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Anesthesia and Otolaryngology

Anesthesia And Otolaryngology

by lauraleighsmith989, Aug 2011

Subjects: principles2 test1

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244 Cards in this Set

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	What is one notable instance when the anesthetist must produce a profound selective muscle relaxation during a period of extreme stimulation?	Suspension Laryngoscopy
	Why is blood loss such an issue during otolaryngological procedures such as tonsillectomies?	B/C these structures are very vascular. There is a generous blood supply to the tonsils from branches of the EXTERNAL CAROTID, maxillary, & facial arteries. These arteries are also closely proximated to the surgical area. blood loss can be masked by blood draining into stomach, b/c blood in stomach is a powerful emetic that increases risk of N/V & aspiration.
	What are the paired laryngeal cartileges?	Arytenoids, corniculates (on top of arytenoids) and cuneiforms.
	What are the unpaired cartilages of the larynx?	Thyroid, cricoid (only contiuous cartilage) and epiglottis.
	What is the correct direction to insert a nasal ETT?	Along the bottom of the nare...along the hard palate....B/C otherwise, the highly vascular turbinates can be damaged and lead to severe bleeding.
	Composition of pharynx Functions:	Pharynx extends from termnal end of nasopharynx, extending to C6. Includes the the oropharynx, and laryngopharynx or hypopharynx Functions: a muscular tube that constricts allowing food passage smooth passage of air voice modulator
	Nasopharynx structure	Continuous with internal nasal cavities (Inferior , Middle, and Superior nasal conchae) and extends to soft palate. Communicates with oropharynx to form posterior aspect of throat.
	Oropharynx structure what is the most sensitive area?	Defined by soft palate, base of tongue, uvula, palatine tonsils and adenoids forming Waldyer's ring. The tonsils are the most sensitive areas. Hypertrophy can cause airway compromise). (tonsillar ring closes off).
	Explain anesthesia and airway management for a thyroidectomy.	Thyroidectomies require isolation of the Recurrent Laryngeal nerve. NIMS tube should be used. The NIMS tube wires should be placed on the VC at the 3 & 9 oclock positions. Use a glidescope to confirm placement with ALL OR staff. Secure NIMS tube so it does not rotate. (Note: NIMS tube will beep before patient coughs/bucks if they are getting light. will also beep with stimulation of recurrent laryngeal nerve.) Pt at risk for hypocalcemia post op.
	Why is it important to have good communication with ENT surgeon?	B/C you are giving control of airway to him/her. Must be able to communicate to keep patient safe.
	What are some anesthetic considerations to ENT surgery?	1) Use of specialized ventilation techniques: Insufflation, Intermittent apnea, Apneic oxygenation 2) Prevention of ETT fire 3) Shared Airway and need for surgical field avoidance. 4) Restricted use of N2O 5) Restricted use of muscle relaxants (due to the need to actively stimulates airway nerves (NIMS tube). 6) Use of specialized equipment: Lasers, High-frequency Jet Ventilation (HFJV). 7) High percentage of pediatric patients. 8) Minimizing blood loss: surgeon may want controlled HOTN during procedure to minimize blood loss. 9) surgeon may want controlled HOTN during procedure to mnimize blood loss and then want normo- or slight HTN at end to perfuse flaps/tissues.
	What is a good reason to extubate a patient deep? What are some disadvantages of deep extubation?	So they will not buck or cough and irritate those surgical beds into rebleeding - which can be significant. Disadvantages: Non-protected airway, risk of aspiration due to loss of reflexes, risk of laryngospasm if extubated in stage II,
	What are the criteria for a deep extubation?	Spontaneously breathing with adequate tidal volumes. At 1.0 MAC agent/deeply anesthetised. Low risk of aspiration or aspiration risk outweighed by benefit of deep extubation. Fully Reversed Well-suctioned.
	When and where is post-extubation respiratory compromise most likely to occur?	In PACU.
	What are some sx of post-extubation resp compromise?	Stridor (inspiratory in peds), snoring, agitation (s/t hypoxia)
	What is the narrowest portion of the airway in adults? Kids?	Remiglottis/ Vocal Cords is the narrowest portion of the airway in adults. The cricoid rings are the narrowest portion of the airway in children (until age 10). .
	What is the tonsil position?	Head down and lateral post-op....allows any blood or secretions to drain out of the mouth.
	What are the two most common lasers used in ENT surgery?	CO2 and Nd:YAG lasers CO2 lasers: Have a longer wavelength. Used for in and around the larynx. Very precise. Use clear goggles. A low energy helium-neon laser is used to air or direct the CO2 laser. Nd:YAG lasers: shorter wavelengths. Shorter wavelength allows the laser to pass through the cornea (less tissue penetration). Stray beams of this laser can traverse the eye to the retina. Use a green lens to protect the eye.
	Shorter laser wavelength allows what? Longer wavelengths?	Less absorption by water and less penetration into tissues. Therefore...longer wavelengths burn more tissue.
	What are some advantages of lasers?	They are precise. produces minimal edema and bleeding. Lasers can be used to cut, coagulate, or vaporize tissues. The exact tissue interaction of a laser is dependent on the type of tissue, wavelength, and the power of the beam.
	What laser is used most often in and around the larynx?	CO2 laser - b/c of shallow depth of burn and extreme precision.
	What are some specific concerns with use of lasers?	1) Eye protection with appropriate colored glasses 2) avoidance of dispersion of noxious fumes. The smoke and vapors from lasered tissue are called plume and are viewed as an environmental hazard...especially when cancerous (want some condolyma in your nares?) 3) fire prevention, particularly airway fires during ENT surgery.
	Glasses for lasers	Clear or basic protective: CO2 Green: Nd:YAG Orange-red: KTP Orange: argon
	What is the main cause of an airway fire in laser surgery?	Laser penetrates ett and ignites the rich O2 supply inside the tube.
	T/F: adding N2O to the gas mix will prevent airway fires.	False: N20, though not flammable, will support combustion (see that little "O" thingy on the end? Yeah, that part...)
	What is the most common hazard caused by lasers? What area of the body does this occur the most?	The most common laser hazard is a thermal burn. The most vulnerable structure are the eyes (of patient and staff). (Lasers do cause airway fires as well but these are rare.)
	What are some techniques for preventing laser injury and fire?	Post warning signs in area. Protect pt eyes with gauze wet with NS and/or glasses. Matte-finish surgical instruments. Use lowest O2 concentration possible or medical air. Avoid use of N2O Be sure lasers are placed in standby when not in use. Use ett specifically prepared for use with lasers (Laserflex, Lasershield). Inflate cuff with NS Shield all adjacent tissuees with wet gauze to prevent laser damage. Suction plume and evacuate from surgical field.
	What technique involving the ETT cuff can aid in preventing airway fires from lasers?	The air in the ETT cuff is combustible and the thin lining in the cuff makes it easier to penetrate with a laser. Fill the ETT cuff with Methylene blue tinged NS. The colored liquid will absorb and disperse heat from the laser and the liquid will reduce combustion.
	Should an airway fire occur, what should the anesthetist do?	#1 concern? Protect and maintain airway. 1 - D/C laser 2 - Stop ventilation, turn O2 off immediately (it is an oxidizing source) and disconnect circuit (it will have bad stuff in it) 3 - Pull ETT immediately (it may be on fire or melting) 4 - Douse fire in airway with NS 5 - Mask ventilate with 100% O2 and reintubate with a smaller tube (the tissues may be edematous and thermally injured - be careful) but one that is large enough to possibly assess the lungs with a bronchoscope. ) 6 - Once airway is secure, examine airway (flexible bronchoscope), remove debris and lavage with NS. 7 - Be ready to have pulmonologist do a flexible bronchoscopy and small airway exam. 8 - Pull ABG, get CXR 9 - Consider steroids to stabilize membranes and minimize edema.
