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44 Cards in this Set

  • Front
  • Back
What are three functions of the larynx?
Airway protection
-reflexive and involuntary
What considerations are there in airway evaluation and management of head and neck surgery?
Airway obstruction, compression of underlying structures D/T tumors, infection, or trauma
-May need radiologic eval

Airway may be shared by surgeon
What problems might be anticipated during placement of PE tubes?
Bad mask airway D/T swollen tonsils/adenoids
-have adjuncts available
-consider ETT

-children are more prone to laryngospasm than adults
-treat with positive pressure ventilation, if unsuccessful, Sux 4mg/kg IM

No IV access

Too much anesthesia
What are anesthetic considerations for PE tube placment?
Procedure is very short
-anesthesia provided with Volatile agent and N2O

case may proceed even if pt has URI; pt may not be free of URI until PE tubes are placed
What are anesthetic considerations for tympanoplasty and middle ear surgery?
1. Pt is 180 degrees from anesthetist
2. head is lateally rotated-avoid tension on head of sternocleidomastoid muscles.
3. Facial nerve monitoring-no NMB per Rich. (BARASCH says preserve a 30% response on twitch if NMB used)
4. long surgery (2-6 hrs) with post auricular incision and minimal blood loss)
5. N2O must be D/C'd 30 minutes prior to graft placement-better not to use ast all
What are two types of Evoked Potential Monitoring done during middle ear reconstruction?
Facial nerve monitoring
Brainstem auditory evoked potential (BAEP)
-monitors CN VIII and partially brain stem function
What type of ETT is best suited for middle ear surgery?
Oral RAE ETT (right angle preformed)
What anesthetic management techniques will be employed with middle ear surgery? (agents, drugs)
No N20 or NMB
Mainteance primarily gas
May use propofol infusion
Minimize use of narcotics
Anti emetics-PONV may "blow" graft
What is used to topicalize in nasal surgery?
Oxymetazoline (0.05%) (Afrin)
What factors should be considered in determiming if MAC (monitored anesthesia care)is appropriate for nasal surgery?
Pain tolerance
Willingness to stay "awake"
What position will the pt be in for nasal surgery?
Head up 30 degrees to decrease bleeding
Bed may be 90 degrees form anesthesia provider
What is used for nasal prep? Why?
4% cocaine pledges-vasoconstriction and numbing. prevents reuptake of catecholamines

Lidocaine with epi (1:100K or 1:200K)-vasoconstriction. epi has sympathomimetic properties
When using local/MAC for nasal surgery, what are the anesthetic management concerns? (agents/drugs)
Enough sedation for comfort but can't stop breathing- Light propofol infusion, versed, fenatnyl or remifentanyl (with remi, its "off" when you turn it off)

Hemodynamic control-esmolol for HTN (HTN increases bleeding), metoprolol for tachycardia

