhythmias)

Ventilation Spontaneous (Short procedure)

Controlled ventilation

Extubation

Throat pack removed

Very light anesthesia (recommended)

Patient turned to one side


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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


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In-Patient Dental AnesthesiaMajor Oral & Fasciomaxillary Surgery


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In-Patient Dental AnesthesiaClassifications:

Major Orthognathic Surgery Tumor Surgery Palate Surgery


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In-Patient Dental AnesthesiaConcerns:

Altered Airway Anatomy Shared Operative Field Anesthetic Drugs Choice Appropriate Time for TrachealExtubation


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Airway Management

Anesthetic Management


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Airway Management


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Airway ManagementChoice of the technique depends on several factors:

Patient safety

Experience of the anesthetist

Known difficult airway

Requirement: nasal or oral

Post operative jaw wiring


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Airway Management History

Physical Examination

Further Evaluation

Difficult Airway & Algorism

Airway Strategies


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History

Documented H istory of Di ff icul tieswith general anesthesia

or, more specifically, mask ventilation or endotracheal

intubation

Congenital Syndromes Associated With Difficult

Endotracheal Intubation

Pathologic States That Influence Airway Management


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Selected Congenital Syndromes Associated With Difficult

Endotracheal Intubation

SYNDROME DESCRIPTIONDown 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


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Selected Pathologic States That Influence Airway Management

PATHOLOGIC STATE DIFFICULTYInfectious epiglottitis Laryngoscopy may worsen obstruction

Abscess (submandibular,

retropharyngeal, Ludwigs

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/mandibularinjury

Airway obstruction, difficult mask ventilation, andintubation; cricothyroidotomy may be necessary

with combined injuries

Laryngeal fracture Airway obstruction may worsen during

instrumentation

Cervical spine injury Neck manipulation may traumatize spinal cord

S l t d P th l i St t Th t I fl Ai M t


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Selected Pathologic States That Influence Airway Management

PATHOLOGIC STATE DIFFICULTYUpper 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


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Selected Pathologic States That Influence Airway

Management

PATHOLOGIC STATE DIFFICULTYAngioedema Obstructive swelling renders ventilation and intubation

difficult

Endocrine/metabolic

acromegaly

Large tongue, bony overgrowths

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


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Physical Examination

Inspection (Obvious Problems)

Mouth Opening (34cm)

Oral Cavity Examination

Mallampati Score

Thyromental Distance (3 large fingers = 5 cm)

Neck Movement


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Further EvaluationPRE-OPERATIVE ASSESSMENT OF THEAIRWAY

Indirect or Fiberoptic Laryngoscopy

X ray: Chest , Cervical Spine

CT or MRI

Flow- Volume Loops

Pulmonary Function Tests


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Cormack-Lehane Laryngeal View Scoring


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Difficult Airway

Difficult airwayThe clinical situation in which a conventionally trainedanesthesiologist experiences difficulty with maskventilation, difficulty with tracheal intubation, or both

Difficult mask ventilation1) inability of unassisted anesthesiologist to maintain

SpO2> 90% using 100% oxygen and positivepressure mask ventilation in a patient whose SpO2was 90% before anesthetic intervention;

Or

2) inability of the unassisted anesthesiologist to preventor reverse signs of inadequate ventilation duringpositive pressure mask ventilation


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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


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Normal Airway

Awake or Sedated Under GA

Difficult Airway

Airway Management


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Difficult Airway

Awake Under GA/SedationAwake Laryngoscopy

Awake Fiberoptic

Tracheostomy

Retrograde Intubation

Different Laryngoscopes,

Stylets

LMA/ I LMA/FO

Fiberoptic

Tracheostomy

Blind Nasal Intubation


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AWAKE TECHNIQUES


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Difficult AirwayAwake

Awake Laryngoscopy

Awake Fiberoptic

Tracheostomy



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AWAKE TECHNIQUES

Glosso-Pharyngeal Nerve IX Nerve

Posterior pharyngeal fold at its midpoint, 1 cm deep to themucosa of the lateral pharyngeal wall