	What is the fire triad?	Fuel source: alcohol, drapes, hair, skin, Ignition source: laser, cauderizer Oxidizing agent (oxygen)
	What do you do if there is an OR fire on the surgical field?	Stop O2, Remove drapes, Flood fields with NS, wet towels
	What happens when an ett is penetrated by a laser?	Blowtorch effect: Positive pressure ventilation in the presence of intralumenal combustion causes blow torch. This burns the respiratory tract/ lungs of the pt.
	T/F: thermal and chemical injury can occur in an airway fire.	True
	What should always be done preop before ENT surgery? Why?	An extensive airway assessment. B/C airway mgmt is nearly always complicated.
	What method of alternative ventilation is an alternative during rigid bronchoscopy?	Ventilation with the Sanders adaptor. Venturi effect entrains air
	If the stream from jet ventilation is not accurately aimed, what are some possible SE?	gastric distention, SQ emphysema, or barotrauma
	In what instances is jet ventilation contraindicated?	Any situation in which an unprotected airway is a concern (full stomach, hiatal hernia, trauma) Jet ventilation can cause gastric distention and increased risk of aspiration.
	Why do you need to plan on using a TIVA when implementing HFJV?	B/C you can't deliver anesthetic gases (reliably in enough concentration to produce depth needed; scavenging can be an issue) in a situation that requires HFJV.
	How is adequacy of ventilaton assess when using jet ventilation?	Observing chest movement, auscultation with a precordial stethoscope, and a pulse oximeter.
	With HFJV which part of the ventilation cycle is active vs passive?	Inspiration is active by the anesthetist triggering the jet ventilation device. Expiration is passive. Be aware that patients with bullae or other airway obstructions can entrain air in their lungs and get highpulmonary pressures, SQ emphysema and pneumothorax.
	When doing pre-op assmt of a child with otitis media what should you assess for?	Assess for sx of URI - these children often have accompanying URIs. Usually, the time between these recurrent episodes is brief, so surgery must be scheduled immediately...myringotomy will resolve the URI. Do not wait.
	Should you reschedule a myringotomy patient with an URI?	Not usually. They are generally on antibiotics and the myringotomy usually resolves the URI. Otitis media can cause hearing loss, so sx needs to happen asap.
	Are sedative premedications routine with myringotomy?	No, even Bilateral myringotomies are brief. The sedative would outlast the surgery & are usually not neccessary.
	T/F: N2O is a safe gas for middle ear surgeries due to its rapid onset and offset.	FALSE: N2O is 34x more soluble in blood than N and therefore diffuses into air-containing cavities faster than into the blood. It can create pressure in the closed space. EXCEPTION: in myringotomy, since the time is short and the tubes are there for pressure relief, this is usually not relevant.
	Why is it critical for patient's head to be still during myringotomy?	B/C a myringotomy knife is used. If they move they can damage the tissues and structures of the middle ear.
	Even if you do not use periop, what should you have ready during myringotomy?	IV supplies (usually no IV) IM Anectine drawn up for pt wt. 1-2 mg/kg IV. 3-4 mg/kg. Atropine 0.2 mg/kg
	During ear and face surgery, what four primary issues does the anesthetist need to be concerned with?	1) Nerve Preservation - particularly cranial nerves VII, IX, X, XI and XII. 2) The effect of N2O on the middle ear 3)Control of bleeding 4)PONV
	T/F: The facial nerve is more sensitive to train-of-four than the ulnar nerve.	TRUE It can show twitches even when the rest of the body is paralyzed.
	What two procedures, especially, require meticulous identification of facial and other cranial nerves?	Resection of glomus tumor or an acoustic neuroma. ID is by electrical stimulation to isolate and verify fx.
	In ear and face surgery, in order to preserve ability of surgeon to isolate and verify nerves, what type of anesthesia should be used?	BALANCED TECHNIQUE W/O NMB'S Skeletal muscle relaxants should be avoided. Volatile inhalants, d/t relaxant properties, should be used judiciously as primary anesthetic...use low doses with opiods. If an opiod-relaxant technique is used, a minimum of 30% muscle response using the peripheral nerve stimulator should be preserved.
	What is a benefit of opioids + low dose inhalants during ENT surgery>>	Provides nerve integrity - get enough anesthesia for procedure while allowing better assmt of fx.
	T/F: It is acceptable to use N2O during a tympanoplasty while the tympanic membrane is open as long as it is turned off as soon as the graft is placed.	FALSE: Administering N2O then d/c'ing the gas after the graft is placed will create a negative pressure in the middle ear that may last up to 6 weeks postop. IF N2O is used, it should be turned off at least 15 minutes BEFORE the graft is placed. Also, use 50% or less N2O...has been shown to cause less graft dysplacement.
	Why do ENT surgeons often inject Epi solutions into the ear?	B/C even one drop of blood can make surgery difficult.
	What are some techniques used to decrease bleeding during middle ear surgery?	---> Injecting the ear with epi (1:1000, 1:50,000, 1:100,000, 1:200,000) in the area of the tympanic vessels to cause VC. ---> Mild head elevation to decrease venous pressure. --->Lowering of arterial pressure with volatile agents. --->Deliberate hypotensive techniques (controversial) ---> Avoid excessive coughing and bucking post-op (deep extubation) ---> Sit pt up post-op.
	During ear surgery, when is the patient at risk for bucking and coughing?	When the head is lifted for bandage application. Pt needs to be deep enough to avoid this. In fact, if not contraindicated, extubate deep.
	Describe a typical anesthetic for a myringotomy?	Inhalational induction with sevo and N2O (ask surgeons permission before using N2O...it will not cause increased middle ear pressure because of the hole in the tympanic membrane). No IV is necessary unless another procedure is being performed that requires an IV (such as PET). No ETT necessary unless difficult airway. Supine position, heat turned to side. Pt must be deep enough to remain completely still so that knife does not damage inner ear with movement. An ear speculum is inserted into the ear canal, cerumen is removed, and an incision is made in the tympanic membrane. Fluid is suctioned out. Tube is inserted in the incision. Antibiotic and steroid eardrops are applied. Sevo is discontinued, N2O is left on. Head is turned to other side and it is repeated.
	What tissues form the tonsillar ring?	Lateral tonsils, tonsillar tissue at base of tongue and adenoids. This ring around the oropharynx can cause airway swelling and closure before and after tonisllectomy.
	What are the anesthetic challenges of an adenotonsillectomy?	risk of airway obstruction, shared airway, mechanical suspension of the airway..(.crow davis mouth gag from mayo table), mgmt of intubation and extubation, pain mgmt and desire for rapid awakening..
	What is a UPPP?	Uvulopalatopharyngoplasty. Done for pickwickian syndrom or OSA.
	T/F: Patients with OSA are at increased risk of right sided heart failure or CHF.	TRUE
	Why are patients having tonsillectomy and/or adenoidectomy at increased risk of obstructing?	B/C their tissues are hypertrophied already.
	In a patient with severea OSA, what would you have available as an option before proceeding with tonsillectomy/adenoidectomy?	The supplies and equipment necc to perform an awake tracheostomy under local anesthesia...just to secure airway before induction of GA.
	What should you consider giving pre-op regardless of what airway mgmt and induction route you choose with tonsillectomy?	An antisialogogue.
	How is anesthesia for T&A usually induced in children?	With a volatile agent, O2 and N2O by mask
	T/F: Tracheal intubation in children is best accomplished by deep inhalational anesthesia or aided by short acting ndNMBD.	TRUE: Tracheal intubation in children is best accomplished by deep inhalational anesthesia or aided by short acting ndNMBD.
	A cuffed tube is reccomended in children older than...	8 to 10 years of age. At 10 years old the cricoid cartiledge is no longer the narrowest part of the airway.
	During T&A surgery, the ett of choice is a _____ tube or _______ tube.	RAE tube or Reinforced tube. Cuffed for kids older than 8-10.
