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92 Cards in this Set

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T & A:
Preoperative assessment [3]
Patient presentation: ASA/age/status
Medications: premeds
T & A:
Intraoperative management [3]
Airway: MAC/Regional/General
Medications: pain/nausea/relaxation/etc.
T & A: pearls
Versed po .5mg kg or nasal preop 5-15 minutes to work
Ussually no sialoagosue
No LMA
Cuffed tubes 6-8 years
You want air leak at about 18cm…..leak at 8 is too much (airway fire)
Zofran .1 per kg, 5years old 2-4 mg (or reglan/anzomet…serotonin)
Agex2+9=wt in kg
Pain fent…..demerol .5 mg/kg…… /morphine .1mg per kg
Mask with sevo/nitrous (start at 5% or se…over pressurize…(mac for 5 year old would be 3)
Mask/transfer to bed,…IV….then propofol 1-3mg/kg…a little narc…..then intubate (in case of laryngospasm)
Adenoids are at what location relative to tonsils
posterior
Cuffed tubes what age?

You want air leak at about _____…..leak at 8 is too much (airway fire)
6-8 years

18cm pressure
pediatric Zofran dose?

ped's MAC demerol/fenanyl dose?
Zofran .1 per kg, 5years old 2-4 mg (or reglan/anzomet…serotonin)

Pain fent…..demerol .5 mg/kg…… /morphine .1mg per kg
Frenulectomy

Preoperative assessment [3]
Patient presentation: ASA/age/status
Medications: premeds
Frenulectomy

Intraoperative management
Airway: MAC/Regional/General
Medications: pain/nausea/relaxation/etc
Frenulectomy pearls
Tongue-tied
Quick-5 minutes
Sevo 6-8% overpressure, mask off, surg…share the airway….
Sevo MAC for 5 yr old?
3
BMT: Bilateral Myringotomy Tubes pearls
FAST…..deep and still with Sevo oral airway……
Tylenol supp..10-15mg/kg…give after induction
ALWAYS monitor TEMP on kids
eye case pearls
Always have atropine ready……
Cocaine 4% (40mg/ml) 1.5 mg/kg
xxxxxxxxx
propofol introcular block dose
30-60mg propofol bolus IV
orbital fracture pearls
Suxx increases IOP secondary to depolarization

1.2 mg per kg for rapid sequence..
No LMA because no access to airway
ORIF Mandible Fracture: Open Repair Internal fixation pearls
Know laforte’s
NO nasal tube if possible/
Possibly fiberoptic..hard to see secondary to blood.
laforte 1?
maxillary below nose-lateral
laforte 2?
max/ethmoid-over nose then down both sides
laforte 3?
across orbits
____________ cant say with recurrent laryngeal nerve damage
Eeeeeeee
Parotidectomy pearls
No paralysis x for sux with intubation
ETT
NIM monitor
a candidate for local anesthesia with IV sedation criteria
a. Must be able to understand directions, lie flat, and remain still for 45-120 minutes.
b. Poor candidates include squirrels, patients with tremors, claustrophobic patients, orthopneic patients, and patients who are not oriented. Chronic cough, alzheimer’s.
2. Remember the coexisting diseases that almost all the elderly patients present with (DM, MI, CHF, CVD). Requires thorough workup by the admitting surgeon and thorough review by you.
xxxxxxx
Goals for the awake patient: [5]
comfort,
cooperative,
intact airway reflexes

maintenance of breathing

decreased anxiety
1. Drug choices for sedation during placement of the retrobulbar block (RBB) include but are not limited to: [5]
a. Propofol 10-20 mg boluses
b. Midazolam .5-2 mg
c. Alfentanil 200-250 uq
d. Fentanyl 25-50 ug
e. Remifentanyl
Remember the slow circulation times for the elderly patient and the synergism between narcotics and benzodiazepines. Apnea is never far off. The goal is to provide some sedation during the placement of the RBB and maintain _________
airway reflexes/respirations
5. Complications of RBB. Overall complication rate is 1:500, usually seen within 15 minutes. [3]
a. Retrobulbar hemorrhage is the most common. Usually noted during injection. Eyeball becomes tense and is displaced anteriorly. Treatment consists of gentle pressure, lateral canthotomy (incising the canthus), or cancellation of the procedure.
b. Oculocardiac reflex is caused by eyeball manipulation or application of the Honan balloon. Treat by releasing the balloon, head down tilt, atropine/glycopyrrolate. Reflex is usually self-limiting and fatigues.
c. trauma to the eye due to poor technique. To avoid, have the patient look straight forward and do not penetrate deep into the orbit with the needle.
Respiratory monitor should include at a minimum a precordial stethoscope. CO2 sampling nasal oxygen cannula can be useful. Remember to provide air flow under the drapes to prevent harmful build up of CO2 and an oxygen enriched environment.
xxxxxxx
Increased IOP is seen with [4]

