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103 Cards in this Set

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T/F - The majority of patients undergoing elective opthamologic procedures are young and healthy.
FALSE - The majority of patient undergoing elective opthamologic procedures are elderly and have multiple comorbidities.

(neonates as well)
A significant percentage of opthmalogic procedures are performed with a ______ _______.
A significant percentage of opthmalogic procedures are performed with a _retrobulbar block__.
T/F: Opthamologic drugs applied topically are slowly absorbed and produce systemic effects only over a long period of time.
FALSE: Opthmalogic medications applied topically to the eye undergo sufficient absorption and may produce systemic effects. These meds may be absorbed by the blood vessel in the conjunctival sac and by the mucosal lining of the lacrimal duct.

Absorption is prompt: faster than SC, slower than IV.
Name some SYSTEMIC drugs that are given for opthamologic purposes & that can have negative SE when combined with anesthesia.
Mannitol (can cause hypovolemia with anesthesia).
Glycerol
Acetazolamide (Diamox)- carbonic anhydrase inhibitor--> decreases aqueous humor production. Pvts IOP with induction. SE: diuresis and hypokalemia metabolic acidosis.
Discuss the implications of ACh in opthamologic surgery:
Indication: Miosis (pupil constriction)

MoA: Cholinergic agonist

SE:
Brochospasm (will increase IOP),

Bradycardia (decrease BP --> HOTN --> ischemia of eye),

HOTN -->ischemic injury to eye.
Dicuss the ophthamologic implications of Acetazolamide?
Opth. Indication: Glaucoma (increased IOP)

MoA: Carbonic Anhydrase Inhibitor
decrease the production of aqueous humor by the ciliary body of the eye. Mild diuretic. IV dose of 500 mg (given in the OR when the eye is tight to reduce IOP). Peak effect is 20 min…good for intraop administration. Can treat cerebral edema from high altitudes.

SE: Mild diruresis (HOTN w/ anesthesia), Hypokalemia, Metabolic Acidosis.
Discuss the opthamologic implications of echothiopate?
Opth Indication: Glaucoma

MoA: IRREVERSIBLE cholinesterase inhibitor - ACh causes miosis, which helps glaucoma.

Systemic Effect: Prolongations of Sux effects (and other drugs metab'ed by cholinesterases - Cleviprex, Esmolol, etc.)
Reduction in plasma cholinesterase act lasts 3-7 weeks after D/C of drug.

Bradycardia (HOTN --> ischemia to eye).

Bronchospasm (increased IOP)
Discuss the opthamologic implications of timolol?
Opth indication: Glaucoma

MoA: Beta-adrenergic antagonist (beta blocker)

Syst Effect: Atropine resistant bradycardia; bronchospasm (increased IOP); exacerbation of CHF (if R heart drainage compromised, pt can get venous congestion and increased IOP); possible exacerbation of Myasth. Gravis.
How can timolol worsen Myasthenia Gravis and why does it matter to an anesthetic?
Not sure but: Beta-adrenergic receptor blocking drugs, particular when used as oral antihypertensives or ocular antiglaucoma agents, have been reported to induce myasthenic symptoms in patients without a history of myasthenia gravis; and worsen sx in a pt with MG.

It can also worsen heart failure (blockade of Beta 1) and breathing problems (blockade of Beta 2 receptors).

Timolol can increase the duration of NMBDs.
What are the opthamologic implications of Atropine?
Opth Ind: Mydriasis (pupillary dilation); opth. capillary decongestion

MoA: Antocholinergic
Atropine causes mydriasis AND cycloplegia. (sys..not much effect. Local only has these effects.
Discuss the opth. implications of Cyclopentolate?
CYCLOPENTOLATE:

Opth Indic: Mydriasis; opthalmic capillary decongestion

MoA: Anticholinergic

Syst Effects: Disorientation, psychosis, convulsions, dysarthria.
Discuss the opth. implications of Epinephrine?
Opth Indic: Mydriasis; opthalmic capillary decongestion

MoA: alpha & beta adrenergic agonist. Epinephrine, decreases aqueous humor production through vasoconstriction of ciliary body blood vessels. Epinephrine's mydriatic effect, however, renders it unsuitable for closed angle glaucoma.

