PERIOPERATIF ANESTESI
OPERASI
ORAL-MAKSILOFASIAL
Dept./SMF Anestesiologi Dan Terapi Intensif
FKUSU/RSUP H.Adam Malik Medan
In-Patient Dental Anesthesia
Major Oral & Fasciomaxillary Surgery
In-Patient Dental Anesthesia
Classifications:
Major Orthognathic Surgery
Tumor Surgery
Palate Surgery
In-Patient Dental Anesthesia
Concerns:
Altered Airway Anatomy
Shared Operative Field
Anesthetic Drugs Choice
Appropriate Time for Tracheal Extubation
Airway Management
Anesthetic Management
Airway Management
Airway Management
Choice of the technique depends on several factors:
Patient safety
Experience of the anesthetist
Known difficult airway
Requirement: nasal or oral
Post operative jaw wiring
Airway Management
History
Physical Examination
Further Evaluation
Difficult Airway & Algorism
Airway Strategies
History
Documented History of Difficulties with general anesthesia
or, more specifically, mask ventilation or endotracheal
intubation
Congenital Syndromes Associated With Difficult
Endotracheal Intubation
Pathologic States That Influence Airway Management
Selected Congenital Syndromes Associated With Difficult
Endotracheal Intubation
SYNDROME DESCRIPTION
Down Large tongue, small mouth make laryngoscopy difficult;
small subglottic diameter possible
Laryngospasm frequent
Goldenhar Mandibular hypoplasia and cervical spine abnormality
make laryngoscopy difficult
Klippel-Feil Neck rigidity because of cervical vertebral fusion
Pierre Robin Small mouth, large tongue, mandibular anomaly; awake
intubation essential in neonate
Treacher Collins Laryngoscopy difficult
(mandibulofacial
dysostosis)
Turner High likelihood of difficult intubation
Selected Pathologic States That Influence Airway Management
PATHOLOGIC STATE DIFFICULTY
Infectious epiglottitis Laryngoscopy may worsen obstruction
Abscess (submandibular, Distortion of airway renders mask ventilation or
retropharyngeal, Ludwigs intubation extremely difficult
angina)
Croup, bronchitis, Airway irritability with tendency for cough,
pneumonia laryngospasm, bronchospasm
(current or recent)
Maxillary/mandibular Airway obstruction, difficult mask ventilation, and
injury intubation; cricothyroidotomy may be necessary
with combined injuries
Laryngeal fracture Airway obstruction may worsen during
instrumentation
Cervical spine injury Neck manipulation may traumatize spinal cord
Selected Pathologic States That Influence Airway Management
PATHOLOGIC STATE DIFFICULTY
Upper airway tumors Inspiratory obstruction with spontaneous ventilation
Lower airway tumors Airway obstruction not relieved by tracheal intubation
Radiation therapy Fibrosis may distort airway or make manipulations
difficult
Inflammatory Mandibular hypoplasia, temporomandibular joint
rheumatoid arthritis arthritis, immobile cervical spine, laryngeal rotation,
cricoarytenoid arthritis all make intubation difficult
and hazardous
Ankylosing spondylitis Direct laryngoscopy maybe impossible
Soft tissue, neck injury Anatomic distortion of airway
(edema, bleeding,
emphysema)
Laryngeal edema Irritable airway, narrowed laryngeal inlet
(postintubation)
Selected Pathologic States That Influence Airway
Management
PATHOLOGIC STATE DIFFICULTY
Angioedema Obstructive swelling renders ventilation and intubation
difficult
Endocrine/metabolic Large tongue, bony overgrowths
acromegaly
Diabetes mellitus Reduced mobility of atlanto-occipital joint
Hypothyroidism Large tongue, abnormal soft tissue (myxedema) make
ventilation and intubation difficult
Thyromegaly Extrinsic airway compression or deviation
Obesity Upper with loss of consciousness airway obstruction
Tissue mass makes successful mask ventilation unlikely
Physical Examination
Inspection (Obvious Problems)
Mouth Opening (3 4cm)
Oral Cavity Examination
Mallampati Score
Thyromental Distance (3 large fingers = 5 cm)
Neck Movement
Further Evaluation
PRE-OPERATIVE ASSESSMENT OF THE
AIRWAY
Indirect or Fiberoptic Laryngoscopy
X ray: Chest , Cervical Spine
CT or MRI
Flow- Volume Loops
Pulmonary Function Tests
Cormack-Lehane Laryngeal View Scoring