	T/F: A properly sized pediatric ett should allow a leak at 20 cmH2O airway pressure which reduces the likelhood of postop croup and edema.	TRUE
	During T&A, where is the ett secured? Why?	Midline. B/C Crowe-Davis mouth gag has a groove midline for the ett to rest in.
	What sort of anesthetic considerations should the anesthetist consider for Maintenance during T&A or similar procedure?	1) Providing depth of anesthesia adequate to blunt strong reflex activity elicted by procedure (and gag insertion). 2) Rapid return of protective reflexes 3)Good postop analgesia 4)Reduced post-op bleeding (no bucking on vent)
	T/F: Intermediate acting muscle relaxants can be used for T&A	TRUE...as long as they are fully reversed at the end of the case.
	T/F: Ketorolac should never be used post T&A d/t bleeding risk.	FALSE: Ketorolac has been successfully used as an alternative to opioids, has not been found to worsen bleeding and has led to shortened hospital stays following tonsillectomy
	For T&A surgery, replacement of blood loss of <10% of calculated volume can be successfully accomplished by ....	admin of 3 ml of crystalloid per 1 ml of blood loss. (same as always)
	Transfusion should be considered if, during T&A blood loss exceeds.....	10% of calculated blood volume.
	Vigorous suctioning of the oropharynx and nares postop T&A may induce what?	Laryngospasm and Bronchospasm
	What is the max dose of 2% topical Lidocaine spray?	3 mg/kg as 2% topical. 5 mg/kg IV injected 7 mg/kg injected with epi
	T/F: A topical spray of 2% lidocaine (max dose 3 mg/kg) on the glottic and subglottic areas before intubation prevents postextubation stridor and laryngospasm following adenotonsillectomy.	TRUE
	How should tonsillectomy patient be transported post op?	In "tonsil position"---head slightly down and lateral. If patient desires to be upright and in Fowler's or semi-Fowler's they need to be alert and recovered enough to manage their own airway.
	What O2 setup do you place on patient postop T&A?	100% oxygen with high humidity mist via facetent or mask.
	What is the most serious complication vs the most common complication resulting in overnight admission post T&A?	Postop BLEEDING is the most SERIOUS complication. Persistent vomiting and poor oral intake is the most COMMON reason T&A's stay overnight.
	T/F: Sudden high flow hemorrhage is the most common bleeding risk post T&A.	FALSE: slow oozing of the tonsillar bed is far more common that profuse bleeding. (this is because tissues are cauderized and not sutured). the oozing makes bleeding less obvious...can be missed. S/S of bleeding = hypovolemia and PONV.
	What are some s/sx that can make the anesthetist aware that a patient is bleeding post T&A?	Pt may present with sx of hypovolemia (tachycardia, HOTN, agitation). N/V s/t blood being swallowed. If patient is to go back to surgery, restore IV volume and/or blood based on volume lost BEFORE induction.
	If a patient post T&A is suspected of blood loss and is to return to surgery, what should be done?	Eval IV patency - may need 2 lines. Assume a significant amt of blood in stomach...consider AWAKE INTUBATION of trachea in order to maintain reflexes initially. Have a second pair of hands to suction the oropharynx. If awake intub. not an option, perform true RAPID SEQUENCE INDUCTION with head down. (to prevent aspiration) Consider NGT prior to induction to evacuate stomach.
	If a patient presents with a peritonsillar abcess, what is a danger?	Rupture of abcess and aspiration of purulent drainage into lungs --> pneumonia. Use care in instrumentation of the airway.
	What are the sensory nerves innervating the larynx & what do they innervate?	Internal laryngeal (vagus): Sensory to laryngeal mucosa above vocal cords (inferior epiglottis) Recurrent Laryngeal: Sensory to laryngeal mucosa below the vocal cords. Glossopharyngeal: Sensory to superior aspect of epiglottis and base of the tongue
	What are the motor nerves innervating the larynx?	Recurrent laryngeal (which is motor AND sensory): All intrinsic muscles except cricothyroid External laryngeal: cricothyroid muscles.
	What are the muscles controlling the laryngeal inlet and what is their action?	Oblique arytenoids: approximate aryepiglottic folds; narrows inlet Aryepiglottic: narrows inlet Thyroepiglottic: Widens inlet by pulling aryepiglottic folds apart.
	What muscles control the movement of the vocal cords and what do they do?	Cricothyroid muscle: tenses VC; tilts cricoid and arytenoids posteriorly Thyroarytenoid and Vocalis muscles: Relaxes VC; pulls arytenoids forward. Lateral cricoarytenoid: adducts vocal ligaments Posterior cricoarytenoid: abducts vocal ligaments Transverse arytenoids: closes posterior part of rima glottis.
	What are the paired vs unpaired cartileges of the larynx?	Paired: arytenoid, corniculate, cuneiform Unpaired: Thyroid, cricoid, epiglottis.
	Why is glycopyrolate a better choice than atropine or scopolamine as an anticholinergic for ENT surgery?	In comparison, glycopyrolate does not readily cross the BBB & lacks sedative effects. It also is less likely to increase IOP than atropine.
	What are some commone epi concentrations used as additives to LAs during ENT surgery?	1:200,000 or 5mcg/ml 1:100,000 or 10 mcg/ml 1:50,000 or 20 mcg/ml
	What impact does epi have on an LA?	Prolongs action by 50% and reduces systemic uptake by 33%
	What is a generally accepted "safe" total dose of epi?	200 mcg (adults) or 1.5 mcg/kg
	What can volatile anesthetics do to epi?	Volatile anesthetics can accentuate toxic reactions to epi. (b/c of sensitization to cathecholamines??) Ex: ventricular dysrhythmias with isoflurane
	What kind of LA is cocaine and what is it's mechanism of action? When and what route is it normally used in ENT surgery? What potentially dangerous interaction can occur when using cocaine with epinephrine and why?	Cocaine is an ester (hydrolyzed by plasma cholinesterase). It provides for VC by blocking the reuptake of catecholamines into the adrenergic nerve ending. Cocaine is used TOPICALLY in ENT sx (4% to 10% solution) intranasally to VC and shrink the mucosa...(specifically in rhinolaryngeal procedures). Epi is usually injected as well right after cocaine is applied. If cocaine and epi became absorbed in the PLASMA, this could cause a problem...cocaine would block the reuptake of epi, leading to an epi overdose. Severe headaches, HTN, tachycardia, and dysrhythmias could occur.
	What are some advantages of using anticholinergics during ENT surgery? Disadvantages?	Premed with anticholinergics reduces vagal tone, reduces secretions and increases bronchodilation. The addition of anticholinergics adn the use of dry (non-humidified) gases during anesthesia can increase the viscosity of secretions during long cases, limiting the evacuation of mucus or even creating a mucous plug in the bronchus or ETT.
	Should you use anticholinergics in patients with a hx of closed angle glaucoma?	No - it can precipitate closed/narrow angle glaucoma (by preventing contraction of the ciliary muscles, which opens a canal allowing humoral fluid to drain)...Narrow angle glaucoma is an ocular emergency.
	Tx of Laryngospasm	NOTE: on page 1200-1201 in Nagelhout 4th edition there are two algorithms that address pediatric laryngospasm. Partial: CPAP 100% Full (kids): IM atropine 0.2 mg/kg and then IM anectine 3-4 mg/kg
	What are the s/sx of an incomplete obstruction/laryngospasm? Complete airway obstruction/laryngospams?	Incomplete obstruction sx: "Grunting" or audible insp/exp sounds as heard through precordial stethoscope along with tracheal tug and thoraco-abdominal asynchrony. Complete obstruction sx: absence of insp/exp sounds along with inability to deliver positive pressure ventilation.
	What are the 3 primary components of managing an incomplete airway obstruction/laryngospasm?	1) D/C responsible noxious stimuli 2) Increase anesthesia depth: increase volatile agent or IV admin of small dose of propofol. 3) Gentle positive pressure ventilation with 100% O2 at 15-20 cmH20 max with properly applied facemask and concurrent airway opening maneuvers (head tilt, chin lift, jaw thrust).
