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Anaesthetic management of patient with Maxillofacial injury

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Presentation on theme: "Anaesthetic management of patient with Maxillofacial injury"— Presentation transcript:

1 Anaesthetic management of patient with Maxillofacial injury
Moderator – Prof Anjan Trikha Presenter - Priya

2 Krishna 25years/male Student Resident of Delhi

3 Chief complaints : Pain and difficulty in chewing × 1 week
Restriction of mouth opening ×1 week

4 History of present illness :
H/O fall from tree one week back Following which patient developed Pain and swelling on left side of jaw Pain on opening mouth Difficulty in chewing food No H/O loss of consciousness No H/O oral, nasal or ear bleed

5 Past history No H/O any previous GA exposure No H/O asthma, TB,DM & any drug allergy Personal history : Non smoker Treatment history : Inter maxillary wiring was done after trauma Family history : Not significant

6 General physical examination
Alert, conscious &oriented No pallor, icterus, clubbing, cyanosis, edema and lymphadenopathy Vitals PR- 70 beats/min all peripheral pulses palpable BP – 124/78mm Hg R, upper arm, supine Weight – 58 kg

7 Airway examination : Inter incisor gap – wiring present
Length of upper incisor -<1.5 cm No buck teeth or loose teeth MMP class – could not be assessed Upper lip bite – unable to do because of wiring Thyromental distance = 6.5 cm Sub mandibular compliance - normal

8 Neck movements Flexion - adequate Extension - adequate Neck thickness normal No short neck Nasal patency – equally patent, no deviation or growth seen

9 Respiratory system : Cardiovascular system:
B/L vesicular breath sounds present No adventitial sounds Cardiovascular system: First and second heart sound heard, no murmur present

10 Central nervous system :
Higher mental functions normal No sensory and motor weakness Abdomen : No visible swelling No organomegaly

11 Investigations: Hb – 12gm% Platelets – 2 lakhs/mm3 TLC – 8400/mm3
Na/K – 140/4.2meq/l Urea/creatinine – 20/0.9mg/dl LFT - WNL

12 OPG X-ray – fracture in ramus of mandible left side with inter maxillary fixation (IMF) in situ

13 Provisional diagnosis
Fracture mandible left ramus with reduced mouth opening posted for open reduction and internal fixation

14 Surgical procedure planned
Open reduction and internal fixation of mandible fracture with plating

15 Summary : 25 year old male with left mandibular fracture with interdental wiring in situ posted for open reduction and internal fixation

16 Plan Nasal intubation laryngoscopy guided after removal of wiring

17 Problems : Nasal intubation – its inherent risks Sharing of airway
Access to airway Extubation issues PONV prophylaxis Post operative airway obstruction

18 Preoperative prepration
Inform about procedure & risk Written consent Premedication aspiration prophylaxis- oral ranitidine antisialogogue – Glycopyrrolate i.m nasal decongestant – xylometazoline drops Pre op fasting Wiring was removed on the day of surgery

19 Ot prepration Check machine and emergency equipments
Standard monitoring – ECG, NIBP, pulse oximetry,capnography iv access secured – extension tubing Nasal prepration with xylometazoline drops Softening of nasal tube Preoxygenation for three minutes

20 Sniffing position Induction – fent 2mcg/kg, propofol 2- 3mg/kg Mask ventilation assessed ->Vecuronium – 0.1mg/kg Lubricated 7.5 size nasal RAE tube introduced through rt nostril Tube guided into glottis under laryngoscopy Equal air entry confirmed

21 Eye padding, oral packing done
Positioning for surgery Maintainence – oxygen, air and isoflurane, vecuronium, fentanyl Antiemetics – dexamethasone and ondensetron Monitor airway pressure

22 Reversal – neostigmine and glycopyrrolate
Removal of pack and thorough suctioning Extubation – fully awake, adequate tidal volume, following commands Postoperative- Oxygen by face mask Pulse oximetry Beware of vomiting aspiration

23 Specific equipments & tools
RAE (nasal) tube, naso pharyngeal airways, warm saline, magill forceps & LA jelly Fibreoptic bronchoscopy, suction apparatus Lidocaine preprations- 2% viscous,2% injectable solution,10 or 15% spray,4% topical solution Eye pads, throat pack, small pillows & rolls Intravenous accesses secured