Syst. Eff: HTN, tachycardia, cardriac dystrhythmias; PARADOXICAL decreased in intraocular pressure and can also be used for acute OPEN ANGLE glaucoma.
Discuss the opth implications of Phenylephrine?
Opth Indic: Mydriasis; decongestion of opthalmic capillaries

MoA - direct alpha agonist; direct acting vasopressor.

Syst Eff: HTN (1 gtt [0.05ml of 10% solution] contains 5 mg of phenylephrine).
Discuss the opth implications of scopolamine?
Opth Ind: Mydriasis; opthalmic capillary decongestion.

MoA: Anticholinergic

Syst Eff: Central Anticholinergic Syndrome (Mad as a hatter - delirium, agitation; Hot as a hare - fever; Red as a beet - flushed skine; Dry as a bone - xerostoma, anhidrosis; Blind as a bat - cycloplegia, photophobia)
What is cycloplegia?
Cycloplegia: Paralysis of the ciliary muscle of the eye leading to loss of accomodation.
How is IOP normally generated?
IOP is generated by the formation and drainage of aqueous humor.
Where is aqueous humor formed?
Posterior chamber by ciliary body: active process involving carbonic anhydrase & cytochrome oxidase; most made by this process. (So if you have a CI inhibitor this would help with glaucoma).

Passive filtration of fluid from vessels on anterior surface of iris.
How does Aqueous Humour drain?
Via the trabecular network, canal of Schlemm and episcleral venous system.

Obst. of drainage system or venous return from eye to right side of heart will --> increased IOP.
What is normal IOP?
Normal eye: 10-22 mmHg

Abnormal: > 25mmHg

Varies 1-2mmHg w/each cardiac contraction

Diurnal variation of 2-5 mmHg (higher on awakening)

High pressures help stroma maintain a constant curvature i.o.t maintain a uniform refractory index.
What factors increase intraocular pressure?
Primary:
-External pressure on eye by contarction of orbicularis oculi muscle and increased tone of extraocular muscles.
-Development of scleral rigidity (s/t aging)
-Hardening of semisolid intraocular contents (lens, vitreous)

External Pressure: venous congestion of orbital veins (accentuated during valsava maneuver/coughing/retching/vomiting)

Trauma to eye (s/t engorgement with blood)

Arterial hypoxemia & hypoventilation (increased intracranial pressure)

Ketamine in larger doses.

Sux (8 mmHg increased w/in 1-4 min post IV admin; returns to baseline in 7 minutes)
What are some factors that can decrease IOP?
IOP reduced by:

Hyperventilation and hypothermia (decr intracranial pressure)

Most inhaled and injected anesthetics (except Ketamine & Sux)

Relaxation of extraocular muscles

Decrease in production of aqueous humour.

Improved drainage via trabecular network (miosis)
Discuss the effects of Succinycholine on IOP and how these effects can be attenuated.
Sux will raise IOP about 8 mmHg w/in 1-4 minutes of admin. IOP will return to baseline in 7 minutes.

Increase in IOP likely d/t:
-Tonic contraction of the extraocular muscles
-Choroidal vascular dilation (incr production of aqueous humor)
-Relaxation of orbital smooth muscle (how does this increase IOP?...)
-Cycloplegic action of Sux

Effects of Sux on IOP can be attenuated by:
-Pretx with NDMR
-Pretx with IV Lidocaine, ACTZ (diamox), or propanolol
What is the oculocardiac reflex? What triggers it? How can it be attenuated/treated?
The oculocardiac reflex consists of a trigeminal afferent and vagal efferent pathway.

Bradycardia most common symptom. Numerous cardiac dysrhythmias can occur ranging from ectopic atrial rhythm to asystole.

Oculocardiac reflex is NOT suppressed by GA and may be augmented by arterial hypoxemia and hypercapnia. For surgery with constant stimulus, you must stop the nerve impulse….local block – retrobulbar block.

The oculocardiac reflex is triggered by:
-External pressure on globe
-Traction on extraocular muscles
-Traction on conjunctiva
-Placement of retrobulbar block

Kids: proph. IV antichol. drug (atropine, glycopyrolate) shortly before trigger stim.
In adults, IM atropine NOT effective.
Elderly can have BP BOTTOM OUT with the bradycardia because they have a stiff ventricle and are RATE DEPENDENT.

Tx: The FIRST action is to remove surgical stim (will quickly return to normal); atropine 10-20 mcg/kg IV; or glycopyrolate IV.
T/F: In infants and children, the use of MAC anesthesia + LAs is recommended b/c it allows faster recovery times.
FALSE: The use of GA in infants and children is necc because patient cooperatino is essential.

