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Anaesthesia for Oncological ENT Surgeries

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Presentation on theme: "Anaesthesia for Oncological ENT Surgeries"— Presentation transcript:

1 Anaesthesia for Oncological ENT Surgeries
Moderators: Prof Chandralekha Dr V Darlong Presenters: Rakesh Garg Prabhu

2 Head and Neck Surgery Laryngectomy Hemimandibulectomy Maxillectomy
Angiofibroma Glossectomy Pharyngectomy Radical neck dissection

3 Cont… Tracheostomy Diagnostic Endoscopic examination Therapeutic
Definitive oncological surgery Reconstructive surgery

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9 Conclusion Duration of anesthesia and ASA class- significant predictors of major complications Comorbidity - established important factor 3 significant risk factors: site of primary tumor adjunctive treatment low hemoglobin

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15 Perioperative Concerns
Prolonged surgery and its complications Blood loss and its conservation strategies Sharing of airway Surgery related implications

16 Indicators of Difficult Airway
Changes in the voice H/o dyspnoea, dysphagia or inability to handle oro-nasal secretions Radiation to head and neck H/o difficult airway Previous head and neck surgery Tumors and edema of pharynx and hypopharynx

17 Airway examination Examination of the oral cavity-site, size and friability of the tumor- indirect laryngoscopy Mouth opening Mallampati grading Mandibular space Assessment of sniffing position. Adequacy of mask placement.

18 Investigations Hematological Biochemical Chest X-ray ECG STN X ray CT
MRI Laryngoscopy / endoscopy PFT / FV loops

19 Premedication Cancer – emotional and psychological state
Cautious premedication Avoid sedative drugs Analgesics

20 Anaesthetic Management
Selecting the appropriate anesthetic technique compatible with the surgical procedure

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25 LMA in ASA DA algorithm

26 260 patients review

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29 Airway Management Awake Oral FOB Awake Nasotracheal intubation
Inhalational induction Tracheostomy under LA Acute airway compromise - Transtracheal Jet Ventilation Tracheal extubation and Jet Stylet Retrograde Tracheal Intubation - awake patient

30 Cont… ETT and connectors Breathing circuit - secured to patient’s head
nonkinking and properly secured Breathing circuit - secured to patient’s head Constant vigilance -prevent the breathing circuit from pulling downward on the tube’s adapter

31 Cont… The lengthy surgical procedure near the airway and bulky flap reconstruction may cause oedema around the airway making extubation even more challenging than the intubation

32 Cont… Nerve blocks – contraindicated- tumour
Coughing and straining :awake intubation - trauma and bleeding Pectoralis major flap tunnelled through the neck- risk of airway obstruction (bulk) than does a free flap. Postoperative local oedema

33 Monitoring Routine Capnography
Invasive monitoring - arterial BP and CVP Arterial line and cannulas Central line - antecubital, subclavian or femoral Two large bore cannulas Urinary catheterization Temperature monitoring

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39 Intraoperative Tracheostomy
100% oxygen Suction Tube pulled just above the tracheal incision TT inserted Ventilations checked Observe –breath sounds, capnography, airway pressure, compliance

40 Extubation Extubation
degree of edema and upper airway distortion produced by the surgery Lengthy procedure, free flap reconstruction- intubated, sedated overnight in the ICU Others extubated in the OT or PACU when they are fully awake Equipment for securing the airway readily available

41 Intraoperative and Postoperative Complications
VAE Carotid sinus manipulation Stellate Ganglion injury Positioning- neck torsion Airway compromise – edema, hematoma

42 Maxilla Cancer Concerns: Difficult Airway Bleeding
CSF leak/ pneumocephalus Infection Visual impairment Enopthalmos

43 Mandible cancer Concerns: Tumour
Primary Infiltration from adjoining structures Resection – segmental/hemimandibulectomy Osteocutaneous flap/plates

44 Reconstructive surgery
Flaps: Skin grafting Local flaps Pedical fasciocutaneous flap Musculocutaneous flap Osteocutaneous flap Evaluated invidualized

45 Intraoperative Considerations
Avoid cannula/monitoring devices at flap donor sites Secure monitoring/airway devices – change of position Blood loss Hemodynamics Hypotension: Avoid vasoconstrictors Decrease inhaltional agents Fluids Avoid shivering/pain - vasoconstriction

