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PERIOPERATIF ANESTESI

OPERASI
ORAL-MAKSILOFASIAL

Dept./SMF Anestesiologi Dan Terapi Intensif


FKUSU/RSUP H.Adam Malik Medan
In-Patient Dental Anesthesia

Major Oral & Fasciomaxillary Surgery


In-Patient Dental Anesthesia

Classifications:

Major Orthognathic Surgery

Tumor Surgery

Palate Surgery
In-Patient Dental Anesthesia

Concerns:
Altered Airway Anatomy

Shared Operative Field

Anesthetic Drugs Choice

Appropriate Time for Tracheal Extubation


Airway Management

Anesthetic Management
Airway Management
Airway Management
Choice of the technique depends on several factors:

Patient safety
Experience of the anesthetist
Known difficult airway
Requirement: nasal or oral
Post operative jaw wiring
Airway Management

History
Physical Examination
Further Evaluation
Difficult Airway & Algorism
Airway Strategies
History

Documented History of Difficulties with general anesthesia


or, more specifically, mask ventilation or endotracheal
intubation

Congenital Syndromes Associated With Difficult


Endotracheal Intubation

Pathologic States That Influence Airway Management


Selected Congenital Syndromes Associated With Difficult
Endotracheal Intubation
SYNDROME DESCRIPTION
Down 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 Laryngoscopy difficult


(mandibulofacial
dysostosis)
Turner High likelihood of difficult intubation
Selected Pathologic States That Influence Airway Management
PATHOLOGIC STATE DIFFICULTY
Infectious epiglottitis Laryngoscopy may worsen obstruction

Abscess (submandibular, Distortion of airway renders mask ventilation or


retropharyngeal, Ludwigs intubation extremely difficult
angina)

Croup, bronchitis, Airway irritability with tendency for cough,


pneumonia laryngospasm, bronchospasm
(current or recent)

Maxillary/mandibular Airway obstruction, difficult mask ventilation, and


injury intubation; cricothyroidotomy may be necessary
with combined injuries
Laryngeal fracture Airway obstruction may worsen during
instrumentation
Cervical spine injury Neck manipulation may traumatize spinal cord
Selected Pathologic States That Influence Airway Management
PATHOLOGIC STATE DIFFICULTY
Upper 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 Mandibular hypoplasia, temporomandibular joint
rheumatoid arthritis arthritis, immobile cervical spine, laryngeal rotation,
cricoarytenoid arthritis all make intubation difficult
and hazardous
Ankylosing spondylitis Direct laryngoscopy maybe impossible
Soft tissue, neck injury Anatomic distortion of airway
(edema, bleeding,
emphysema)
Laryngeal edema Irritable airway, narrowed laryngeal inlet
(postintubation)
Selected Pathologic States That Influence Airway
Management
PATHOLOGIC STATE DIFFICULTY
Angioedema Obstructive swelling renders ventilation and intubation
difficult

Endocrine/metabolic Large tongue, bony overgrowths


acromegaly
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
Physical Examination

Inspection (Obvious Problems)


Mouth Opening (3 4cm)
Oral Cavity Examination
Mallampati Score
Thyromental Distance (3 large fingers = 5 cm)
Neck Movement
Further Evaluation
PRE-OPERATIVE ASSESSMENT OF THE
AIRWAY

Indirect or Fiberoptic Laryngoscopy


X ray: Chest , Cervical Spine
CT or MRI
Flow- Volume Loops
Pulmonary Function Tests
Cormack-Lehane Laryngeal View Scoring
Difficult Airway
Difficult airway
The clinical situation in which a conventionally trained
anesthesiologist experiences difficulty with mask
ventilation, difficulty with tracheal intubation, or both

Difficult mask ventilation


1) inability of unassisted anesthesiologist to maintain
SpO2 > 90% using 100% oxygen and positive
pressure mask ventilation in a patient whose SpO2
was 90% before anesthetic intervention;
Or
2) inability of the unassisted anesthesiologist to prevent
or reverse signs of inadequate ventilation during
positive pressure mask ventilation
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
Airway Management