In ADULTS, most eye proc can be done with MAC, pulse ox, capnography, and use of a regional block (retrobulbar, peribulbar).

Most NMBs can be used (even Sux if time allowed for transient increase in IOP to abate)(or give a defasc dose or use Diomax (ACTZ) before giving.).

Avoid coughing, N/V on emergence and postop.
When can a retrobulbar and peribulbar block be used effectively?
Retrobulbar and peribulbar blocks can be used for:
* surgery involving the cornea, anterior chamber and lens
* Procedures lasting UNDER two hours(otherwise the block will wear off)
* If the pt is able to cooperate otherwise...might be difficult to place the block....could have oculocardiac reflex.
What are the anesthetic goals of opthamologic surgery?
Control of Intraocular Pressure
Intense Analgesia
Akinesia of eye
Avoid oculocardiac reflex
Awareness of potential drug interactions
Emergence/awakening w/o coughing/N&V/retching.
Describe the technique for placing a retrobulbar block:
Patient supine and nose towards ceiling.

Instruct pt to look supranasally & palpate inferior orbital margin at its most lateral and inferior aspect.

At that site, insert blunt 25g needle through a skin wheal & direct toward top of orbital pyramid WHILE REMAINING INFERIOR TO GLOBE (i.e. - don't poke the pt in the eye with the needle).

Advance 25g needle about 35mm to the apex of the muscle cone & inject 2-5 ML of LA solution + hyaluronidase (enhances spread of LA) with frequent aspiration to min risk of vasc inj of LA.

Massage injection site 2-5 minutes to facilitate spread of LA.
Info on the orbital pyramids.
Morphologically, each orbit is a four-sided pyramid with a posterior apex, anterior base and a medially tilted axis
Although simple, this fact constitutes the basis of the human stereoscopic vision and allows for understanding the location of orbital foramina.

In the orbit, all openings are arranged around the base, apex or between the orbital walls. Along the base are the infraorbital and supraorbital canals and the zygomaticofacial foramina; between the roof and the lateral wall are the superior orbital fissure and the lacrimal foramen; between the roof and medial wall are the optic, anterior, and posterior ethmoidal canals; between the lateral wall and floor is the inferior orbital fissure, and between the medial wall and orbital floor is the cranial opening of the nasolacrimal duct.
What are some SE of retrobulbar block?
Retrobulbar hemorrhage (hit an artery or vein)
Stimulation of oculocardiac reflex (BRADYCARDIA)
Puncture of posterior globe.
IV injection of LA.
Central retinal artery occlusion. - BLINDNESS
Subdural injection. - **Spread of LA to the brainstem causing delayed onset loss of consciousness b/c of resp depression!!!**
Blindness
Penetration of optic nerve.
Staphyloma (abnormal protrusion of the uveal tissue through a weak point in the eyeball. The protrusion is generally black in colour.)

Paralysis of contralateral extraocular muscles s/t LA spread to midbrain.
What nerves are affected by a retrobulbar block?
Nerves blocked are those within the annulus of Zin (the cone)

Optic (Cranial Nerve 2)
Oculomotor (superior and inferior branches).(Cranial Nerve 3)
Nasociliary
Abducens. (Cranial Nerve 6).
What is the technique for placing a peribulbar block?
Technically easier than & fewer complications than retrobulbar block.

Peribulbar block done with pt in supine position.

Skin wheal on lower lid, just above inferior orbital rim, 1.5 cm from lateral canthus.

Inject LA (4ml of 2% Lidocaine; 4 ml of 0.5% bupivicaine) + hyaluronidase through wheal toward the orbit until lower orbital septum is penetrated.

Needle advanced toward the equator of eye and angled in superomedial direction.

Additional 2-3 ml of LA +Hyalouronidase injected into upper lid, 1-2 mm medial and inferior to supraorbital notch.

As needle withdrawn, 1 ML LA injected into obicularis muscle.

Apply external pressure to area for 10 minutes to facilitate spread of LA.
What nerves are blocked with a peribulbar block?
Nerves blocked with a peribulbar block include:

Lacrimal (smallest of three branches of the opthalmic [sensory only] division of trigeminal nerve)

Frontal (branch of facial nerve; sensory to skin of forehead).