2 drugs
2 actions
ketamine, succinylcholine, laryngoscopy and intubation.
Normal IOP is
12-20 mmHg.
a. Most anesthetic agents decrease IOP by [4]
relaxing extraocular muscle tone
decreasing blood pressure
decreasing CVP
improving outflow of aqueous humor
IOP and antisialagogues...
IV/IM no increase seen, however, topical use on the eyeball may increase IOP via mydriasis (pronounced dilation).
narcotic effect on IOP?
c. Narcotics: no change or slight decrease
CNS depressant effects on IOP...
Thiopental, etomidate, and propofol decrease IOP.
Volatile agents effects on IOP
decreased IOP assuming normocarbia (hypercarbia and hypoxemia will cause vasodilation and increased IOP).
Ketamine effects on IOP...
early studies show that IM/IV use increased IOP. Later data indicated that after a benzodiazepine premed or narcotic pretreatment that no change in IOP was recorded.
Nondepolarizing neuromuscular blockers effect on IOP...
decreased IOP
Depolarizing neuromuscular blockers effects on IOP...
succinylcholine causes a significant transient increase in IOP (10-20 mmHg). Tonic response by the extraocular muscles. No attempts at preventing IOP increase with sux have been successful. However, no case reports exist describing further eye damage or loss of vitreous with the use of sux.
Penetrating eye injuries
a. Balance aspiration risk against sudden increase in IOP
b. If possible, H2 blocker, metoclopramide (.15 mg/kg), and a nonparticulate antacid, ie. Sodium citrate (30cc) preoperatively
c. Pretreat with lidocaine (1-1.5 mg/kg IV), narcotic (fentanyl 2 ug/kg or sufentanil .1 mg/kg), labetalol or esmolol.
d. Rapid sequence induction: d-tubocurarine .05 mg/kg, sux 1.5 mg/kg, thiopental 4-6 mg/kg, propofol 1.5 mg/kg
e. Consider a modified rapid sequence induction with rocuronium .6-1.2 mg/kg. Guard against intubating too early thus causing coughing, bucking, and increased IOP.
f. Maintenance: ensure adequate depth of anesthesia. Carefully monitor neuromuscular block.
g. Emergence: ensure that airway reflexes and spontaneous ventilation are present. Consider lidocaine 1.5 mg/kg 5 minutes before emergence to decrease coughing.
h. Bottom line: protect the patient from aspiration. Do a RSI with sux if indicated. Focus on a smooth intubation with minimal sympathetic stimulation.
Strabismus surgery (amblyopia)
a. Early surgical intervention (4 months of age) is needed to allow stereoscope visual development to proceed.
b. May be associated with underlying myopathies which can be related to an increased risk of malignant hyperthermia and/or masseter muscle spasm.
c. Employ usual monitors and heighten your vigilance level to the early signs of malignant hyperthermia.
d. Incidence of postoperative nausea and vomiting (PONV) varies from 48-85%. Caused by eye muscle manipulation and vagal stimulation.
i. Consider ondansetron .15 mg/kg
ii. Propofol infusion (if <3 years of age)
iii. Decreased narcotic use or avoidance.
iv. Oral gastric tube, IV hydration
Oculocardiac reflex (OCR)
1. Caused by eyeball traction, eyeball pressure, eye pain, or orbital hematoma.
2. It is a trigeminovagal reflex
a. Ectopic beats, nodal rhythms common.
b. Bradycardia progressing to asystole.
c. Ventricular fibrillation
3. Incidence of OCR varies, 32-90%.
4. Hypoventilation and increased PaCO2 can significantly increase the incidence of bradycardia.
5. Treatment:
a. Stop stimulation
b. If needed, give atropine .007mg/kg IV (007-for your eyes only) or glycopyrrolate (.005-.01 mg/kg)
c. Ensure adequate depth of anesthesia and normocarbia.
____ and ____ are most susceptible to the systemic effects of these medications.
Infants and elderly
Phenylephrine: sympathomimetic mydriatic (dilation)