Normal Airway Difficult Airway

Awake or Sedated Under GA


Difficult Airway

Awake Under GA/Sedation

Different Laryngoscopes,
Awake Laryngoscopy Stylets

Awake Fiberoptic LMA/ I LMA/FO

Tracheostomy Fiberoptic

Retrograde Intubation Tracheostomy

Blind Nasal Intubation


AWAKE TECHNIQUES
Difficult Airway

Awake

Awake Laryngoscopy

Awake Fiberoptic

Tracheostomy

Retrograde Intubation
AWAKE TECHNIQUES
Glosso-Pharyngeal Nerve IX Nerve

Posterior pharyngeal fold at its midpoint, 1 cm deep to the


mucosa of the lateral pharyngeal wall
AWAKE TECHNIQUES

Superior Laryngeal Nerve

Pyriform Fossa
External :1 cm medial to the superior cornu of the Hyoid
Bone to pierce the thyrohyoid membrane
AWAKE TECHNIQUES
Trachea & Vocal Cord

Atomizer
Injection
AWAKE TECHNIQUES

Laryngoscope Blades
AWAKE TECHNIQUES

McCoy
AWAKE TECHNIQUES
AWAKE TECHNIQUES

FIBER OPTIC INTUBATION


AWAKE TECHNIQUES

SURGICAL AIRWAY
Under General Anesthesia

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

1) Inhalational / asses: Ventilation / Veiw

2) Stillete / Different Laryngeoscopes

(=/- short acting MR)

3) LMA / LMA + F.O.

Face Mask + F.O. + Modified Oral AW

4) F.O using Sedation Or light GA

5) Tracheosyomy under light GA

6) Blind Nasal Technique


GA TECHNIQUES

Laryngoscope Blades
GA TECHNIQUES

McCoy
GA TECHNIQUES
Laryngeal Mask Airway (LMA)
GA TECHNIQUES

LIGHTED STYLETS/LIGHTWAND

Well Circumscribed Glow


GA TECHNIQUES

Unconventional LMA

F.O. + LMA Fast Track LMA


GA TECHNIQUES
Blind Nasal Intubation

90% successful but may need several attempts


Contraindicated in fractured base of skull
Cervical collar in situ
GA TECHNIQUES
FIBER OPTIC INTUBATION
GA TECHNIQUES

Rigid Fiberoptic
laryngoscope

Retromolar
Fiberscope
GA TECHNIQUES
BULLARD LARYNGOSCOPE
GA TECHNIQUES

SURGICAL AIRWAY
Classification According to Mouth Opening

Awake or Sedated
Normal mouth opening

SLN block +Transtracheal LA

Limited

Retrograde Intubation

Extremely limited

Awake Intubation with F.O.


Awake Intubation Under Anesthesia Blind Technique
Spontaneously Risk of apnea with Blind technique such
breathing awake difficulty mask as BNI, Light wand,
patient without the risk ventilation Retrograde wire
of apnea intubation, LMA, and
Suitable for patients Combi tube are C/I in
Suitable for patients with no obstructive tumor patients
with obstructive symptoms because of the risk of
symptoms bleeding and tumor
dislodgement.
Needs patients
cooperation
Success rate in good
experienced hands
Risk of complications
from nerve block
Failure to intubate may
Incase of failure , can result in fatal outcome
be postponed for Multiple attempts may
reconsideration lead to bleeding and/or
aspiration
Techniques
Under Vision

Awake Intubation
Fiberoptic Tracheostomy
Laryngoscopic Under GA
Blind
Techniques

Retrograde Wire
Lighted Stylet/ Blind Nasal
Intubation Combi-Tube
Light wand Intubation
Modified
Techniques

Bullard
Wu Scope
Laryngoscope
NEVER PARALYSE UNTILL POSSIBLE VENTILATION
HAS BEEN ESTABLISHED