	Mgmt of laryngospasm (from lecture)...	Tab's points: -Premix your anectine and atropine (IV and IM) before the case. Sux: IV 1.5-2mg/kg or IM 3-4 mg/kg. Atropine: IM 3-4 mg/kg...can mix mix atopine 0.02 mg/kg for peds. -Partial & Total: 100% O2 pos pressure CPAP at 15-20 cmH20 max. -3-4 attempts at positive pressure CPAP max then give 1/2 cc of Anectine (sux) before sats drop.
	What is a danger, particularly in young health patients, during complete laryngospasm?	Neg Pr Pulm Edema. Can happen in as few as 4-5 negative pressure breaths. Sx: pink, frothy sputum, won't respond to 100% O2; you have perfusion without ventilation (V/Q=0 so a shunt) (fluid causes consolidation of alveoli).
	What are some issue associated with a Crowe-Davis mouth gag?	Can get ett displacement to right mainstem or extubation. Increased PAP s/t kinking under the gag. The gag is very stimulating. Gag is attached to Mayo stand so if pt bucks can damage dentition and oral tissues, extubate self, disconnect circuit or sustain neck injury. Needs to be taken down intermittently to allow reperfusion of tongue. Can get tongue ischemia in long case (e.g. - can't dry tonsillar beds). Surgeon should release between tonsils to allow perfusion.
	T/F: The bleeding tonsil is a pediatric emergency.	TRUE
	Should an NG/OG be placed to evacuate stomach in a patient returning with bleeding tonsils?	Yes, if patient can tolerate. Use NS lavage to break up clots that may have formed in stomach.
	What are some anesthetic issue to consider in the care of a patient with bleeding tonsils?	Normal adjuncts such as glidescope may be useless d/t blood obscuring view. Have the difficult airway cart in room and have the airway mgmt plan/supplies easily at hand. Expect edema and blood in airway.
	What is an expected order of airway mgmt in a patient with bleeding tonsil?	Pre-op: replace blood loss with blood transfusion BEFORE going to OR. (Need IV). 1) Assume alot of blood in stomach 2) Awake intubation should be considered to maintain airway reflexes. (If awake intubation not practical RSI with criciod. (Glideoscope will not work due to blood in airway.) 3)Have a second person to suction airway. 4) NGT/ OGT to aspirate stomach contents before induction. Remove after induction.
	T/F: Epiglottitis can be pretreated with aggressive steroid therapy and observed before attempting risky airway manipulation.	FALSE: Epiglottitis is a life-threatening emergency and requires immediate tx. It can rapidly progress from sore throat to complete airway obstruction in <1 hour.
	What are the s/sx of acute epiglottitis?	acute difficulty swallowing, high fever and inspiratory stridor dev w/in LESS THAN 24 HOURS. Posture: sitting upright and leaning forwarder with chin up and mouth open. Changes in posture may increase obstruction.
	T/F: Epigglottitis in children should be confirmed with gentle and careful visualization using toungue blade.	FALSE: Any instrumentation of airway, even a tongue blade, can invoke a laryngospasm. ABG sampling, IV placement and venipuncture are avoided to avoid upsetting the child & trigger laryngospasm
	T/F: In a case of epiglottitis, the anesthesia provider should have a trach tray in the room, open and ready at all times.	TRUE: Total airway obstruction can occur at any time, esp with instrumentation of upper airway. The anesthesia provider needs to be ready and able to rapidly est. a surgical airway if ett cannot be placed. Tracheal intubation is the primary goal - followed by tracheostomy. Definitive tx is prompt extablishment of a secure airway and admin of antibx effect against H. influenzae after blood and throat cx are done.
	Describe the anesthetic mgmt of epiglottitis.	Otolaryngologist present at induction. Induction with Sevo in 100% O2 with child in sitting position. When drowsy, child then supine and assisted mask vent prn to overcome obstruction & deepen anesthesia. Place IV, DL and drop ett 1/2 size smaller than ordinarily selected for that patient. After ett placed, thorough DL to confirm dx. Some MDAs will change oral ett for nasal ett if can do safely.
	What is a sign of resolution of acute epiglottitis?	Development of a leak around the tube. Airway is assessed via DL or fiberoptics while pt under anesthesia to confirm resolution before patient is extubated.
	Why do you go straight from one shot at an ett to a surgical airway in a case of acute epiglottitis?	These kids have no reserve. There is not time to mess around.
	What action can the anesthetist take to prevent the blade of the laryngoscope from slipping into the cleft of a cleft palate pt.?	Pack the cleft with gauze
	Why is it neccessary to get ALL air bubbles out of IV lines/devices when doing a cleft lip/palate case?	B/C these pts often have concomitant cardiac anomalies/defects. Any air in the IV line could be shunted from venous to arterial circ across an atrioventricular defect. Also, because of congenital heart diseases...must be careful with drugs used for maintenance of anesthesia and for infiltration of the operative site (especially epi).
	____ tubes are an excellent choice for cleft palate repair, tonsillectomy, uvulopalatopharynggoplasty, and procedures of the eye or upper face.	Oral RAE tubes. For cleft palate..a flexible connector secured at midline of lower lip. would also work.
	Why is a suture placed in the tip of the tongue and then taped to the patients cheek before emergence of cleft lip/palate surgery?	To eliminate need for oral airway in emergence (keeps the tongue out of the way). If mild obstruction occurs, traction on the suture can clear it. Beyond that, more aggressive airway measures should be taken.
	T/F: If a Logan bow is used on the upper lip after a cleft lip repair, the suturing should be further protected by a deep extubation.	FALSE: When the Logan bow is placed, mask ventilation will be difficult or impossible. Therefore extubation should only be done when the patient is fully awake and has reflexes intact.
	What is a Hunsaker tube?	The Hunsaker Mon-Jet Ventilation Tube is a small diameter, dual-lumen tracheal tube. The overall length of the device is approximately 33 cm, including a positioning structure on the distal end of the tube intended to maintain the position of the jet tube in the central portion of the lumen of the trachea. The larger diameter lumen of the tube is intended for the intermittent jet ventilation delivery of oxygen. The smaller diameter tube lumen is intended to be connected to a gas monitor for monitoring of respiratory gasses and/or airway pressures. An internal stainless steel wire is provided within the larger lumen tube to facilitate extubation in the event of laser damage to the tube. Both the jet tube and the monitoring tube are fitted on the proximal end with a luer type fitting for connection to operating room gas supplies and monitoring equipment. INTENDED USE The Hunsaker Mon-Jet Ventilation Tube is intended to be used as a device for ventilating the patient by the administration of pressurized anesthesia gases, a technique referred to as jet ventilation, in microlaryngeal surgical procedures. CONTRAINDICATIONS The Hunsaker Mon-Jet Ventilation Tube should not be used in patients with narrow airways which could restrict ventilation inspiration and expiration, and result in excessive elevation of intratracheal pressures.
	T/F: Aspiration of purulent peritonsillar abcess exudate can prove fatal.	TRUE: Patients can develop pneumonia very rapidly. It can lead to a case on the M&M review.
	UP3 gets deep extubation, right?	WRONG...these people have OSA. They get a fully awake extubation! Anticipate a difficult airway! Be sure and ask surgeon about steroids to minimize swelling.
	Should you use a precordial stethoscope during ENT procedures?	YES - always when peds cases. Not a bad idea with adult cases.
	What are some considerations for the anesthetist when planning the anesthesia for an ENT case?	Sharing the airway with surgeon. Ett smaller than normal and to one side to allow access to surgical field. A vulnerable airway to which the anesthetist has little/no access s/t table rotation. Preventing extubation, disconnects and leaks. Clear and adequate communication on changes in patient status both ways between anesthetist and surgeon. Providing a smooth transition with protection of established airway and prevention of hypoxia are a primary concern during repositioning of table. Limited visualization of patient's head d/t draping. Far positioning from patient's head or side due to surgical team accessing abdomen for tissue donations.