S/A's [3]
a. Increased blood pressure, can be severe.
b. Headache
c. Myocardial ischemia
Epinephrine: sympathomimetic

s/a's [4]
a. Decreases aqueous humor formation
b. Tachyarrhythmias
c. Premature ventricular complexes
d. Angina and myocardial ischemia
Timolol: beta adrenergic receptor blocker

s/a's [4]
a. Glaucoma treatment to decrease aqueous formation and IOP
b. Decreases heart rate and blood pressure
c. Exacerbates obstructive lung disease
d. Congestive heart failure in susceptible patients.
5. Echothiopate: miotic (constricting)

s/a's [2]
a. Decreased plasma cholinesterase levels for 4-6 weeks after cessation of the drug
b. Prolonged response to sux, mivacurium, and ester local anesthetics.
Acetylcholine: miotic

s/a's [3]
a. Used after cataract surgery
b. Decreases heart rate and blood pressure
c. Bronchospasm and increased salivation are possible
Pilocarpine: miotic

s/a's
a. Causes transient fall in blood pressure then possible severe increases due to excitation of the muscarinic receptors on sympathetic ganglion cells.
b. Bronchospasm
Scopolamine/atropine: mydriatic

s/a's [3]
a. Disorientation/hallucinations
b. Increased IOP
c. Anticholinergic symptoms
9. Cocaine: sympathomimetic, local anesthetic