O2 cannula in mouth- head is completely draped- beware of combustion danger-vent O2 from under drape
What considerations/techniques will be useful during GETA in nasal surgery?
Oral RAE tube
VA- hypotensive technique to control bleeding (4% uncontrolled bleeding)
emergence-suctrin oropharynx well, use OG tube
Anti emetic-Zofran 4mg IV
What is the most common elective pediatric procedure?
What are three major considerations in airway evaluation for T&A?
Adenoidal hyperplasia
Tonsilar Hyperplasia
Obstructive sleep apnea
Why is sevofluranre used for T&A?
Pt will probably not have an IV. need to mask pt to sleep with nonpungent agent. Halothane not generally used in US, can't acheive MAC with N2O alone.
If the pt does not have an IV, how will you achieve NMB to intubate for T&A?
Use Sevoflurane to 5 or 6% (depth alone)
If IV is obtained, which NMB is indicated for T&A? What precautions should you use with this drug and why?
Mivacron-short acting
If given too fast, or too high dose, massive histamine release
On emergence it is ESSENTIAL to remember to:
Remove the throat pack!
When should be considered when giving a narcotic in T&A?
Give up front-want pt to breathe/wake up at end of case!
What post op T&A problem can be minimized by the anesthtist?
PONV from blood in the stomach-suction oropharynx and stomach on emergence, adm antiemetics: Decadron and Zofran potentiate and decrease swelling
What potential problems may be encountered post T&A?
1. difficult to ventilate-may require oral airway or CPAP
2. No IV access
3. Procedure is stimulating (temporarily) don't over narcotize and slow wake up
The pediatric pt post T&A is swallowing frequently, but is not drinking. What actions do you take-or instruct family to take? When is this most likely to occur?
Pt is bleeding-this is an emergency! Usually occurs in first 6 hrs post op, but may occur when "scab" falls off 7-10 days post op. Pt should go to ER stat. Anesthesia-considered full stomach, RSI indicated-must have IV.
What is UPPP? What are the potential complications?
Uvula palato pharyng oplasty
Laser removal of uvula, soft palte for obstructive sleep apnea. Same complications as T&A
What nerve may be damaged during thyroidectomy? How will this impact the anesthesia plan?
Recurrent laryngeal nerve
Do not give NMB or tell surgeon when "twitches" have returned so surgery can procede.
What position will the pt be in for thyroidectomy?
HOB 30 degrees with shoulder roll, head hyperextended to expose surgical field.
What methods for airway placement may be considered?
awake fiberoptic intubation, armored or NIM ETT
Is NMB used in thyroidectomy?
Not usually , may be done with regional
What nerve injury will you posssibly see with thyroid surgery? How will you respond?
recurrent laryngeal nerve injury-unilateral causes hoarseness; bilat causes adduction of cords, stridor and inability to vocalize-requires immediate re-intubation
If pt is not euthyroid pre-op, what should you consider?
Delay surgery or take actions to treat thyroid storm-cooling blanket and invasive monitoring
How is vocal cord function assessed?
Before and after surgery, have pt say "eeee: or : moon"
Can visualize cords prior to extubation
Which electrolyte should be monitored post op and why?
Ca++ Hypoparathyroidism D/T inadvertant surgical removal of parathyroids
In assessing a pt pre op for radical neck dissection, what is important to consider?
1. Airway will probaly be distorted-evaluate with radiolgraphy and old chart for approaches that have worked
2. Pt may have been smoker/ drinker -evaluate all pertinint resp, CV, hepatic
what are the sx of venous air embolism?
decreased ETCO2, hypotension, dysrhthmias, mill wheel murmur
How is venous air embolism treated?
notify surgeon, flood field, t-burg, left lateral, aspirate CVP, 100% O2, fluid and vasopressors as needed
Is cricoid pressure used with an upper airway foreign body removal? Lower airway/esophageal?
Upper-no cricoid pressure
lower/esophageal-cricoid pressure
what are the advantages of laser airway surgery?
precision, minimal bleeding, minimal,edema, rapid healing
What staff precautions should be taken with laser?
0.1 micron mask -prevent microbacterial disease transmission

eye protection, pt and staff

FiO2 <30%

replace N20 w/ air or helium

fill cuff with saline/methylene blue

use fire resistant tube

Have 60ml syringe filled and ready

motionless surgical field

use smallest ETT possible
If no ETT, ventilate pt very slowly or use operative laryngoscope eith jet ventilation
What is the airway fire protocol?
Stop ventilation-turn off O2
Immediately remove ETT
Submerge ETT in H20
Ventilate with face mask
Assess airway damage
Consider bronchial lavage, steroids
What are the anesthetic considerations of an operative laryngoscope?
edema: laryngeal or subglottic
What is Ludwig's angina?
a septic cellulitis of the submandibular region that typically occurs in a patient who has undergone dental extraction of the second or third molars. Soft tissue edema coupled with upward and posterior displacement of the tongue anf the frequent presence of laryngeal edema can result in upper airway obstruction.
In which type of Le Forte fx is NTT or NGT contraindicated? why?
LeForte II & III . Pt may have basilar skull fx. Risk of intubating th ebrain if attempted nasally.
What must always be attached to the bed of a pt whose jaw is wirted shut?
Wire cutters