	How does the anesthetist assess for adequacy of ventilation?	observation of chest movement pulse oximetry EtCO2 and blood gas analysis.
	A sudden loss of breath sounds, rising insp pressures, or drip in EtCO2, esp w/sharp reduction in insp effort, may be to what factors?	Deflation of ett cuff Obstruction of ett Dislodgement of ett Disconnect of anesthesia circuit. Surgical dissection of ett.
	The anesthesia circuit and monitors should be briefly d/c'ed before turning the bed. Why? What should be done first? After?	To prevent undue traction and loss of airway or access. Ventilate pt with 100%O2 for 3-5 minutes with normal TVs. Sats of 100% reasonable goal. If gas is primary anesthetic agent, add IV anesthetic during pre-oxyg. to maintain adeq anesth depth during turning. After turning, reconnect and reassess airway access before pt draped.
	T/F: Reconnection of circuit should be done immediately after bed is relocked.	TRUE
	T/F: After bed reposition, all parameters of adequate ventilation and oxygenation as well as access and monitor fx should be completed before prepping is started.	TRUE
	What side should you put the IV lines, art lines, and CV lines on?	Nonoperative side - and, if possible, make that the side nearest the anesthetist during the procedure.
	T/F: Stimulation of the tibial nerve produces flexion of the big toe and is similar to that of the adductor pollis (arm).	TRUE - good TOF monitoring can be done at this site.
	T/F: The calf will yield too much variance in NIBPs to be of use during ENT surgeries as an alternate BP site.	FALSE: it is an acceptable site for NIBP measurement.
	The speed of the ENT case is a challenge to achieve adequate relaxation and maintain ability to rapidly & safely turn the case. What is one anesthesia method that can achieve this goal?	Intubating dose of SUX followed with a SUX gtt (500mg/500cc NS) on mini-gtt.
	What are some benefits and disadvantages of glucocorticoids in ENT surgery? When should they be given?	Advantages: Glucocorticoids are known to decrease inflammation and decrease N/V. Therefore they can decrease laryngeal edema, reduce N/V and PROLONG effect of LAs (by reducing inflammation/ pain and blood flow to the area). Disadvantages: can delay wound healing and increase the risk of infection due to immunosupression. Give as early as possible in periop period so they can reach peak effect prior to incision.
	T/F: LMAs are never used in ENT surgery d/t risk of routing emetic materials into airway.	FALSE: LMAs can be used for diagnostic fiberoptic larygnoscopy & bronchoscopy; visualization of VC & VC fx; establishing ventilation and intubating patients with difficult airways.
	What are some types of airway devices available to be used during ENT surgery?	Standard ett with flexible adaptor. Microlayrngeal etts (small diam + lg cuff) Red rubber ett (old, since 60s) NIM-EMG ett: assess VC & recurrent laryngeal fx during surgery. RAE: cuffed/uncuffed, oral/nasal, adult/ped. Anode, armored, reinforced, and Kant Kink tubes: embedded plastic or wire coil for >flexibility & memory. Useful when acute neck flexion or sever ETT angles are required as in surg on base of skull or post aspect of neck. Laser resistant etts (several types): usually cuff is filled with NS and a blue dye. NS dampens in prevents ignition...blue dye alerts to cuff penetration by laser. Carden tube/Xomed-Treace Mon-jet tube: small diam cuffed tube spec for use with hi-flow jet ventilation in procedures of larynx & subglottic area. Hand-controlled Venturi jet ventilation through needle tip: Needle fits in side port of laryngo-/bronchoscope & entrains air as it exits at hi pressure. Allows for intermittent O2/anesthetic gas delivery during the procedure. LMA
	What's the problem with using a small diameter tube in an adult airway for ENT procedures? (you'd think it would be a good idea to provide more room for surgery...)	1) It will lead to less ventilation via increased airway resistance. 2) The ETT cuff will be so small that only a small portion will contact the trachea...so you will not have a good seal.
	T/F: Nasal intubation of unconscious patient w/facial trauma is best avoided. Why or why not?	TRUE..to prevent possible penetration of the brain with ett. (Pt may have a LeFort II or III fracture). also avoid NGT's
	Endoscopic surgery includes what procedures?	Panendoscopy Laryngoscopy Microlaryngoscopy Esophagoscopy Bronchoscopy All performed with a rigid or flexible endoscope.
	What is one of the most common endoscopies performed?	Endoscopic sinus surgery.
	Why can a patient get excessive plasma levels of LA & epi during endoscopy (or any ENT surg)?	B/C surgeon gives repeated doses and may give additional epi to vasoconstrict vascular tissue & control bleeding.
	What is a particular risk in endoscopy?	Eye trauma Epistaxis Laryngospasm Bronchospasm Excessive plasma levels of LA & epi
	Compare and contrast some anesthetic considerations of long (>30 min) vs short (<30 min) endoscopies/ENT procedures.	For both, light sedation preop:(older adults & kid esp) may experience resp depression n worse airway obstruction. For longer, airway must be protected from aspiration, esp s/t prolonged airway manipulation and deeper sedation. Both, premed with antisialogogue to dry secretions. Both, an awake oral or nasal intubation w/minimum sedation & topical anesthesia of oral cavity, pharynx, larynx and nasopharynx may be indicated. Short ENT, anethesia maintained with short-acting inhalation and IV agents so that: no patient or VC motion & control SNS response to brief periods of extreme manipulation. Long, intermediate action NMBD for initial intubation.
	Emergence from endoscopy should include what?	Adequate oropharyngeal suctioning, humidified O2, observation in PACU for laryngeal spasm or post-extub croup.
	What is an MLT?	It is a small diameter/lg cuff ett that allows for easier sharing of airway.
	What is the intermittent apneic technique?	Repeated oxygenation of pt via ett and removal of ett (apneic period), during which time surgeon operates. Then anesthetis reinserts ett. ADV: no special equipment. DISADV: It sounds like a freaking nightmare. Labile VS s/t airway manipulation for patient already predisposed to such (etoh abusers, heavy smokers); unprotected airway at times. When would anyone ever use this? "Sounds like a good outpt technique to me, Earl! Stand back n watch this!"
	Why use heliox? How?	B/C the combo of helium and oxygen flows through smaller orifices (tubes, occluded airways) with less turbulence b/c heliox is not so dense; can decrease FiO2 to limit flammability. Add it via a blender from an E-cylinder or wall supply.
	During rigid laryngoscopy with a suspension device, what must the anesthetist be cognizant of?	Depth of anesthesia - the arch is secured to patient's chest/abdomen or the Mayo stand. If pt gets light and moves, they can have laryngopharyngeal trauma and injury.
	A metal needle secured to surgical endoscope or passed through VC can be used to provide what???	Jet ventilation...manually or mechanically. Use as low an FiO2% as possible to minimize flammability.
	What is HFJV?	High Flow Jet Ventilation A ventilation technique with low tidal volumes and high resp rates. A metal needle is mounted in the operating laryngoscope or passed through the cords. Tip of needle is either above or below glottis. The anesthetist direct high-velocity jet stream of O2 into airway lumen. The mixture of O2 forces air into lumen and lungs are ventilated. The high pressure (up to 60 cmH20) jet-injected O2 entrains room air into lung and allows thejet stream of gases into airway for ventilation. Allow enough time for expiration, particularly if patients with severe respiratory disease, to avoid barotruama. Oxygen only HFJV can dry out tissues and provide O2 and gas for ignition...this can increase the risk of airway fire.
	The majority of aspirated items are what?	Food particles.
	Where do aspirated items commonly end up?	Right bronchus: Supine - it may go to RUL Standing - it may go to RLL
	During bronchoscopy, if the telescopic eyepiece is switched for another instrument what happens?	A leak in the ventilatory circuit (remember, ventilation if via a side port and jet ventilation) occurs and protracted periods can lead to apnea. Use of an anesthesia circuit with high FGF, large TVs and high concentrations of inspired volatile gas can compensate for this.