s/a's [2]
a. Ocular use can cause severe bradycardia
b. Used for dacryocystorhinostomy as a topical anesthetic and vasoconstrictor.
Patients undergoing head and neck surgery frequently have significant coexisting diseases. [5]
1. Emphysema
2. Heart disease
3. Alcohol related disorders
4. Potential or actual airway management problems
5. Hypothyroid or hyperthyroid symptoms
Anesthetic techniques for head and neck cases [3]
1. Tracheostomy under local may be the first procedure followed by the main dissection.
2. General anesthesia with inhaled anesthetics/narcotics.
3. Discuss the use of neuromuscular blockers with the surgeons preoperatively.
Hemodynamic changes during radical neck dissection are caused by __________. Bradycardia, hypotension, and cardiac arrest can result.
by manipulation of the carotid sinus
Trauma to the right stellate ganglion and cervical autonomic nervous system during the neck dissection may cause: [4]
1. Prolonged Q-T interval
2. Decreased ventricular fibrillation threshold
3. Tachyarrhythmias
4. Cardiac arrest
Venous air embolism
1. Incidence is low. Watch for decreases in end tidal carbon dioxide readings.
2. Hypotension and arrhythmias are late signs.
3. Treat with positive pressure, 100% oxygen, jugular vein compression, head down tilt, left lateral positioning, and aspiration of a right arterial catheter.
Trauma to the neck and larynx
a. Internal damage may be extensive with minimal external damage.
b. Stridor and cyanosis may be present.
c. Signs of airway problems include:
1. Wheezing and coughing
2. Changes in voice
3. Hemoptysis
4. Subcutaneous emphysema
d. Always assume that a C-spine fracture exists until proven otherwise.
e. Decompensation may be rapid. Do not leave the patient unattended.
f. Stabilize the neck by holding it in a neutral position and intubate the patient orally. Do not apply traction.
g. Tracheostomy under local is a frequent intervention
Foreign body in the airway.
a. Very common cause of acute onset respiratory distress in young children.
b. Any intervention by you must not convert a partial obstruction into a total obstruction. Techniques include:
1. Awake fiberoptic exam.
2. Awake direct laryngoscopy.
c. Use extreme caution with sedation.
d. Maintain spontaneous ventilation
e. Do not induce anesthesia until the ENT surgeon is scrubbed in and the tracheostomy set is in the room and opened.
Microlaryngoscopy
a. Anesthetic goals
1. Provide surgeon with a clear view, immobile field, and adequate room to work.
2. Protect the trachea, ensure adequate ventilation and oxygenation, minimize secretions, and provide rapid awakening with return of protective airway reflexes.
b. Preoperative glycopyrrolate and midazolam will dry secretions and decrease anxiety.
c. Communication with the surgeon is imperative. Find out the location and size of the area in question. Discuss the surgical technique and expected duration of the procedure.
d. Ensure that you understand the sequence of the procedure.
e. Check that all adapters/special equipment is available and functioning before the patient arrives in the OR suite.
f. Most microsurgical procedures on the larynx can be accomplished around a small (6mm) endotracheal tube.
g. TIVA
1. Adequate muscle relaxation is a must
i. Sux drip, 1-2 mg/kg then 30-150 ug/kg/min
ii. Mivacurium infusion
h. Ensure adequate depth of anesthesia
1. IV: Midazolam 1-4 mg, propofol 2 mg/kg for induction, then 150 ug/kg/min with Fentanyl 1-2 ug/kg
2. Consider topical lidocaine in the airway (LTA)
3. Beta-adrenergic blocking medications for heart rate control.
Laser surgery in the airway
a. Fire in the airway
1. Can involve subglottic, epiglottic, and oropharyngeal areas.
2. Inhalation of smoke produces bronchospasm and edema.
b. Reduce the incidence of fire by:
1. Maintaining high vigilance and an increased index of suspicion during the case.
2. Keep FIO2 <30% by using air or helium with oxygen.
3. Use laser endotracheal tubes.
4. Only water soluble lubricants on the endotracheal tube.
5. Keep paper drapes away from operative field.
6. Fill cuff of OETT with saline, tint with methylene blue
c. Treating an airway fire
1. Disconnect circuit
2. Remove OETT
3. Reintubate trachea
4. Flush trachea with cold saline
5. Use humidified oxygen
6. Rigid bronchoscopy to check airway for damage and residual endotracheal tube.
7. Consider steroids, mechanical ventilation, and ICU observation.
Tonsillectomy Anesthetic goals [3]
1. Provide deep general anesthesia to prevent HTN, tachycardia, and arrhythmias.
2. Provide adequate muscle relaxation for mouth gag placement.
3. Rapid recovery with return of protective airway reflexes. (Extubate when awake)
Tonsillectomy Preoperative
1. Check for loose teeth.
2. Observe size of tonsils.
3. Check for presence of an upper respiratory infection.
4. Ask about aspirin and nonsteroidal anti-inflammatory use.
5. Consider PO/intranasal midazolam premedication for pediatric patients. PO dose .5 mg/kg, Intranasal .2-.3 mg/kg for children > 1year of age.
Tonsillectomy Anesthetic technique
1. Mask induction with Sevoflurane for children too young for an awake IV start (<12).
2. Follow with an IV after asleep, then intubate either deep using inhalation agent or by using a neuromuscular blocker.
3. Remember to hold the endotracheal tube while the bed is turned 90 degrees and while the surgeon places mouth gag. Chance of extubation is very high at this time. Remember to check breath sounds after the surgeon secures the mouth gag.
4. Maintenance with N2O, narcotic, short acting paralytic, gas.
5. Hydrate with a crystalloid
6. Remember: blood loss can be hard to estimate, may total 5% of total blood volume. Blood loss is much less as more ENT surgeons use the suction bovie technique for tonsillectomy vs. a tonsil snare forceps technique.
7. Extubate in OR when awake and airway reflexes present. Lidocaine at 1-1.5mg/kg can decrease post extubation laryngospasm incidence
Tonsillectomy Transport to the PACU
1. Tonsil position (side, slight head down)
2. 100% O2 mist
tonsillectomy PONV management (can be as high as 70%) [5]
1. Suction stomach for blood at the conclusion of the case.
2. Use propofol when possible.
3. Administer prophylactic antiemetic.
4. Appropriate IV hydration.
5. Do not force PO fluids or food.
Peritonsillar abscess
1. Abscess can cause severe pain, trismus, dysphagia, and respiratory obstruction
2. Surgeon may needle aspirate abscess prior to general anesthesia.
3. Expect difficult intubation due to:
i. Distorted anatomy
ii. Edema
iii. Trismus
4. Airway options if obstruction is expected include:
i. Awake intubation (FOB)
ii. Tracheostomy, especially if stridor is present at rest.
Microlaryngoscopy Anesthetic goals [2]
1. Provide surgeon with a clear view, immobile field, and adequate room to work.
2. Protect the trachea, ensure adequate ventilation and oxygenation, minimize secretions, and provide rapid awakening with return of protective airway reflexes.
Most microsurgical procedures on the larynx can be accomplished around a small ______ endotracheal tube.
(6mm)
Reduce the incidence of fire in the airway by: [6]
1. Maintaining high vigilance and an increased index of suspicion during the case.
2. Keep FIO2 <30% by using air or helium with oxygen.
3. Use laser endotracheal tubes.
4. Only water soluble lubricants on the endotracheal tube.
5. Keep paper drapes away from operative field.
6. Fill cuff of OETT with saline, tint with methylene blue
Treating an airway fire [7]
1. Disconnect circuit
2. Remove OETT
3. Reintubate trachea
4. Flush trachea with cold saline
5. Use humidified oxygen
6. Rigid bronchoscopy to check airway for damage and residual endotracheal tube.
7. Consider steroids, mechanical ventilation, and ICU observation.
Uvulopalatopharyngoplasty (UPPP)
Definition
indications
sleep apnea types
a. Definition: tonsillectomy, adenoidectomy, uvulectomy, resection of redundant tissue of soft palate and oral pharynx.
b. Indications:
1. Snoring
2. Sleep apnea (60-70% effective)
c. Sleep apnea types:
1. Central: cessation of air flow and respiratory effort due to decreased neural output
2. Obstructive: cessation of air flow due to upper respiratory obstruction
3. Mixed
Uvulopalatopharyngoplasty (UPPP)