Trochlear (CN IV; a motor nerve ; a “somatic efferent” nerve; that innervates a single muscle: the superior oblique muscle of the eye)

Oculomotor (CN III)

Nasociliary (branch of opthalmic nerve)

Abducens (CN VI; a somatic efferent nerve that controls the movement of a single muscle, the lateral rectus muscle of the eye in humans)

Infraorbital (After the maxillary nerve enters the infraorbital canal, the nerve is frequently called the infraorbital nerve. This nerve innervates the lower eyelid, upper lip, and part of the nasal vestibule.)

Zygomatic ( a branch of the maxillary nerve that divides into a facial branch supplying the skin of the prominent part of the cheek and a temporal branch supplying the skin of the anterior temporal region)
What cranial nerves affect the extra orbital muscles of the eye?
CNs III, IV and V innervate the extraorbital muscles and position the globe of the eye.

(Oculomotor, Trochlear, Trigeminal).
What nerves are blocked by BOTH the retrobulbar and peribulbar blocks?
Oculomotor nerve
Nasociliary nerve
Abducens nerve
How is a facial block performed? Why is it performed?
Given with retrobulbar block to prevent squinting & allow placement of a lid speculum.

Block performed by SQ injection of LA into region of outer canthus; first directed towards eyebrow and then toward infraorbital foramen.

Can also be done in area of stylemastoid as nerve exits with vagus and glossopharyngeal n. (has risk)
What are some risks of placing a facial block in the area of the stylemastoid as the nerve exits with the vagus and glossopharyngeal nerves?
vocal cord paralysis
Laryngospasm
Dysphagia
Respiratory distress
What are some anesthetic considerations of truamatic eye injury patient?
Consider to have full stomach & assoc risk of aspiration.

Avoid any sudden increases in IOP (extrusion of ocular contents & loss of vision)

H2 receptor antagonist (Cimetidine) + reglan to decrease gastric acidity and volume.

Awake tracheal intubation? Greatest safety margin but usually not feasible.

Retrobulbar block? No - can cause extrusion of orbital contents.

RSI - for trauma to eye and globe. Succs + pretx with NDMB offers advantage of rapid intubation w/minimal change in IOP.

Alternative: lg dose NDMB & modified RSI will REDUCE IOP facilitate trach intub.

Wait on PNS to confirm onset of blockade before DL.

Interventions to blunt CV response to DL & ett i.o.t avoid increase in IOP.
When can strabismus surgery provide proper steroscopic visual development?
If done by 4 mos. of age.

If done in children older than that, it is done for cosmetic purposes.(cannot fix vision)
What are some special considerations of strabismus surgery?
In strabismus surgery there is:
-An increased risk for development of MH. ((TIVA!!!) Have dantrolene readily availiable. First sign DEFINITE SIGN of MH is INCREASED ETCO2.)
-A high incidence of postop N/V (d/t postop diplopia)
-A risk for oculocardiac reflex during surgery (s/t manipulation of extraocular muscles).

AVOID KETAMINE!!! Will cause nystagmus and and eye deviation from center.
AVOID SUCCS!! Will cause issues with muscle tone and is a trigger for MH.
Pt can have diplopia (blurred vision) post op. This can cause PONV!
Why is there an increased risk of MH during strabismus surgery?
B/C strabismus is thought to reflect an underlying myopathy.

Incidence of isolated masster muscle spasm after halothane & sux is 4x higher in these pts.

Avoid known MH triggers (i.e. - Sux)
T/F: Strabismus surgery is associated with increased incidence of N/V. Why/why not?
TRUE - high incidence of N/V assoc with strabismus surgery may be associated with manipulation of extraocular muscles or pain --> oculocardiac vagal response.

Tx: limit dose of opioids; substitute propofol for inhaled anesthetics, use of 5-HT3 selective anti-emetic have been shown to be highly effective.
___________ is a condition in which elevated IOP compresses capillaries and subsequent blood flow to optic nerve leading to ischemia and eventual blindness.
__Glaucoma__ is a condition in which elevated IOP compresses capillaries and subsequent blood flow to optic nerve leading to ischemia and eventual blindness.
Compare and contrast Open-angle glaucoma, Closed-Angle glaucoma and glaucoma occurring in children.
Open-Angle (Chronic) Glaucoma: most common adult form; impaired drainage s/t sclerosis of trabecular tissue. Affects both eyes, IOP elevates slowly, progressive damage of optic nerve.
Tx: Meds that produce Miosis (ex - cholinergic agonist) and trabecular stretching.