	What is the best anesthetic technique for rigid laryngoscopy and bronchoscopy?	TIVA - it allows greater control of CV stability, allows for relaxation for shorter periods, ventilation with 100% O2 - which allows for longer periods of hypoventilation without hypoxia.
	What are the complications of endoscopy?	General risk of damage to dentition and oral tissue. Eye trauma Laryngospasm Bronchospasm Vagal stim with extreme head extension Tracheal tears by scope. Need for emergent tracheotomy or cricothyrotomy if complete obstruction occurs. Inadequate ventilation (hypoxemia, hypercarbia, dysrhythmias, barotrauma) Excessive plasma levels of LA and epi
	How do you check for airway edema post endoscopy?	Deflate the ett cuff if pt condition allows, occlude lumen for 1-2 breaths and listen for inspiration/expiraton around cuff.
	Is it easy to place an ett post-endoscopy?	Well, just treat it like a tube exchange...use the tube exchanger b/c you can jet ventilate through it if needed.
	What sort of tube would you use for a parotidectomy? Why?	MIM tube - to monitor proximity to nerves.
	What are some patient factors making radical neck dissection difficult to manage?	Tumors often friable and bleed easily, therefore intubation can induce hemorrhage and edema, compromise of airway. Pts freq have hx of heavy etoh & smoking habits - present with bronchitis, emphysema, or CV disease. Prior radiation may leave soft neck tissues stiff - more difficult to DL and intubate. Pt often >65: # of complications double vs <65.
	What are some considerations when placing invasive lines for a radical neck dissection?	Place lines based on condition/need of patient. Consider placement of: CVP line, Foley catheter, arterial line (for beat-to-beat BP during deliberate HOTN), Pulm Artery Cath (if pt has hx of cardiac problems). Avoid internal jugular approach b/c it is proximal to surgical site. Try subclavian as first alternate site; then femoral. Have one (pref 2) lg bore PIVs (14-16g) Have a Type, screen & XM performed and units available.
	Why is it important to carefully monitor fluid balance and not get too positive during a radical neck dissection?	A positive fluid balance at end of surgery can cause edema and congestion in the flap - resulting in vascular compromise. These pts are usually dehydrated with electrolyte balances due to inability to eat/drink with a tumor. So you need to give them fluids...but don't give to too much... Use of colloids may be used to help limit amt. of crystalloid required.
	T/F: Frequently, a tracheostomy is performed preop before radical neck/jaw/tongue dissection.	TRUE
	Describe the placement of a tracheostomy prior to a radical neck/tongue/jaw dissection.	Patient should receive 100% O2. Place ETT. Surgeon will transect trachea - suction the airway & withdraw ETT superior to level of incision. Surgeon places tracheostomy tube in the incision. Once trach tube us placed, withdraw ett, and reassess & confirm trach tube placement. A reinforced tube is then placed in the distal airway by the surgeon and connected to the anesthesia machine. Reassessment of ventilation is performed and the reinforced ETT is then sutured to the chest wall for the entire surgical duration. At the end of surgery, the reinforced tube is switched for a tracheostomy cannula.
	What type of reaction can occur during radical lymph node dissection?	Vagal rxn (bradycardia, HOTN, or cardiac arrest) s/t carotid sinus manipulation. Tx: small dose LA near carotid sinus; admin of an antimuscarinic.
	Explain the risk of venous thrombus & air embolus in radical neck dissection.	Risk of venous thrombus is high s/t long surgery & interruption of venous blood flow. Risk of air embolus is increased s/t head up position and open veins.
	What provides the best dx of air embolism during a radical neck surgery?	Precordial Doppler sonography or Transesophogeal Echocardiography (TEE). Tx: Immediate aspiration of air via CVP is essential.
	What is a big risk when using jet ventilation/HPJV?	Subq emphysema that can lead to an impaired airway.
	Why would you not use N2O during middle ear procedures?	It can sequester in middle ear and cause increased pressure in this closed space. If left on after a graft is placed in a tympanoplasty, it can cause displacement of the graft. If N2O is not turned off at least 15 minutes BEFORE graft is placed during tympanoplasty, it can cause neg pressure that lasts up to 6 weeks. Either one of these scenarios will cause serous otitis, disarticulation of the stapes, displacement of grafts, and impaired hearing. (N2O COULD be used during a myringotomy due to the tubes allowing the escape of air...but ask surgeon before using. ).
	Would you be concerned with PONV with middle ear surgery?	yes - use a multimodal approach; PONV is a real problem.
	Are dissections for head and neck tumors long or short?	Long - often >12 hours. Pt therefore has to be admitted afterwards.
	If procedure calls for delib HOTN, what must be done first?	Assmt preop to determine a safe mean pressure...usually not <60mmHg to maintain cerebral and renal autoreg. & coronary artery blood flow. Recc: art line for sec to sec BP and sampling for lab values.
	T/F: Patients presenting for nasal surgery present no greater risk than the average patient?	FALSE: Patients presenting for nasal surgery often have increased incidence of reactive airway disease.
	What is the Samter Triad?	Nasal polyps, asthma, ASA allergy.
	What types of anesthesia are good for nasal surgery?	LA, LA + IV sedation, GA (prefers IV since inhal. agents vasodilate) Likely with elevated HOB and hypotensive technique to control bleeding. But whatever technique you use, there will be a need for profound vasoconstriction. (with epinephrine, cocaine, or tetracaine).
	What are the most common vasoconstrictive drugs used for nasal surgery?	Epinephrine and cocaine. (cocaine topical , epi injected). Epinephrine and tetracaine 2%
	What can be done to minimize postop retching and vomiting post nasal surgery?	Placement of an oropharyngeal pack & light suctioning of the stomach at emergence. Remove packing and extubate pt when fully awake & regained control of prot reflexes. Use of IV or topical Lidocaine to reduce some coughing prior to extubation to min rebleeding which can drain into stomach and cause N/V.
	What is the max does of Cocaine?	Same as marcaine....3mg/kg is the max dose of cocaine.
	What is the max dose of lidocaine?	4 mg/kg without epi 7mg/kg with epi
	When using an LTA or IV/topical lidocaine post nasal surgery...what is critical to monitor?	The total dose of Lidocaine used by surgeon and anesthetist.
	What sort of ett would you use with nasal surgery?	Oral RAE.
	Nasal packing post nasal surgery will make your patient an ______ _______ ________.	Nasal packing post nasal surgery will make your patient an obligate mouth breather.
	What is an acceptable safe dose of of epinephrine?	1.5 mcg/kg (200 mcg in adults)
	What is the max safe dose for: Cocaine Lidocaine Epineprine	Cocaine: 3 mg/kg Lidocaine: 4 mg/kg without epi 7 mg/kg with epi Epinephrine: 1.5 mcg/kg; (200 mcg in adults)
	Why worry about plasma levels of epi/LA during nasal surgery?	B/C the surgeon may give multiple infusions of LA with epi for pain and control of bleeding.
	What type of ett will be preferred for maxillofacial surgery that does not allow for oral intubation?	Nasal ett/Nasal RAE inserted after serial dilation with nasopharyngeal airways. Pretx with nasal vasoconstrictor med.
	Why is it important to do a thorough preop assment on dental surgery/oral surgery candiates?	Many dental surgery pts have developmental or physiological anomalies that impact anesthesia (downs syndrome, etc). -Small oropharynx -Enlarged tonsils -Large tongue -Increased secretions -Atlanto-occipital instability -Congenital heart disease.
	How are seizure d/o's related to blood loss during oral surgery?	Dilantin causes gingival hyperplasia; which can lead to significant blood loss.