Difficult Airway
Difficult airway
The clinical situation in which a conventionally trained
anesthesiologist experiences difficulty with mask
ventilation, difficulty with tracheal intubation, or both
Difficult mask ventilation
1) inability of unassisted anesthesiologist to maintain
SpO2 > 90% using 100% oxygen and positive
pressure mask ventilation in a patient whose SpO2
was 90% before anesthetic intervention;
Or
2) inability of the unassisted anesthesiologist to prevent
or reverse signs of inadequate ventilation during
positive pressure mask ventilation
Difficult Airway
Difficult Laryngoscopy
Not being able to see any part of the vocal cords
with conventional laryngoscopy
Difficult Intubation
Proper insertion with conventional laryngoscopy
requires either :
a) > 3 attempts
b) > 10min
Airway Management
Normal Airway Difficult Airway
Awake or Sedated Under GA
Difficult Airway
Awake Under GA/Sedation
Different Laryngoscopes,
Awake Laryngoscopy Stylets
Awake Fiberoptic LMA/ I LMA/FO
Tracheostomy Fiberoptic
Retrograde Intubation Tracheostomy
Blind Nasal Intubation
AWAKE TECHNIQUES
Difficult Airway
Awake
Awake Laryngoscopy
Awake Fiberoptic
Tracheostomy
Retrograde Intubation
AWAKE TECHNIQUES
Glosso-Pharyngeal Nerve IX Nerve
Posterior pharyngeal fold at its midpoint, 1 cm deep to the
mucosa of the lateral pharyngeal wall
AWAKE TECHNIQUES
Superior Laryngeal Nerve
Pyriform Fossa
External :1 cm medial to the superior cornu of the Hyoid
Bone to pierce the thyrohyoid membrane
AWAKE TECHNIQUES
Trachea & Vocal Cord
Atomizer
Injection
AWAKE TECHNIQUES
Laryngoscope Blades
AWAKE TECHNIQUES
McCoy
AWAKE TECHNIQUES
AWAKE TECHNIQUES
FIBER OPTIC INTUBATION
AWAKE TECHNIQUES
SURGICAL AIRWAY
Under General Anesthesia
Chidren / Uncoaperative Adults / Sepsis Assess / Anticholinergic / Anxiolytic ( if any)
1) Inhalational / asses: Ventilation / Veiw
2) Stillete / Different Laryngeoscopes
(=/- short acting MR)
3) LMA / LMA + F.O.
Face Mask + F.O. + Modified Oral AW
4) F.O using Sedation Or light GA
5) Tracheosyomy under light GA
6) Blind Nasal Technique
GA TECHNIQUES
Laryngoscope Blades
GA TECHNIQUES
McCoy
GA TECHNIQUES
Laryngeal Mask Airway (LMA)
GA TECHNIQUES
LIGHTED STYLETS/LIGHTWAND
Well Circumscribed Glow
GA TECHNIQUES
Unconventional LMA
F.O. + LMA Fast Track LMA
GA TECHNIQUES
Blind Nasal Intubation
90% successful but may need several attempts
Contraindicated in fractured base of skull
Cervical collar in situ
GA TECHNIQUES
FIBER OPTIC INTUBATION
GA TECHNIQUES
Rigid Fiberoptic
laryngoscope
Retromolar
Fiberscope
GA TECHNIQUES
BULLARD LARYNGOSCOPE
GA TECHNIQUES
SURGICAL AIRWAY
Classification According to Mouth Opening
Awake or Sedated
Normal mouth opening
SLN block +Transtracheal LA
Limited
Retrograde Intubation
Extremely limited
Awake Intubation with F.O.
Awake Intubation Under Anesthesia Blind Technique
Spontaneously Risk of apnea with Blind technique such
breathing awake difficulty mask as BNI, Light wand,
patient without the risk ventilation Retrograde wire
of apnea intubation, LMA, and
Suitable for patients Combi tube are C/I in
Suitable for patients with no obstructive tumor patients
with obstructive symptoms because of the risk of
symptoms bleeding and tumor
dislodgement.
Needs patients
cooperation
Success rate in good
experienced hands
Risk of complications
from nerve block
Failure to intubate may
Incase of failure , can result in fatal outcome
be postponed for Multiple attempts may
reconsideration lead to bleeding and/or
aspiration
Techniques
Under Vision
Awake Intubation
Fiberoptic Tracheostomy
Laryngoscopic Under GA
Blind
Techniques
Retrograde Wire
Lighted Stylet/ Blind Nasal
Intubation Combi-Tube
Light wand Intubation
Modified
Techniques
Bullard
Wu Scope
Laryngoscope
NEVER PARALYSE UNTILL POSSIBLE VENTILATION
HAS BEEN ESTABLISHED
RECENT SUCCESSFUL INTUBATION DOESNOT MEAN
FUTURE POSSIBLE INTUBATION
FULL RANGE OF DIFICULT INTUBATION EQUIPMENT
MUST BE AVAILABLE
ALL PHYSICIANS RESPONSIBLE FOR AIRWAY
MANAGEMENT SHOULD BE PRACTICED IN AT LEAST
ONE ALTERNATE TO BAG & MASK VENTILATION.