Closed Angle Glaucoma: pts born w/narrow angle between iris and cornea, swelling of crystalline lens, trauma/displacement of lens; peripheral iris comes in direct contact with posterior corneal surface & mech. obstr. of outflow occurs.
Tx: surgical tx may be necc.

Glaucoma in Children:
-Infantile Type: birth to 3 years.
-Juvenile Type: 3-30 years old.
-Usually d/t obstructed outflow.
-Tx: surgical, route for flow of aq. humor into canal of Schlemm often req.
What is the most common surgical tx of glaucoma?
Trabeculectomy (can be done under MAC)

If that fails, a glaucoma seton implant is placed (often done under GA).

Infants and children may get goniotomy (opening of canal of Schlemm under direct visualization).
What are some special considerations for patients having glaucoma surgery?
-Continue miosis inducing meds periop'ly.
-Avoid venous congestion d/t increase in IOP.
-Awareness of interaction between antiglaucoma drugs and anesthetic meds.
-Avoidance of coughing, N/V, retching
What type of anesthesia is normally provided for cataract extraction?
MAC + retrobulbar block

Incision is SMALL…lens is placed through a trochar in the eye folded up and then unfolded once in the eye…cuts down on complications.
What are some common techniques used for repair of a detached retina?
Retinal detachment: HIGH risk of ischemia to retina and death of retina (disrupted from the vascular bed). Meds must be given to get the retina to lay back flat to the vascular bed.

* EndoLaser Surgery for retinal tears but not detachments. - welds it back together.

* Scleral Buckle Procedure: Use a cryoprobe to weld it back on all the way around and the apply a synthetic ring around teh sclera to hold it down while it heals.

* Pneumatic Retinoplasty: Inert, water insoluble, low diffusable gas (Sulfur Hexafluoride, Perfluoropropane) bubbles are injected into the vitreous humor of the eye to tampenade teh retina onto the back of the eye. Avoid N2O, which will expand the bubble, increase IOP, and PONV. The bubble will last for 28 days postop so avoid N2O during this entire period.
Anesthesia for repair of a Retinal Detachment
Regional Anesthesia (but general can be used to).

With GETA, avoid skeletal muscle paralysis. Pvt coughing and bucking on tube with emergence.

Avoid N2O with Pneumatic Retinopathy...will expand the gas bubble and raise IOP!! If GETA is used and N2O is used, D/C N2O 20 min before intravitreal injection of gas. (washout of N2O is 90% complete in 10 min).

Avoid N2O for 10-28 days after Pneumatic Retinopathy...the gas bubble will stay in the eye for this period!!!
What are some injuries that can occur to eye during anesthesia?
**EYE INJURY IS MOST OFTEN MANIFESTED AS POSTOP EYE PAIN AND IS USUALLY CAUSED BY CORNEAL ABRASION**

Corneal Abrasion: sensation of foreign body in eye, conjunctivitis, photophobia, tearing;
Prophylaxis - nonionic petroleum -based ophth. ointment, securely tape eyelids, discouragement of pt rubbing eyes on emergence.
Dx: fluorscein staining
Tx: antibx opth. ointment & eyepatch for 48 hrs.

Acute Glaucoma:
-s/t drugs that induce mydriasis (atropine, cyclopentate, Epi, Scopolamine, Phenylephrine)
-Sx: dull periorbital pain early postop
-Tx: Mannitol, ACTZ

Ischemic Eye Injury:
-s/t unrecognized pressure on globe while prone
-If external pressure. >Venous Pressure (but not arterial) veins collapse & arterial hemmorhage may occur
-If external pressure > Art. Pr. --> ischemia of retina.

Unexpected Patient Movement:
-s/t coughing & reacting to ett
-Tx: monitor NMB with PNS to maintain drug-induced paralysis.
T/F: Manipulation of head, larynx, pharynx and neck can precipitate cardiac dysrhythmias.
True.
Is blood loss in otolaryngological procedures usually overestimated or underestimated?
Underestimated - b/c blood loss can be hidden in the drapes and blood can be swallowed into the stomach.
What are some specialty ETTs used in otolaryngology?
Oral RAE & nasal RAE: tonsillectomies and procedures in oral cavity.