24 Airway management choices
Fibreoptic guided intubation after i.v induction,paralysis & IPPV awake with sedation Blind nasal intubation- awake post induction and paralysis Light wand guided Retrograde intubation tracheostomy

25 Difficult airway: A clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation or both

26 Difficult mask ventilation
It is not possible for unassisted anaesthesiologist to maintain the SpO2 > 90% using 100% O2 and positive pressure mask ventilation in a patient whose SpO2 was > 90% before or It is not possible for the unassisted anaesthesiologist to prevent or reverse signs of inadequate ventilation during mask ventilation

27 Difficult laryngoscopy
It is not possibe to see any portion of the vocal cords after multiple attempts at conventional laryngoscopy Difficult tracheal intubation A clinical situation in which intubation requires more than three attempts or ten minutes using conventional laryngoscopic techniques

28 Optimal laryngoscopy attempt
Performance by a reasonably experienced laryngoscopist The use of the optimal sniffing position The use of OELM One change in length/type of blade

29 Assessment History Specific tests for assessment
Difficult mask ventilation Difficult laryngoscopy Difficult surgical airway access Radiologic / photographic assessment

30 History Congenital difficult airways Acquired Iatrogenic
Rheumatoid arthritis, Acromegaly, tumors of tongue, larynx Iatrogenic radiotherapy, Laryngeal/tracheal/TMJ surgery Reported previous anaesthetic problems Database

31 11 point scoring Inter-incisor gap : >3cm Buck teeth +
Length of incisor: <1.5cm Upper lip Bite MMP class Palate: arching / narrowing TMD: >6cm Mandibular compliance Neck length: sufficient Neck diameter: thin or thick Neck movement

32 Specific Tests Mouth opening
Evaluation of tongue size relative to pharynx Mandibular space Mobility of the joints TMJ Neck mobility

33 Inter-incisor Gap With maximal mouth opening
Acceptable value > 4 cm Positive results: Easy insertion of a 3 cm deep flange of the laryngoscope blade < 3 cm: difficult laryngoscopy < 2 cm: difficult LMA insertion Affected by TMJ and upper cervical spine mobility

34 Evaluation of tongue size relative to pharynx
Samsoon-Young’s modification of Mallampati Test Patient in sitting position Maximal mouth opening in neutral position Maximal tongue protrusion without arching No phonation

35 Class III or IV: signifies that the angle between the base of tongue and laryngeal inlet is more acute and not conducive for easy laryngoscopy Limitations Poor interobserver reliability Limited accuracy

36 73% 19% 8%

37 Correlation between MMP score and laryngoscopy grade
MMP class Cormack and Lehane grade Grade 1 Grade 2 Grade 3 Grade 4 Class I (73%) 59% 14% - Class II (19%) 5.7% 6.7% 4.7% 1.9% Class III & IV (8%) 0.5% 5% 2.5% Airway Management, Jonathan Benumof

38 Mandibular space Thyromental distance (Patil test)
Distance from the tip of thyroid cartilage to the tip of mandible Neck fully extended Minimal acceptable value – 6.5 cm Significance Negative result – the larynx is reasonably anterior to the base of tongue Very low sensitivity-20%

39 Sternomental Distance (Savva Test) >12.5cm
Modification to improve the accuracy Ratio of height to thyromental distance (RHTMD) Useful bedside screening test RHTMD < 25 or 23.5 – very sensitive predictor of difficult laryngoscopy Sternomental Distance (Savva Test) >12.5cm

40 Evaluation of Neck Mobility
Patient is asked to hold the head erect, facing directly to the front  maximal head extension  angle traversed by the occlusal surface of upper teeth Grade I : > 35° Grade II : 22-34° Grade III : 12-21° Grade IV : < 12°


42 Placing one finger on the patient’s chin  One finger on the occipital protuberance
Result Finger on chin higher than one on occiput  normal cervical spine mobility Level fingers  moderate limitation Finger on the chin lower than the second  severe limitation Angle traversed by the vertex or forehead > 90° from max flexion to max extension is a specific +ve test for atlanto-occipital joint.