	How are throat packs helpful in oral surgery?	They help prevent PONV by keeping blood out of the stomach. MUST MONITOR THEIR REMOVAL AND GET RIGHT COUNT TO PREVENT OBSTRUCTION OF AIRWAY FOLLOWING EXTUBATION!!!
	What is a good premedication for children and people with developmental disability?	Oral midazolam 0.5 mg/kg Ketamine IM 3-4 mg/kg (Ketamine dart)
	If a patient presenting with trauma is unable to be safely intubated by DL, what other options do you have for tracheal intubation?	Fiberoptic intubation Retrograde wire placement Jet ventilation via cricothyrotomy Emergent tracheostomy
	What issues may the anesthetist see in a trauma patient that will dictate intubation strategy?	Tracheal deviations Hematomas & bleeding in airway Edema of soft tissues of airway Foreign bodies, avulsed teeth, bone fragments. Injury of pharynx & sinuses Limited oral opening (splinting s/t pain)
	If an anesthesia provider sees a patient with facial trauma what should that alert him/her to consider?	Cervical spine injury - secure the cervical spine. Lateral images should have c1-c7 visible. C7 most common site of traumatic fx. Use MAIS (manual in-line axial stabilization) and/or rigid c-collar to minimize risk of further injury.
	If a trauma patient has signs of smoke and blistering evident in are of mouth and nares OR has hx of inhalation of toxic combustion smoke, what should happen IMMEDIATELY?	Intubate this patient IMMEDIATELY...edema of face and glottis can occur very rapidly after this type of exposure and produce severe airway compromise.
	Are nasal intubations a likely option for a facial trauma patient? NGTs?	No - if the patient has a LeFort II or LeFort III fx (which disrupts the cribiform plate and opens the underside of the cranial cavity), may result in a tube to the brain...which recent research indicates is not the best way to oxygenate a patient. The NGT will introduce contaminated material into the subarachnoid space and cause meningitis in addition to mechanical injury to brain itself.
	Can a patient with a LeFort I fx be safely nasally intubated?	Yes - no disruption of cribiform plate. Can go nasal or oral
	What s/sx should the anesthetist be vigilant for that would indicate disruption of the cribiform plate in a facial trauma paient?	Cerebral fluid in nose (CSF) Blood behind tympanic membrane (look in ears) Periorbital edema "Raccoon eyes" hematoma
	If in doubt about the suitability of an airway for intubation of a facial trauma patient, what should you consider?	Awake oral intubation with topical anesthetic. OR Tracheostomy under LA
	Mandibular fractures: oral or nasal intubation?	Nasal- if possible, so alignment issues can be resolved.
	NGT for mandibular fracture?	Yes, to decompress and evacuate the stomach and minimize blood in the stomach during surgery.
	What should always be easily reached and available at the bedside of a mandibular fx patient upon emergence and postop?	WIRE CUTTERS.
	Mandibular fx: extubate deep or awake?	Awake extubation...mouth is wired shut.; possibly will leave intubated and sedated if swelling or residual somnolence persists.
	Orthognatic Surgery/ Osteotomies: hypotensive technique?	Probably...facial surgeries have alot of blood loss.
	How are orthognatic procedures performed? What types of Lefort fx's may be purposefully performed? What type anesthesia?	MANDIBLE is sagitally split to move the lower jaw either forward or back. A lefort I or II fx may be created to move the MAXILLA as well to correct for anomalies. Nasal intubation Deliberate HOTN to control bleeding. Mouth wired shut with emergence. Awake extubation with reflexes intact. Wire cutters at bedside during emergence and postop. Pt may have edema that progress for 24 HOURS POSTOP. Pt may have to remain intubated for several days.
	Anesthetic considerations of orthognathic surgery?	nasally intubated TXM - can have extensive blood loss Wire cutters at bedside. Prep for hypotensive technique. Be prepared to deal with small mouth openings, anomalies and challenges to the airway. Pt. may need to be intubated several days d/t extensive edema. Extubate only when awake and in full command of protective reflexes.
	What nerves coordinate swallowing and movement of the larynx up to meet the epiglottis?	Superior Laryngeal Nerve Recurrent Laryngeal Nerve Glossopharyngeal Nerve
	What bone supports the larynx?	The Hyoid Bone It provides the connection of the oropharynx to the trachea.
	What is the function and branches of the facial nerve?	Temporal Zygomatic Buccal Mandibular Cervical Posterior auricular The motor and sensory supply to the muscles of the face involved in facial expressions.
	What are the branches and function of the trigeminal nerve?	Opthalamic Maxillary Mandibular Provide sensory and motor innervation to the nose, sinuses, palate, and tongue (along with the glossopharyngeal nerve.)
	What is the function of the glossopharyngeal nerve?	Provides motor and sensory innervation for the base of the tongue, nasopharynx, and oropharynx. Responsible for the gag reflex.
	What are the branches of the superior laryngeal nerve and their functions?	Internal laryngeal Nerve - Pierces the thyrohyoid membrane and provides sensory to the Larynx ABOVE THE VOCAL CORDS. External Laryngeal Nerve - It descends on the larynx, beneath the sternothyroid muscle, to supply MOTOR the cricothyroid muscle. (all other motor is provided by the recurrent laryngeal nerve).
	What is the function of the recurrent laryngeal nerve?	Lies b/n the trachea and the esophagus. SENSORY to the larynx BELOW THE VOCAL CORDS MOTOR to ALL the muscles of the larynx EXCEPT THE CRICOTHYROID MUSCLE.
	Why can laryngoscopy cause bradycardia?	The sensory to the inferior aspect of the epiglottis and to the vocal cords is via the recurrent laryngeal nerve...which is part of the vagus nerve. This leads to vagal stimulation.
	If the surgeon needs to access the chest and abdomen for a skin graft for the esophagus, where does the CRNA need to be positioned in regards to the pt for ENT sx?	At the foot of the bed.
	What are the diff kinds of ETT cuffs?	Low volume, high-pressure High volume, low pressure Self inflating foam (binova) cuff Automatic regulating cuff. (purpose was to reduce pressure on the tracheal wall to pvt injury)...problem is that with over inflation or movement...cuff can leak or increase pressure anyway.
	Describe a NIM tube (reinforced ETT) and explain it's function.	It has a red area that must sit directly in contact with the vocal cords. Two wire electrodes allow for monitoring vocal cord movement. This allows the surgeon to identify the recurrent laryngeal nerve (which supplies motor to the vocal cords) prior to traction or severing the nerve.
	What is a problem with RAE tubes?	The preformed bend may be too short or long for an individual pt's airway...must CAREFULLY check breath sounds, chest rise, and inspiratory pressures after intubation to make sure that it is not too deep or shallow.
	What is a FastTrac LMA or ILMA?	Intubating LMA - well suited for visualization of the vocal cords adn their function. With the use of a Portex connector that has a diaphragm port, a fiberoptic scope may be inserted into the lumen of the LMA w/o interrupting ventilation. A small flap moves to all ETT placement. (Pt must be deep enough to prevent laryngospasm.)
	The most common used LA's for ENT sx are _____'s.	The most common used LA's for ENT sx are amide's.
	What types of conditions can alter the effects of LA's	Acidosis, infection, hyperthermia, Hypercarbia. Mx or large doses of LA, acidosis, liver disease, and hypovolemia all lower the toxic threshold of LA adn are important considerations in calculating total dose.
	When using an LA for ENT surgery, what information must you know before injecting any LA?	The total dose based on pt weight must be determined prior to injection and must take into acct all LA used during the case by the surgeon AND the CRNA.
	What is a neat trick to prevent toxic effects of an LA?	Mixing an ester with an amide ex: Chloroprocaine mixed with bupivicaine allow for a quick onset of action and an extended block.
	The duration of action of an LA is proportional to ?	The duration of action of an LA is proportional to the time the drug is in contact with nerve fibers. Therefore vasoactive drugs like epi will limit systemic absorption and maintain higher drug conc at nerve fibers...increasing duration of action.