Armored ett: laser procedures & laryngectomy

Wrapped ett: laser procedures.
__________ is an exaggerated and prolonged response of the protective glottic clusure reflex, mediated by the superior laryngeal nerve.
_Laryngospasm_ is an exaggerated and prolonged response of the protective glottic clusure reflex, mediated by the superior laryngeal nerve.

False cords & epiglottic body come together, airflow absent, no vocal sound (duh), true cords hidden.

If persists, the hypoxemia/hypercapnia eventually decrease post-syn potentials & brainstem output to SLN & spasm intensity decreases.

Tx: 100% O2 CPAP via facemask.
-IV admin of Sux (0.25-1mg/kg)
-ETT in selected pts.
What are some indications for T&A?
Recurrent URTI
Upper Airway Obstruction (esp during OSA)
Are special studies required preop for otherwise normal pts who have slassic sx of server upper airway obstruction and adenotonsillar hypertrophy?
NO, not normally.
TRUE/ FALSE :Sedative premeds should be avoided in children with OSA, intermittent upper airway obstruction or very large tonsils.
TRUE: Sedative premeds should be avoided in children with OSA, intermittent upper airway obstruction or very large tonsils.
Patients with OSA are often _____, with potentially ______ upper airway mgmt.
Patients with OSA are often obese, with potentially difficult upper airway mgmt.

(pt likely to have short thick necks, large tongues ad redundant pharyngeal tissue so that upper airway obstr is frequent and awake tracheal intubation is neccessary)
T/F: polysomnography to eveluate severity of OSA is neccessery preop.
FALSE: polysomnograpy is expensive, requires hospitalization and is rarely needed.
What do you do if your patient arrives for T&A and has a severe URTI?
Postpone 7-14 days; until resolution of URTI.

Laryngospasm more likely in presences of URTI.
In what type of children is GERD a significant anesthetic consideration?
GERD may be found in children w/
-Chronic lung dz (s/t increased neg intrathoracic pr)
-Upper Airway Obstruction (s/t increased neg intrathoracic pr.)
-Neurologically abnormal pts (hypotonia, dev delay)
What does mgmt of T&A anesthesia focus on?
Mgmt of anesthesia for T&A focuses on AIRWAY CONSIDERATIONS & BLEEDING.

-CPAP during induction = alleviate obstruction
-Cuffed ett = decr. aspiration
-Cuffed OR uncuffed tube: allow 20-25 cmH20 leak at PAP. Only inflate further if more PAP needed to ventilate lungs or if hemm suddenly develops.
-Use of oral RAE to optimize visualization of surg field.
-Maintain leak if petr. gauze used for supraglottic pack.
-Be sure all packing removed pre-extubation.
-OG tube to aspirate stomach before extubation .
-TRACHEAL EXTUBATION IS PERFORMED WHEN THE CHILD IS AWAKE AND RESPONDING.
-Pts with RAD (asthma) may be extubated deep to min laryngospasm & bronchospasm.
What are some T&A postop care issues & complications?
PONV - Give Dex (also helps with pain), intraop antiemitic & aspirate stomach contents before extubation.

Hemm from tonsillar beds - can be sig & most can go to stomach; don't oversedate d/t aspiration risk.

Airway obstruction - retention of pharyngeal jack or acute laryngospasm

NPPE - acute laryngospasm
Why monitor T&A patients for 24 hours for postop airway obstruction?
B/C postop airway obstruction can occur in children younger than 4 years of age as late as 18-24 hours postop.

Risk increases with prematurity or recent URTI.
Advantages of laser surgery in otolaryngology?
Precise targeting of airway lesions.
Minimal bleeding and edema.
Preservation of surrounding structures.
Rapid healing.

CO2 laser good for tx of laryngeal/VC papillomas, laryngeal webs, resection of redundant subglottic tissue and coag of hemangiomas.
What size ETT in laser surgery in otolaryng. cases?
5 to 5.5 ID ett...necc. for optimum exposure.
Maintenance of anesthesia for a otolaryng. laser case?
Sux gtt for brief paralysis.
T/F: All PVC tubes are flammable and can ignite and vaporize in presence of a laser.
TRUE
What are some alternatives to flammable PVC tubes?
-Shieled laser ett.
-Direct laryngoscopy with intermittent jet ventilation (Sanders delivers at 50 psi via port in scope.)
-
What are risks of jet ventilation?
Pneumothorax & Pneumomediastinum s/t rupture of alveolar blebs or a bronchus .
What are risks assoc w/ laser surgery?
Plume of smoke and particle deposition in alveoli if aspirated. (use evacuator and special masks).