43 Mandibular Protrusion Test
Class A: able to protrude the lower incisors anterior to the upper incisors Class B: lower incisors just reach the margin of upper incisors Class C: lower incisors cannot reach the margin of upper incisors Significance Class B and C: difficult laryngoscopy

44 Upper Lip Bite Test Less inter-observer variability
Class I: Lower incisors can bite the upper lip above vermilion line Class II: can bite the upper lip below vermilion line Class III: can not bite the upper lip Less inter-observer variability

45 Predictors of Difficult Mask Ventilation
Age > 55 years BMI > 26 kg/m2 History of snoring Beard Edentulous

46 Difficult LMA Insertion
Mouth opening < 2 cm Intraoral/pharyngeal masses (e.g. lingual tonsils) Difficult Direct Tracheal Access Gross obesity Goitre Deviated trachea Previous radiotherapy Surgical collar

47 Statistical Significance
Diagnostic test MMP TMD Sternomental distance Mouth opening Wilson score MMP+TMD Sensitivity 49% 20% 62% 22% 46% 56% Specificity 86% 94% 82% 97% 89%

48 Combination of predictors
Wilson Score 5 factors Weight, upper cervical spine mobility, jaw movement, receding mandible, buck teeth Each factor: score 0-2 Total score > 2  predicts 75% of difficult intubations

49 Quick look back Difficult mask ventilation Mask fit Obesity Age
No teeth Snoar

50 Difficult laryngoscopy
Look Evaluate…3.3.2 Mallampati Obstruction Neck movement

51 “LEMON” Assessment L - Look externally (facial trauma, large incisors, beard, large tongue) E - Evaluate rule 3 - inter incisor gap 3 - hyomental distance 2 - hyoid to thyroid distance M - MMP score O - Obstruction (epiglottitis, quinsy) N - Neck mobility Ron and Walls’ Emergency Airway Management

52 Difficult EGD insertion
Restricted mouth opening Obstruction of upper airway Disrupted/distorted anatomy Stiff lungs/cervical spine

53 Difficult cricothyrotomy
Surgery Hematoma Obese Radiation / burn Tumor

54 Awake intubation

55 Why awake?

56 Patent airway Spontaneous breath Larynx-No anterior displacement Aspiration-protection Neck movement-minimal Neurological monitoring

57 Who needs?

58 H/o difficult intubation & Predicted difficult airway
May be considered in the following situations (usually with a coexisting difficult airway): High risk of aspiration Hemodynamically very unstable Respiratory failure

59 Where not to?

60 Patient refusal Uncooperative 1.child 2. mentally retarded 3. intoxicated 4. combative Allergic to all LA

61 What to inform?

62 Need for alternative intubation
Difficult, time consuming but safer Slightly uncomfortable but pain-free Injections required for better tolerance Recall ± LA complications rarely Experienced physician-extra safety measures Pt may opt for conventional - last resort

63 Do you premedicate?

64 Anti-anxiety : Options
BZD…Midazolam 20-40mcg/kg i.v bolus Opioid…fentanyl mcg/kg i.v bolus remifentanil mcg/kg/min Ketamine… mg/kg i.v Propofol…0.25mg/kg i.v bolus 50-100mcg/kg/min infusion Dexmedetomidine…1mcg/kg i.v followed by mcg/kg/hr Inhalations…Sevo / Des …pediatric DA

65 Aspiration prophylaxis
Adequate fasting H2 blocker Metoclopramide Sodium citrate Anti-sialogogue Atropine mcg/kg i.v or i.m Glycopyrollate mcg/kg i.v or i.m Scopolamine mg i.v or i.m or s.c

66 Mucosal vasoconstictors
0.025% to 0.05% oxymetazoline nasal drops in each nostril; once before shifting from ward & once in holding area. 4% cocaine + 2% lidocaine + 1% phenylephrine

67 Any preparation?

68 Staff to assist Monitors : ECG, BP, EtCO2, SpO2 Supplemental oxygen Airway equipments-Difficult airway cart Surgeon ready for tracheostomy 1. Pt in extremes 2. Airway catastrophy

69 Airway Anesthesia:

70 What are the options?

71 Flexible fibrescope guided
Blind nasotracheal Rigid fibrescope guided Trachlight / light wand guided ILMA guided Other SGA guided Retrograde intubation Direct laryngoscopy

72 Blind nasotracheal intubation
Supine sniffing position Guided by breath sound or capnography Lubricated tube Patent nare Gently advance

73 Five response positions:
Position T (Trachea): Goal position! Breath sound +; tube advances, patient coughs Position A (Anterior): breath sounds+; the tube stops , and the patient coughs Response A:withdrawal and re-advance; neck gradually flexed Position L or R (Left or Right pyriform sinus): breath sounds STOP, unable to advance tube, NO coughing; tube may be palpable on one side of the neck. Response L or R: slight withdrawal till breath sounds resume; slow rotation of head to opposite side and re-advance.