46 Laryngeal cancer Conservative laryngeal procedures  total laryngectomy Laser surgery Vertical hemilaryngectomy Supraglottic laryngectomy Supracricoid partial laryngectomy tracheostomy

47 Direct Laryngoscopy Microlaryngoscopy Laser Laryngoscopy Microlaryngeal Endoscopic Surgery
Goals: Dry immobile field Securing Airway and protection Oxygenation and ventilation Anaesthetic technique – short, rapid and full recovery Hemodynamic stability

48 Anaesthesia No airway compromise – premedication, standard induction
Antisialagogue, sedation Vigilant – inadveretent extubation, kinking, disconnection Cardiac monitoring Induction and maintenance – short acting agents, muscle relaxant, narcotics, beta blockers

49 Cont… Posterior commissure – MLS tube Protection of eyes/teeth
Anaesthesia machine and monitors – side of patient, head end free

50 Other Ventilatory Strategies
Supraglottic jet ventilation Subglottic jet ventilation Transtracheal jet ventilation Free access to expiration Intravenous anaesthesia, unpredicted inhalation Pneumothorax, pneumomediatinum, submucosal emphysema Blood, debris – tracheal ingress Postoperative CxR Apneic ventilation Tracheostomy

51 MAC In selected patients, high risk patients Topical, regional anaesthesia

52 Neck Dissection Lymph node and fibrofatty tissues
Therapeutic neck dissection Elective neck dissection Radical neck dissection Modified neck dissection Selective neck dissection

53 Laser and Anaesthesia Light amplification by stimulated emission of radiation

54 Laser beam is intense light, emitting identical coherent, excited photons in one direction
Beam focused to small spot – precise controlled coagulation Incision or vaporization of tissue

55 Types Solid – ruby, YAG, xenon Gas – co2, argon, krypton, excimer
Liquid - liquid dyes

56 Laser Hazards Misdirected – burn : eyes are vulnerable, CO2 – corneal burn; tissue / vessel perforation Fire & explosion (thermal effect) Ignition of inflammable materials – ETT, breathing circuits, drapes Atmospheric contaminations

57 Safety Considerations
OT warning sign for laser use Restrict entry into OT Protective eye glasses (wave length specific) Avoid flammable materials Patient eye care – taped closed & covered wet pads protection glass Wet towels for draping

58 Cont… Competent personal for equipment use Avoid misdirection of beam
Avoid ETT in short procedure, use venturi Use fire proof tubes with saline filled cufffs Cover visible cuff area with moist cotton pledgets Ready bucket of clean water Smoke evacuators at surgical site

59 Special ETT & Protection
Wrapping with wet muslin, dental acrylic coating (disadv : mucosal trauma) Wrapping with metalised foil tape– Al, Cu, plastic+metal Solid copper foil or aluminium (protect from Nd:YAG laser for 60 sec) Cuffs unprotected – fill with saline / dye

60 FDA approved – Material & ETT
Merocel laser guard (tube wrap) –metal foil with sponge surface Xomed laser shield tube for co2 laser (silicone with outer aluminium powder coating) Laser shield II (silicone tube with cuff)

61 Metal Endotracheal Tube
Norten’s tube – stainless steel spiral without cuff , walls not air tight Laser flex tube – air tight stainless steel spiral with two distal cuffs Bivona fome coff – aluminium spiral tube with outer silicone coat & self inflating foam sponge filled cuff

62 Anesthetic Technique Sharing of airway – use microlaryngeal ETT, ventilating bronchoscope, jet ventilation Irregular respiratory movement – use muscle relaxant Postoperative laryngeal edema – use adrenaline, steroids, head up position, remove stimulus

63 Airway Fire - Protocol Fatal due to:
Thermal injury, chemical burn, bronchospasm, edema, melting & burning ETT lead to obstruction Management: Use of special tubes Stop O2, remove ETT, flood with saline Bag and mask / venturi ventilation If difficult airway, remove ETT on guide wire Check bronchoscopy Post operative, head up, x-ray chest, antibiotics, humidified O2, steroids

64 Thanks


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