Perforation of viscus & transection of blood vessels.

Venous gas embolism

Ocular injury

Airway fires.
How do you protect a pt's eyes during laser surgery?
Tape them shut.
cover with wet gauze pades
Cover that with metal shield to protect eyes.
What can you do to attenuate risk airway fire in laser oral surgery?
Fill trach cuff with CMB (appearance of dye is early warning of cuff rupture s/t laser)

FiO2% max 30% & delivered with air. (Both O2 and Nitrous support combustion.)

Ensure adequate airflow to prevent flammable gas trapping.
What to do if there is an airway fire?
D/C circuit from ett and turn off O2.

Remove ett from patient's airway/extubate trachea.

Flood field with sterile NS (if flame persists the article says - I thought we did that per protocol.)

Ventilate patient's lungs with O2 by facemask.

Direct exam of larynx and pharynx to determine extent of damage.

Reintubation with regular ett and monitor for at least 24 hours.

Rigid bronchoscopy to assess airway damage and remove debris.

Assess oropharynx and face.

Obtain chest radiograph.

Consider bronchial lavage, cortisteroids and antibx.
What organism is responsible for epiglottitis?
H. Influenza type B
What are s/sx of epiglottitis?
Rapid progression from sore throat --> airway obstruction --> death if dx & tx delayed.

1) Sudden onset of fever, dysphagia, drooling, thick muffled voice, preference for sitting position with head extended and leaning forward.

2) retractions, labored breathing and cyanosis when resp obstruction is present.
Describe the tx of epiglottitis.
DO NOT attempt direct visualization in an awake patient and do not stimulate the patient b/c it could lead to airway compromise.

Sevo inhalation induction while maintaining spontaneous ventilation.

Secure airway w/o stimulating airway (it is REACTIVE).

Have emergency airway cart & trach tray open.

Continuous obs & radiographic confirmation of ett placement.

Tracheal extubation attempt in 48 - 72 hours when sig leak around ett present (indicates swelling abatement). & this is confirmed by flex fiberoptic bronchoscopy.
What are the clinical manifestations of a foreign body aspiration?
Sudden onset difficulty breathing.
Dry cough.
Hoarseness.
Wheezing (young children)
Describe tx of a foreing body aspiration.
Care taken not to make partial obstr. a full obstruction.

Awake direct laryngoscopy OR rigid bronchoscopy (if this, IV anesth to avoid exposing doc to VAs) WITHOUT application of Positive Pressure.

Surgeon present & ready to do emergent trach or cricothyrotomy if total obstruction occurs.

Close observation in recovery for postop edema and resp dysfx.

Humidified O2.
Why is parotid gland surgery performed?
Tumors
Infectious disorders

*May be assoc w/etoh abuse & pts may have s/sx of etoh-related dz.
What type of anesthesia is provided for parotid gland surgery?
General anethesia for parotid gland surgery + facial nerve monitoring.

Avoid NMBDs if nerve mon. is done.

If radical parotidectomy is performed, facial nerve may be cut and rebuilt with graft from contralateral greater auricular nerve.

NTT preferable over ETT if mandible has to be dislocated.
Describe the different LeFort classifications of facial trauma?
LeFort I: fx extends across lower portion of maxilla & does NOT extend up into medial canthal region

LeFort II: extends across maxilla but at a more cephalad level and continues up to medial canthal region.

LeFort III: high level transverse fx above the malar bone and through the orbits; complete separation of maxilla from craniofacial skeletone.
If a patient has suspected intranasal damage what should you avoid?
Nasotracheal intubation
Avoid putting anything into the nose b/c it can enter the cranial vault.
Why and where is functional restoration nasal surgery done?
Nasal surgery for fx-al restoration is done for congenital or post-traumatic deviations of the septum.

Typically performed in physicians office with LA and IV sedation.
What drugs used during nasal surgery can have a profound systemic impact?
Cocaine and Epi used for drug-induced vasoconstriction.

These meds can have profound CV effects, esp in the elderly and those with known cardiac dz.
How can the anesthetist help decrease nasal surgical bleeding?
Moderate degree of controlled HOTN + head elevation.