Preoperative assessment [4]
1. Examine sleep studies, ABG’s
2. Consult cardiology for evaluation of right ventricular hypertrophy/performance
3. Patients are frequently obese so apply the usual aspiration prophylaxis
4. Thorough airway exam. Counsel patient for an awake intubation and possible arterial line.
Uvulopalatopharyngoplasty (UPPP)

Intraoperative management
1. Do not hesitate to do an awake intubation if questions exist regarding the ability to do a safe asleep induction.
2. Consider the use of an arterial line.
3. Many similarities to the anesthetic management for the tonsillectomy patient.
Uvulopalatopharyngoplasty (UPPP)

Postoperative care
1. Extubate when awake with intact airway reflexes
2. Overnight stay is a must with the documented sleep apnea patient.
______ % of patients have the recurrent laryngeal nerve running through the thyroid fascia or between the arterial branches that supply the thyroid
25%
An enlarged thyroid gland extends ________. Displacement or impairment of the recurrent laryngeal nerve can occur. The thyroid can also cause deviation and/or compression of the trachea.
retro-sternally.
___________ places the hyperthyroid patient at increased risk for corneal abrasions. Also, congenital hypothyroidism patients have large tongues causing problems for the anesthetist during mask ventilation and making direct laryngoscopy more difficult.
Exophthalmos
Do not hesitate to employ invasive blood pressure monitoring if the thyroid gland is large requiring dissection close to the ________ arteries.
carotid
Usually thyroidectomy cases are ______ in blood loss with virtually no third space fluid losses.
low
Airway management difficulties are common in patient’s with large goiters. Physical exam, CT scan, or MRI scans should be employed to evaluate the degree of displacement or impingement of the trachea.
xxxxxx
Evaluate possible preoperative impairment of the vocal cords due to recurrent laryngeal nerve compression. Techniques include indirect mirror exam or direct exam by fiberoptic instruments.

