Presentation on theme: "Anesthetic management of maxillofacial surgery By: Alaa Samir El Kateb Lecturer of anesthesia and intensive care Ain Shams university."— Presentation transcript:
Anesthetic management of maxillofacial surgery By: Alaa Samir El Kateb Lecturer of anesthesia and intensive care Ain Shams university
Objectives: - Preoperative airway assessment. - Learn how to perform awake intubation. - How to draw a fluid chart. - What is massive blood transfusion and its complications. - Know complications and prevention of hypothermia.
Le fort classification Transverse crossing floor of nose, separating of the palate from the maxilla. Fracture of maxilla, where body of the maxilla is separated from the facial skeleton (pyramidal in shape) The entire maxilla and one or more facial bones are completely separated from the craniofacial skelton
Cont. Preoperative airway evaluation 2- PHYSICAL EXAMINATION: Thick, short & muscular neck Receding or hypoplastic mandible Edentulous, prominent incisors High arched palate, large tongue Presence of ear or hand deformities
Cont. Preoperative airway evaluation Hyomental distance: 2 fingers Thyromental distance: 6.5 cm Mouth opening: (TMJ) 3-4 cm Neck Movement: 35 degree flexion at lower cervical and 80 degree extension at atlanto-occipital
I. Anesthesia of the Nasal Mucosa and Nasopharynx ( Sphenopalatine ganglion and ethmoid nerve) - Lidocaine + epinephrine or lidocaine + phenylephrine - Long cotton-tipped applicators: 1 st : 45 degree to the hard palate 2 nd : parallel to the dorsal surface of the nose - Left in place for 5 minutes - Should be done bilaterally
II. Anesthesia of the mouth, oropharynx and base of tongue (Glossopharyngeal & superior laryngeal nerves ) - Lidocaine gel on tongue blade and patient "sucks“. Peak on set 15 min. OR Lidocaine can be placed in a nebulizer for 5-7 min OR The tongue and posterior pharynx are sprayed with the atomizer.
Glossopharyngeal nerve block
Superior laryngeal nerve block
III. Anesthesia of the hypopharynx, larynx and trachea Transtracheal block (RLN)
After anesthetizing the airway you may use: Direct laryngoscopy Blind intubation Retrograde intubation Fiberoptic intubation PLEASE Maintain spontaneous breathing
ctrachcombitube ILMA COPA
LMA_supreme2 AIRtraq glidescope video assessted
Nasal intubation - Vasoconstrictor minutes earlier. - Insert ETT parallel to hard palate. - Bevel is medial (turbinates are lateral) - During blind nasal: _ Introduce the ETT during inspiration _ You may use capnography
Fiberoptic bronchoscopy - May turn to be an emergency situation. - If to be used, use it as the first choice. - Pull the tongue forward, jaw thrust. - Put the patient in sitting position. - Keep the midline against hard palate. - You may dim room light and use it as illuminating stylet.
- For nasal intubation!!
Safe extubation “air leak test” is done to evaluate whether or not the patient is capable of breathing spontaneously You may use a hollow introducer or a tube- exchanger, bronchoscope or NGT
- Wide pore canula / central venous access Fluid therapy Deficit Hourly maintenance * fasting hours Maintenance - 4 cc/Kg for 1 st 10 weight - 2 cc/Kg for 2 nd 10 weight - 1 cc/Kg for remaining weight Losses - Ryle - UOP - Bleeding - 3 rd space loss
Gross ’ s simplified formula Allowable blood loss = [(Starting Hct – target Hct) / Starting Hct] X Estimated blood volume. Estimated blood volume Adults: cc/kg Infants: 80 cc/kg Neonates: 85 cc/kg Newborn: cc/Kg Amount to be transfuse (ml)= [Target haemaglobin – Current haemaglobin] X 4 X weight (kg)
Massive blood transfusion American Association of Blood Banks definition: 10 units of blood in 24 hrs or 5 units of blood in 4 hrs
Complications of massive blood transfusion 1- Coagulopathy: At least 1.5 times blood volume to become a clinical problem. 2- Hypothermia. 3- Citrate toxicity: > unit/5 min 4- Hyperkalemia
Complications of hypothermia: 1- Arrhythmia: PVC (<30°C) – VF (<28°C) 2- ↓ O 2 delivery to tissues: O 2 dissociation curve, VC, ↑ blood viscosity. 3- ↓ GFR and UOP stops at 20°C 4- ↑ blood viscosity, ↑ rouleaux formation, coagulopathy (depressed clotting mechanism and platelets function). 5- Metabolic acidosis. 6- Post-operative shivering.
How to prevent? - ↑ ambient air temperature. - Humidify inspired air - Warm mattress - Plastic or cotton wraps - Warm fluids