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AWAKE TECHNIQUES

Superior Laryngeal Nerve

Pyriform Fossa

External :1 cm medial to the superior cornu of the Hyoid

Bone to pierce the thyrohyoid membrane


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AWAKE TECHNIQUES

Trachea & Vocal Cord

Atomizer

Injection


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Laryngoscope Blades

AWAKE TECHNIQUES


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McCoy

AWAKE TECHNIQUES


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AWAKE TECHNIQUES

AWAKE TECHNIQUES


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AWAKE TECHNIQUES

FIBER OPTIC INTUBATION


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AWAKE TECHNIQUES

SURGICAL AIRWAY

Under General Anesthesia


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Chidren / Uncoaperative Adults / Sepsis Assess / Anticholinergic / Anxiolytic ( if any)

Under General Anesthesia

1) Inhalational / asses: Ventilation / Veiw

(=/- short acting MR)

2) Stillete / Different Laryngeoscopes

Face Mask + F.O. + Modified Oral AW

3) LMA / LMA + F.O.

4) F.O using Sedation Or light GA

5) Tracheosyomy under light GA

6) Blind Nasal Technique


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Laryngoscope Blades

GA TECHNIQUES


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McCoy

GA TECHNIQUES


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GA TECHNIQUESLaryngeal Mask Airway (LMA)


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GA TECHNIQUES

LIGHTED STYLETS/LIGHTWAND

Well Circumscribed Glow


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Unconventional LMA

Fast Track LMA.O. + LMA

GA TECHNIQUES


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90% successful but may need several attempts

Contraindicated in fractured base of skull

Cervical collar in situ

GA TECHNIQUES

Blind Nasal Intubation


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GA TECHNIQUES

FIBER OPTIC INTUBATION


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Rigid Fiberoptic

laryngoscope

Retromolar

Fiberscope

GA TECHNIQUES


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GA TECHNIQUES

BULLARD LARYNGOSCOPE


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GA TECHNIQUES

SURGICAL AIRWAY


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Classification According to Mouth OpeningAwake or Sedated

SLN block +Transtracheal LA

Normal mouth opening


Limited

Awake Intubation with F.O.

Extremely limited


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Awake Intubation Under Anesthesia Blind Technique

Spontaneouslybreathing awakepatient without the riskof apnea

Suitable for patientswith obstructivesymptoms

Needspatients

cooperation

Success rate in goodexperienced hands

Risk of complicationsfrom nerve block

Incase of failure , canbe postponed forreconsideration

Risk of apnea withdifficulty maskventilation

Suitable for patientswith no obstructivesymptoms

Failure to intubate mayresult in fatal outcomeMultiple attempts maylead to bleeding and/oraspiration

Blind technique suchas BNI, Light wand,Retrograde wireintubation, LMA, andCombi tube are C/I intumor patients

because of the risk ofbleeding and tumordislodgement.


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TechniquesUnder Vision

AwakeLaryngoscopic Fiberoptic IntubationUnder GA Tracheostomy


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Blind

Techniques

Retrograde Wire

IntubationLighted Stylet/

Light wandCombi-Tube

Blind Nasal

Intubation


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ModifiedTechniques

Wu Scope

Bullard

Laryngoscope


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NEVER PARALYSE UNTILL POSSIBLE VENTILATION

HAS BEEN ESTABLISHED

RECENT SUCCESSFUL INTUBATION DOESNOTMEAN

FUTURE POSSIBLE INTUBATION

FULL RANGE OF DIFICULT INTUBATION EQUIPMENT

MUSTBE AVAILABLE


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ALL PHYSICIANS RESPONSIBLE FOR AIRWAY

MANAGEMENT SHOULD BEPRACTICED IN AT LEAST

ONE ALTERNATE TO BAG &MASK VENTILA TION.

THESE ALTERNATIVE INCLUDES THE FOLLOWING:

LARYNGEAL MASK AIRWAY

COMBI TUBE

TRANSTRACHEAL TECHNIQUES

LMA PROVIDE RESCUE VENTILATION IN 94% OF

CASES OF UNANTICIPATED DIFFICULT INTUBATION


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HAVING DISCUSSED ALL THE MANAGEMENT

STRATEGIES AWAKE TECHNIQUE IN GENERAL &AWAKE FIBER OPTIC TECHNIQUEESPECIALLY, ISTHE MOST COMMONLY USED & SAFE TECHNIQUE


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ANESTHESIA MANAGEMENT


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Special Consideration

Preoperative Management

Intraoperative Management

Post operative Management


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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.