Vocal cord paralysis is caused by bilateral nerve damage and usually produces respiratory compromise.
xxxxxxx
Nitrous oxide is _____ times more soluble in blood than nitrogen
34
Middle ear pressure can reach ______mmH20 within 50 minutes of using N2O.
375
__________ will usually vent the middle ear. Surgery, disease, and edema will decrease tube function.
Eustachian tube
Once N2O is stopped, a negative middle ear pressure can occur from the gas leaving the middle ear. If used, maintain at <50%.
E. Turn off at least 15 minutes prior to closure of the middle ear.
Potent inhaled anesthetics at proper MAC provide anesthesia, amnesia, analgesia, and muscle relaxation adequate for surgery of this type. Consider avoiding N2O completely unless the case is a BMT (bilateral myringotomy tubes).
xxxxx
Control of bleeding during ear surgery...[3]
1. Surgical area injected with epinephrine containing local anesthetic solutions.
2. Slight head up position to improve venous drainage can be helpful.
3. Deliberate hypotension (MAP between 60-70 torr).
Deliberate hypotension is frequently employed to lower EBL and facilitate surgery. (MAP 55-60 torr) by....
i. Volatile inhaled agent.
ii. Head up position to provide better venous drainage
iii. Labetalol boluses and/or esmolol

Consider placing an arterial line to monitor hct., acid/base balance, and blood pressure. Especially indicated for cases greater than 4 hours when using deliberate hypotension.
Elective orthognatic surgery
a. Patients are generally young and healthy
b. Used to treat dental malocclusion and balance facial proportions.
c. Most common procedure is a sagittal split osteotomy of the mandible (BSSO).
d. LeFort I osteotomies move the maxilla forward or backwards. A combined LeFort/BSSO can be a 5-6 hour surgery.
e. Intubate nasally with a nasal RAE tube to facilitate surgical access. Be sure to avoid pressure of the tip of the nose through out the case.
f. EBL ranges from 300cc to 2,000cc for a LeFort osteotomy. Greatest blood loss is during the down fracture of the maxilla. Autologous blood donation is common.
. Surgeons can easily damage and/or cut the endotracheal tube during the operation. Be vigilant, watch airway pressures, tidal volume, ventilator bellows and expired carbon dioxide measurements. Listen to your precordial stethoscope. Have a back up plan.
j. Insert an NG in the other nare at the beginning of the case to aspirate blood from the stomach.
k. A throat pack is always inserted at the beginning of the case. Document on the patient’s chart. A retained throat pack will cause airway problems after extubation.
l. Monitor the endotracheal cuff pressures throughout the case. This can be accomplished by routinely checking the pilot balloon.
m. Steroids (decadron) may be given for swelling.
Extubation after oral surgery
a. Patient must be awake, able to swallow, and follow commands. All other extubation criteria must be met as well.
b. If surgery has been >8 hours, deflate cuff, occlude the endotracheal tube, and have the patient breathe around the tube. This allows you to assess for airway edema.
c. Remember, most patients will be in intermandibular fixation, ie. Jaws wired shut with wires or elastic bands. Make sure wire cutters are at the bedside or on the patients chart.
Management of facial trauma

Active management of the airway is a must.
1. Institute in-line neck stabilization. Do not apply traction.
2. Suction the oral pharynx of blood, dirt, teeth, etc.
3. Oxygenate
4. Attempt oral intubation initially.
5. Do not nasally intubate patients if a cerebrospinal leak is present or if the nasal passages are severely disrupted.
6. Severe facial derangement may mean an emergency tracheotomy.
7. Do not disregard the possibility of a C-spine or intracranial injury. The forces necessary to cause facial trauma usually result in associate injuries.
8. Exercise caution when applying cricoid pressure. The downward pressure can cause flexion on an unstable C-spine.
If there is any doubt about the ability to intubate the patient with facial trauma, consider: [5]
1. Awake FOB intubation
2. Awake blind technique (oral)
3. Retrograde wire technique
4. Needle cricothyroidotomy with jet ventilation
5. Tracheostomy under local anesthesia
Procedures of the nose [7]
a. Oral tube, ORAE is a good choice
b. Be sure to use oral suction before extubation
c. Surgeon will usually place splints before he is done.
d. Sometimes nasal packing/ointment is used
e. Protect self/others from the patient coughing up blood
f. Won’t be able to breathe through their nose
g. Surgeon will usually localize first to help decrease bleeding