	What two types of ENT procedures have the highest risk of PONV?	Surgery of the middle ear. (avoid N2O) Tonsillectomies...due to the amt of bleeding and risk of blood draining into the stomach (blood in stomach is a big cause of N/V). (Throat packs intraop can pvt this.)
	What effect does remifentanyl have on ENT sx?	remifentanyl reduces middle ear blood flow, creating a dry surgical field for tympanoplasty. Used with propofol drip to create deliberate HOTN.
	What must you monitor when creating deliberate HOTN for ENT surgery?	MAP (>60...or higher with HTN pts). Urine output cerebral and cardiac perfusion pressure). ABG's (might need an art line).
	Explain necessary anesthesia for microsurgery of the larynx.	Good muscle relaxation of the cords is mandatory. Short acting NMB can be used for brief procedures. A microlaryngeal airway may be used to share the airway with the surgeon without risking inadequate cuff size. Another technique is Intermittent apnea, requireing frequent intubations and extubations...this is risky.... Another method is HFJV.
	Pt's with COPD, obesity, bronchospasm, decreased pulmonary compliance or increased airway resistance are at risk for what with HFJV?	Hypoventilation.
	Foreign body aspiration most often occurs in the ______ of the lungs. If aspiration occurs while lying down, the object will end up _____> If aspiration occurs while standing up, the object will end up ______.	Foreign body aspiration most often occurs in the right bronchus of the lungs. If aspiration occurs while lying down, the object will end up in the right upper lobe. If aspiration occurs while standing up, the object will end up right lower lobe.
	How do you provide anesthesia to remove a foreign aspirated body?	Place pt in the sitting position. Administer an antisialagogue, H2 antagonist, and reglan to decrease secretions and risk of N/V. Inhalational induction...do not breathe for the pt...might push the object farther down. Allow spontaneous respirations. Use magill forceps if above the larynx. If below the larynx, use a rigid bronchoscope with a telecope eyepiece and optical forceps. Bronchoscope goes through the vocal cords, ventilating with a side port. COUGHING AND BUCKING MUST BE AVOIDED to pvt injury to pt...pt must be deep. B/C of this...TIVA is better after induction...switch to TIVA and ventilate with 100% O2 to pvt hypoxia.
	What are some complications to be wary of during and after removal of foriegn body aspiration?	Damage to dentition, gums, upper lips Vagal Stimulation. Tracheal tears Hypoxemia Hypercarbia barotruama dysrhythmias Laryngeal or subglottic edema post-removal...can occur for up to 24 hours post removal.
	Differentiate b/n chronic and recurrent otitis media. Treatment?	Chronic Otitis media manifested as fluid in the middle ear. Recurrent otitis media is defined as six or more episodes of otitis media in the past year. Treatment is a myringotomy (tubes in the tympanic membrane) to pvt damage and hearing loss.
	Explain the mouth gag used in T&A's	The surgeon inserts a mouth gag before the procedure (after sedation and intubation) to prevent blood from dripping back onto the vocal cords. It had a groove midline for the ETT. Pt must be deep enough to not gag on the gag during or after insertion. at the end of the procedure, the surgeon will release the gag to ensure that all bleeding has been controlled. An orogastric tube is inserted and irrigated to remove blood and secretions to pvt PONV. Light suction only to pvt laryngospasm.
	Explain the stages of cleft palate repair.	Lip and hard palate are repaired in 1st surgery. Soft palate and other deformities are repaired in subsequent surgeries after the child is 6 months old..
	How can a pt taking Phenytoin complicate dental surgery?	Phenytoin for seizures can cause gingival hyperplasia. Because the gingiva are highly vascular, any surgical manipulation during restoration may lead to significant blood loss.
	What type of anesthesia is best for Dental Restoration Procedures?	Nasal intubation with general anesthesia. Nasal Intubation: Give a topical VC like cocaine or nasal spray. Lubricated intranasal trumpets may be inserted into the most patent nasal airway. Starting with a smaller nasal trumpet increasing size to dilate the airway. Nasal tube is then placed and then threaded through Vocal cords with magill forceps and laryngoscope. Throat packs are placed to prevent blood from seeping on to vocal cords. (Must chart removal of throat packs post op to prevent respiratory obstruction following extubation.)
	Explain anesthesia for nasal surgery.	High incidence of reactive airway disease due to allergies. (sinus surgeries). Use epi and cocaine or tetracaine to VC the nasal tissues. Use a hypotensive technique or slight head elevation (10 to 20 degrees) during the procedure. Use TIVA (propofol) instead of volatiles because volatiles can increase VD and bleeding. Place an oropharyngeal pack and give light suctioning of the stomach at emergence to pvt N/V. Use an Oral RAE ETT. Use an LTA kit ot prevent coughing and bucking with emergence. Extubate an awake pt who has regained control of protective reflexes.
	What is samter syndrome?	Pt's with allergies who need sinus surgery will have nasal polyps, asthma, and an aspirin allergy.
	What is the best way to ascertain the extent of traumatic injury to neck/ air way (dislocations and fractures?) What is the most common area of injury to the spine?	What is the best way to ascertain the extent of traumatic injury to neck/ air way (dislocations and fractures?) lateral cervical radiograph What is the most common area of injury to the spine? C7 Suspect injury to the vertebral artery until you know otherwise.
	Define all 3 Lefort fx's and explain their anesthesia care.	LEFORT 1: A horizontal fx of the maxilla extending from the floor of the nose and hard palate, through the nasal septum, and through the pterygoid plates posteriorly. The palate, the maxillary alveolar bone, lower pterygoid plate, and part of the palatien bone are all mobilized. (looks like a mustache). Causes little difficulty for anesthsia provider. : ie oral or nasal intubation is not a problem. LEFORT 2: A triangular fracture running from the bridge of the nose, through the medial and inferior wall of the orbit, beneath the zygoma, and through the lateral wall of the maxilla and the pterygoid plates. (looks like tear tracts.). Disruption of the cribiform plate can occur, opening the underside of the cranial cavity...ie you could intubate the brain. LEFORT 3: Fracture totally seperates the midfacial skeleton from the cranial base, traversing the root of the nose, the ethmoid bone, the eye orbits, & the sphenopalatine fossa. (looks like dark circles under the eyes). Disruption of the cribiform plate can occur, opening the underside of the cranial cavity...ie you could intubate the brain. Nasal intubation with a lefort II and III fracture can cause brain intubation or meningitis (if it only goes into the subarachnoid space.).
	If you have a trauma pt with a small mouth opening...what do you do to differentiate the cause (pain related or mechanical) ?	Give a short acting dose or narcotic or midazolam. Opens = pain related Doesn't open = mechanical...could be a mandibular or maxillary fx...need to nasally intubate...pt's mouth will be wired shut.
	Explain anesthesia with a mandibular or maxillary fx.	Nasally intubate. Mouth wired shut after fixation. Emergence: pt must be fully awake wiht intact reflexes to extubate. Have wire cutters availiable in case of airway emergency.
	Venous stasis and disruption of flow in radical neck dissections can cause what problems?	1) Venous thrombus 2) Laryngeal edema, vascular occlusion, and obstruction
	Explain the population of pt's that need radical neck dissections. What type of anesthesia?	Older > 65 years. Smokers: COPD, emphysema, CV problems, At high risk of hemmorage and edema with intubation. Pt's that have recieved radiation will have soft tissues that are less mobile and are harder to intubate. Tumors that interfere with eating and drinking will cause hypovolemia, electrolyte imbalances, malnutrition. Anesthesia: inhalation agent and supplemental narcotics. Nerve stimulators and NIMS tube used to detect nerves. Deliberate HOTN can be used to pvt excessive blood loss. CVP adn art line. Foley. Trach may be placed.
	How can you minimize the risk of post op croup or edema in children with ENT sx?	A properly sized pediatric ett should allow a leak at 20 cmH2O airway pressure

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