Placement of oropharyngeal pack or suctioning stomach at end of surgery can attenuate postop N/V and retching.
What are some common ear surgeries and what type of anesthesia do they require?
Placement of myringotomy tubes.
Tympanoplasty.
Placement of cochlear implants.

Generally require GA.

Avoid/greatly decrease dose of NMBs if neuromonitoring is used.
N/V are common after ear surgery. What can attenuate this?
Pretx with antiemetics
Inclusion of propofol and sevofluorane in anesthetic.

These actions will decrease PONV after ear surgery.
Why do we NOT premedicate children undergoing myringotomy?
B/C the effect of most sedative drugs outlast the surgical procedure.
How do we provide anesthesia for myringotomy?
Volatile anesthetic, O2 and N2O delivered by facemask.
Describe the anesthetic mgmt for middle ear surgery (tympanoplasty & mastoidectomy).
Use of oral/nasal RAE (min. intrusion into surg field)

Turn off N2O at least 30' before placement of tympanic membrane graft. (avoid displacement of graft).

Deep extubation (to avoid bucking that may displace graft).

PONV: decompress stomach after induction, limit use of opioids, prophylactic antiemitics.
What are the principle structures involved in neck dissection?
1) Sternocleidomastoid muscle.
2)Cranial Nerve XI (Accessory Nerve_
3) Internal & External jugular veins and Carotid artery.
Why do patients having neck dissection often warrant a pulmonary workup?
B/C their tumors are often associated with a hx of etoh and tobacco abuse. Pulmonary dz is likely.
Describe anesthetic mgmt of a neck dissection.
High % cases bilateral: trach to protect upper airway.

Hx of radiation tx (stiffness, scarring, malalignment) or presence of tumors may make upper airway mgmt difficult.

Avoid/decrease dose of NMDs of Neuromonitoring is used.

Bradycardia s/t dissection around carotid bulb. Tx: injection of IV LA into carotid bulb (didn't we learn this was supposed to go between bifurcation of IJ and EJ earlier this semeste?), IV atropine/glycopyrolate.

Drains to minimize postop laryngeal edema.
What are some postop complications of radical neck dissection?
VC dysfx - injury to RLN

Airway obstr - bilateral RLN injury.

Hemi-Paralysis of diaphragm - injury of phrenic nerve.

Impairment of spont breathing - bilat phrenic nerve injury.

Pneumothorax

Hematome and airway compromis - s/t excessive coughing and agitation postop.
Flurbiprophen (Ocufen)
Topical Non-steroid Antiinflammatory for the eye.

There is a high level of inflammation during surgery of the eye. Eye pts are always on anti-inflamms.
Mannitol IV
Osmotic Diuretic

Mannitol IV will have max effect in the eye after 1 hour. Sys effects include hypovolemia….WATCH IN THE ELDERLY POST OP!!! Electrolyte imbalances d/t diluted electrolytes. CNS effects if too much given pulls water out of the brain).
Glycerin (Osmoglyn)
Osmotic Diuretic

Given PO. Can cause hypovolemia and HOTN with anesthesia.

Metabolism of Glycerin can cause hyperglycemia. Check BG levels.
Topical Cholinergic Agonists used in eye surgery to cause miosis post-procedure
Pilocarpine
Carbachol
Acetylcholine
Ester LA used for periorbital and retrobulbar blocks in eye surgery
Cocaine
Tetracaine
Proparacaine
Amide LAs used for periorbital and retrobulbar blocks in eye surgery
Lidocaine
Bupivacaine
Ropivacaine
Meds for Glaucoma
* Alpha2 Agonists (Alphagen) - cause decr aqueous humor production and increased outflow.
Less-selective alpha agonists, such as epinephrine, decrease aqueous humor production through vasoconstriction of ciliary body blood vessels. Epinephrine's mydriatic effect, however, renders it unsuitable for closed angle glaucoma.

* Beta Antags (Timolol/ timoptic) - reduce aqueous humor production by the ciliary body. . (Will make ephedrine ineffective).

*Cholinesterase Inhibitors (Echothiaphate): cause miosis and increased drainage. Will prolong Succ. Must d/c days before sx.
Dacryocystorhinostomy
Opthalmologic Procedure

Obstructed tear ducts to nasal passages are opened. Opth and ENT surgeon are working together. Cocaine is injected into nasal cavity.
Frontalis Sling
Opthalmologic Sx - Ptosis Repair.

Minimize coughing and bucking.