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PRE-OPERATIVEMANAGEMENT

Adequate pre-operative work-up ofCardiac Status &Pulmonary Functions should be carried out using

various diagnostic modalities with the objective of

optimizing patients condition

RECONSTRUCTIVE MAXILLOFACIAL


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RECONSTRUCTIVE MAXILLOFACIAL

SURGERY

Problems:

Major problem: Airway Management

Extensive, long operation Significant blood loss

Poor nutritional status

Micro-vascular surgery

Caution with Vasoconstrictors Caution with Transfusion

Caution with Diurresis

Blood Rheology (Hct:25-27)


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INTRA-OPERATIVE Routine

Monitoring

NIBP

ECG

SPO2

ETCO2

TEMPERATURE

Choice of Volatile Agent

Choice of Anesthesia


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INTRA-OPERATIVE MANAGEMENTSPECIAL CONSIDERATIONS

Two large bore canulae Invasive blood pressure monitoring Central venous pressure monitoring Use of muscle relaxants Induced hypotension Blood loss & transfusion Haemodynamic changes Venous air embolism


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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.


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INTRA-OPERATIVE MANAGEMENTInvasive 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 tomanipulation in the area of carotid body and sinus.


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INTRA-OPERATIVE MANAGEMENT

Central Venous Pressure Monitoring

Risk of venous air embolism during neckdissection

As a guide to the management of fluid therapy

The site of insertion is either:

Antecubital vein

Femoral vein


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INTRAOPERATIVE MANAGEMENT

Use of Muscle Relaxants

During surgery IPPV is carried out without muscle

relaxant as surgeons need to identify the nerves

during surgery


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Induced Hypotension

Mild degree of hypotension is required during

surgery to reduce the blood loss. This can beachieved by following:

15-30 degree head up tilt Increasing the conc. of volatile anesthetics

Use of peripheral vasodilators

Use of beta blockers


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INTRAOPERATIVE MANAGEMENTBlood Transfusion

Before the decision of blood transfusion the following

points should be considered

Patients underlying medical condition

Possibility of risks of transfusion hazards

Increased risk of post-transfusion cancer recurrence as a

result of immune suppression


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Haemodynamic Changes

During radical neck dissection, the traction or

pressure on the carotid sinus and / or stellateganglion can cause following:-

Brady-dysrhythmias

Sinus arrest leading to asystole

Wide swings in blood pressure

Prolonged QT Interval


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INTRAOPERATIVE MANAGEMENTHaemodynamic Changes Treatment

Immediate cessation of the stimulus

Blockage of the sinus with local anesthetic by the

surgeon

Vagolysis by atropine


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INTRAOPERATIVE MANAGEMENTVenous Air Embolism

When the venous pressure in neck veins is low andthese veins are open to atmosphere, air is sucked in

causing air embolism.

Diagnosis

Early Detection

Hypoxia Hypotension

Hypocarbia


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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



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POST-OPERATIVE CARE

I. ROUTINE CARE

II. SPECIAL CONSIDRATIONS

ICU care & Possible mechanical Ventilation

Hemodynamic Instability

Analgesia

Tracheostomy


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POST-OPERATIVE CAREICU Care & Possible Mechanical Ventilation

Patient should be kept in the intensive care unit for

24-48 hours Prolonged Surgery

Airway Oedema

Co-existing diseases

Risk of bleeding and/or neck hematoma


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POST-OPERATIVE CAREHaemodynamic Instability

As bilateral neck dissection may result in post-operativehypertension and hypoxic drive because of the denervation

of the carotid sinus and carotid body


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POST-OPERATIVE CARE

Analgesia

Non Steroidal Anti-inflammatory Agents should beused as opioids cause respiratory depression in

spontaneously breathing patients

When patient is on ventilator opioid analgesia canbe given


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POST-OPERATIVE CARE

Tracheostomy Care

Humidified Oxygen

Intermittent Suction

Sterile Precautions

Adjustment of cuff pressure to15-20mmHg

Complications


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anesthesia for maxillofacial procedure

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