RECENT SUCCESSFUL INTUBATION DOESNOT MEAN


FUTURE POSSIBLE INTUBATION

FULL RANGE OF DIFICULT INTUBATION EQUIPMENT


MUST BE AVAILABLE
ALL PHYSICIANS RESPONSIBLE FOR AIRWAY
MANAGEMENT SHOULD BE PRACTICED IN AT LEAST
ONE ALTERNATE TO BAG & MASK VENTILATION.
THESE ALTERNATIVE INCLUDES THE FOLLOWING:

LARYNGEAL MASK AIRWAY


COMBI TUBE
TRANSTRACHEAL TECHNIQUES

LMA PROVIDE RESCUE VENTILATION IN 94% OF


CASES OF UNANTICIPATED DIFFICULT INTUBATION
HAVING DISCUSSED ALL THE MANAGEMENT
STRATEGIES AWAKE TECHNIQUE IN GENERAL &
AWAKE FIBER OPTIC TECHNIQUE ESPECIALLY, IS
THE MOST COMMONLY USED & SAFE TECHNIQUE
ANESTHESIA
MANAGEMENT
Special Consideration

Preoperative Management

Intraoperative Management

Post operative Management


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.
PRE-OPERATIVE

MANAGEMENT

Adequate pre-operative work-up of Cardiac Status &


Pulmonary Functions should be carried out using
various diagnostic modalities with the objective of
optimizing patients condition
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)
INTRA-OPERATIVE
Routine
Monitoring
NIBP
ECG
SPO2
ETCO2
TEMPERATURE

Choice of Volatile Agent


Choice of Anesthesia
INTRA-OPERATIVE MANAGEMENT
SPECIAL 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
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.
INTRA-OPERATIVE MANAGEMENT

Invasive 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 to


manipulation in the area of carotid body and sinus.
INTRA-OPERATIVE MANAGEMENT

Central Venous Pressure Monitoring

Risk of venous air embolism during neck


dissection

As a guide to the management of fluid therapy

The site of insertion is either:


Antecubital vein
Femoral vein
INTRAOPERATIVE MANAGEMENT

Use of Muscle Relaxants

During surgery IPPV is carried out without muscle


relaxant as surgeons need to identify the nerves
during surgery
INTRAOPERATIVE MANAGEMENT

Induced Hypotension

Mild degree of hypotension is required during


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

15-30 degree head up tilt


Increasing the conc. of volatile anesthetics
Use of peripheral vasodilators
Use of beta blockers
INTRAOPERATIVE MANAGEMENT

Blood 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
INTRAOPERATIVE MANAGEMENT

Haemodynamic Changes
During radical neck dissection, the traction or
pressure on the carotid sinus and / or stellate
ganglion can cause following:-

Brady-dysrhythmias
Sinus arrest leading to asystole
Wide swings in blood pressure
Prolonged QT Interval
INTRAOPERATIVE MANAGEMENT

Haemodynamic Changes Treatment

Immediate cessation of the stimulus

Blockage of the sinus with local anesthetic by the


surgeon

Vagolysis by atropine
INTRAOPERATIVE MANAGEMENT
Venous Air Embolism

When the venous pressure in neck veins is low and


these veins are open to atmosphere, air is sucked in
causing air embolism.

Diagnosis
Early Detection
Hypoxia
Hypotension
Hypocarbia
INTRAOPERATIVE MANAGEMENT

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
POST-OPERATIVE CARE

I. ROUTINE CARE

II. SPECIAL CONSIDRATIONS

ICU care & Possible mechanical Ventilation


Hemodynamic Instability
Analgesia
Tracheostomy
POST-OPERATIVE CARE
ICU 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
POST-OPERATIVE CARE

Haemodynamic Instability

As bilateral neck dissection may result in post-operative


hypertension and hypoxic drive because of the denervation
of the carotid sinus and carotid body
POST-OPERATIVE CARE

Analgesia

Non Steroidal Anti-inflammatory Agents should be


used as opioids cause respiratory depression in
spontaneously breathing patients

When patient is on ventilator opioid analgesia can


be given
POST-OPERATIVE CARE

Tracheostomy Care

Humidified Oxygen
Intermittent Suction
Sterile Precautions
Adjustment of cuff pressure to15-
20 mmHg
Complications
THANK
YOU

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