74 Position E (Esophagus): Breath sounds STOP, tube advances, NO coughing.
Response E: withdrawing until breath sounds resume and then : 1. Extend patient's head and re-advance. 2. Largely inflate cuff, advance tube until resistance is felt, maintain some advancing pressure on tube while cuff is slowly deflated. 3. Apply posterior pressure on the larynx and re-advance tube. 4. Leave one ETT inside esophagus to block it and insert another ETT to intubate the trachea.

75 Assisted methods Beck Airway Airflow Monitor(BAAM)- (Tracheal Whistle) disposable device that magnifies the patients respirations with a whistle sound. Bougie guided blind intubation NG tube guided blind intubation

76 ASA task force on management of DA (Anesthesiology May 03;98)
Explicit descriptions of DA Difficult face mask ventilation Difficult laryngoscopy Difficult tracheal intubation Failed intubation Purpose- facilitate mx. of DA, ↓adverse outcomes Focus on anaesthesia care All locations, all ages

77 ASA task force on management of DA
Basic preparation Inform Ascertain help Preoxygenation Supplemental oxygenation throughout Portable storage unit Rigid laryngoscope blades ETTs ETT guides LMAs FFOI equips RI Em NI a/w vent Em invasive a/w Exhaled CO2 detector

78 ASA task force on management of DA
Strategy depending on Anticipated surgery Patient condition Skill & preference of anaesthesiologist 4 basic problems 3 basic management choices Primary approach Alternative approach Exhaled CO2 to confirm tracheal intubation


80 LMA in ASA DA algorithm

81 ASA task force on management of DA
Strategy for extubation of DA Awake? Adverse impacts on ventilation Further A/w management plan Guide for reintubation Follow up

82 Limitations of ASA guidelines
Open ended, wide choice of techniques Emphasis on prediction of difficult airway No stratification of available a/w devices No expression of strength of recommendation

83 DAS guidelines (Anaesthesia.2004.59)
Management of un-anticipated difficult intubation in an adult non-obstetric patient Paediatric, obstetric patients & patients with upper a/w obstruction excluded Flow charts based on series of plans Careful planning with backup plans Maintenance of oxygenation takes priority Seek the best assistance available



86 Points to be considered prior to the performance of airway blocks
Complete explanation of the reason for performing the airway nerve blocks, is essential Consider (a) an alternative plan, i.e the direct spray of LA or spray with a nebulizer (b) the time available (c) the patient's condition Use of appropriate sedation to maintain patient comfort These techniques should be practiced in nonemergency situations so that when their success is required for a difficult intubation they can be performed appropriately

87 Airway anaesthesia Topical Nerve blocks individual multiple Spray Jel
Injection nebulization Nerve blocks individual multiple

88 Available Lidocaine Preparations
Dose Injectable/topical solution 1% , 2%,4% Viscous solution 1%, 2% Ointment 2%,5% Aerosol 10%

89 Systemic Absorption and Toxicity
Amount of LA absorbed varies Systemic absorption of topically applied lidocaine is limited 5 mcg/ ml , toxic limit of blood lidocaine Chinn and colleagues found plasma lidocaine levels of 0.44 μg/mL after inhalation of 400 mg of nebulized lidocaine Baughman and associates found that patients breathing 4 mg/kg aerosolized lidocaine developed plasma levels of less than 0.5 μg/mL Oral lidocaine produced even lower plasma levels because much of the dose is swallowed & subjected to first-pass metabolism by the liver Swallowed lidocaine in the setting of topical airway anesthesia can cause nausea and vomiting

90 Systemic Absorption and Toxicity
Lidocaine applied directly to the trachea and bronchi results in higher plasma levels Viegas and Stoelting found plasma levels of 1.7 μg/mL 9 minutes after tracheal installation of 2 mg/kg lidocaine Sutherland and Williams in their study found that despite a total dose of lidocaine (5.3 ± 2.1 mg/kg), the mean peak arterial plasma lidocaine concentration was low (0.6 ± 2.1 μg/mL) Gargling of large volumes (0.3 mL/kg) of 2% lidocaine may be associated with peak lidocaine concentrations approaching a potentially toxic level

91 British Thoracic society guidelines on FOB
Total dose of lidocaine should be limited to 8.2 mg/kg in adult pts Take extra care in elderly & pts with liver, cardiac impairment Minimum amount of lidocaine necessary should be used when installed through FOB Thorax 2001;56 (suppl 1)

92 Predominant nerve supply of airway

93 Sensory innervations of airway
Anterior ethmoidal nerve Anterior 2/3 of nasal septum Lateral wall of nose Sphenopalatine N Posteroir 1/3 of septum Floor of nose Glossopharyngeal N Posterior 1/3 of tongue Posterior & lateral pharyngeal wall Anteror surface of epiglottis Internal br of superior laryngeal N Larynx includ. Vocal cords Recurrent laryngeal N Below the level of vocal cords trahea

94 Nasal cavity and nasopharynx
Plethora of sensory fibers Multiple origins Topical application – the best and safe Nerve blocks Sphenopalatine N Anterior ethmoidal N

95 Method of packing nasal cavity

96 Atomizer

97 Sphenopalatine & Ant Ethmoidal N block

98 Oropharynx Vagus, facial, glossopharyngeal N
Topical anaesthesia sufficient in majority Gag reflex difficult to suppress by topical alone

99 Gag reflex Deep ,sub mucosal pressure receptors
Postrerior 1/3 of tongue Gag happens more on oral intubation Glossopharyngeal nerve (GPN) – the afferent arc

100 Glossopharyngeal nerve block

101 GPN block

102 GPN block

103 Clinical Tips The use of a tongue blade facilitated by application of a topical LA to mouth If air is aspirated, needle needs to be withdrawn If blood is aspirated, it is arterial (carotid artery), the needle is too posterior and too lateral. It needs to be redirected medially

104 Anesthesia of Larynx Topical spray Atomiser Spray as you go
Transcricoid injection Nebulized lidocaine Superior laryngeal nerve block

105 Innervations of Larynx

106 SLN block External approach Cornu of hyoid Cornu of thyriod
Thyroid notch Internal approach piriform fossa

107 SLN block – Hyoid landmark

108 Superior laryngeal nerve block- thyroid cornu as landmark

109 Clinical tips Caution not to insert the needle into the thyroid cartilage, injection of LA into vocal cords cause edema If air is aspirated, the needie pierced laryngeal mucosa & to be retrieved If blood is aspirated (superior laryngeal artery or vein), needle to be redirected more anteriorly For evaluation of vocal cord movement, only the internal laryngeal nerve needs to be blocked For awake intubation, SLN and RLN need to be blocked

110 SLN block – piriform fossa

111 SLN block – Piriform fossa

112 Trachea and vocal cords
Translaryngeal injection Spray as you go Labat’s technique

113 Cricothyroid membrane

114 Technique of transcricoid injection

115 Transcricoid injection

116 Clinical tips Pt needs to be informed that the injection of LA solution make him or her cough Contraindicated in patients with unstable neck During the block, pt should not talk, swallow, or cough Catheter left in place until the intubation is completed for injecting more LA if necessary& to decrease the likelihood of subcutaneous emphysema

117 “Spray as you go” Non invasive Useful in pts at risk of aspiration
Injecting LA through suction port of FOB Wait sec before advancing to deeper structure and repeat the maneuver Two methods oxygen spray technique Catheter technique

118 Oxygen spray technique
Attach three-way stopcock to suction port Connect oxygen tubing with l /min Through other port of 3 way inject LA Advantages high Fio2 delivery clean lens disperse mucous away aids innabulizing LA

119 Catheter technique Pass a angiographic or epidural catheter into suction port of FOB Till it project 5 mm beyond FOB lens Inject LA through proximal connection Allows accurate placement of LA

120 Nebulizing LA Safe, non invasive technique
Useful in pts with unstable neck, ↑IOP &ICP Needs pt’s cooperation 5ml of 4% flow of 6L/min, ultrosonic nebulizer over min period O2 flow < 6L/min yields droplet size of microns









129 Le fort classification








137 Sub mental intubation

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