THESE ALTERNATIVE INCLUDES THE FOLLOWING:
LARYNGEAL MASK AIRWAY
COMBI TUBE
TRANSTRACHEAL TECHNIQUES
LMA PROVIDE RESCUE VENTILATION IN 94% OF
CASES OF UNANTICIPATED DIFFICULT INTUBATION
HAVING DISCUSSED ALL THE MANAGEMENT
STRATEGIES AWAKE TECHNIQUE IN GENERAL &
AWAKE FIBER OPTIC TECHNIQUE ESPECIALLY, IS
THE MOST COMMONLY USED & SAFE TECHNIQUE
ANESTHESIA
MANAGEMENT
Special Consideration
Preoperative Management
Intraoperative Management
Post operative Management
PRE-OPERATIVE PROBLEMS
Elderly, Chronically Debilitated Patients
Malnourished
H/O Heavy Smoking with Resultant COPD
H/O Alcoholism
Co-existing disease such as HTN,D.M, IHD,
etc.
PRE-OPERATIVE
MANAGEMENT
Adequate pre-operative work-up of Cardiac Status &
Pulmonary Functions should be carried out using
various diagnostic modalities with the objective of
optimizing patients condition
RECONSTRUCTIVE MAXILLOFACIAL
SURGERY
Problems:
Major problem: Airway Management
Extensive, long operation
Significant blood loss
Poor nutritional status
Micro-vascular surgery
Caution with Vasoconstrictors
Caution with Transfusion
Caution with Diurresis
Blood Rheology (Hct:25-27)
INTRA-OPERATIVE
Routine
Monitoring
NIBP
ECG
SPO2
ETCO2
TEMPERATURE
Choice of Volatile Agent
Choice of Anesthesia
INTRA-OPERATIVE MANAGEMENT
SPECIAL CONSIDERATIONS
Two large bore canulae
Invasive blood pressure monitoring
Central venous pressure monitoring
Use of muscle relaxants
Induced hypotension
Blood loss & transfusion
Haemodynamic changes
Venous air embolism
INTRA-OPERATIVE MANAGEMENT
Two Large Bore Canulae
After induction of anesthesia, two large bore
canulae can be put in large veins so that rapid fluid
replacement can be carried out in case need arises.
INTRA-OPERATIVE MANAGEMENT
Invasive Blood Pressure Monitoring
is indicated due to following reasons :
Blood loss may be rapid secondary to
Neck dissection
Pre operative radiotherapy
Surgery close to big vessels of neck
Frequent fluctuations in the blood pressure due to
manipulation in the area of carotid body and sinus.
INTRA-OPERATIVE MANAGEMENT
Central Venous Pressure Monitoring
Risk of venous air embolism during neck
dissection
As a guide to the management of fluid therapy
The site of insertion is either:
Antecubital vein
Femoral vein
INTRAOPERATIVE MANAGEMENT
Use of Muscle Relaxants
During surgery IPPV is carried out without muscle
relaxant as surgeons need to identify the nerves
during surgery
INTRAOPERATIVE MANAGEMENT
Induced Hypotension
Mild degree of hypotension is required during
surgery to reduce the blood loss. This can be
achieved by following:
15-30 degree head up tilt
Increasing the conc. of volatile anesthetics
Use of peripheral vasodilators
Use of beta blockers
INTRAOPERATIVE MANAGEMENT
Blood Transfusion
Before the decision of blood transfusion the following
points should be considered
Patients underlying medical condition
Possibility of risks of transfusion hazards
Increased risk of post-transfusion cancer recurrence as a
result of immune suppression
INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes
During radical neck dissection, the traction or
pressure on the carotid sinus and / or stellate
ganglion can cause following:-
Brady-dysrhythmias
Sinus arrest leading to asystole
Wide swings in blood pressure
Prolonged QT Interval
INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes Treatment
Immediate cessation of the stimulus
Blockage of the sinus with local anesthetic by the
surgeon
Vagolysis by atropine
INTRAOPERATIVE MANAGEMENT
Venous Air Embolism
When the venous pressure in neck veins is low and
these veins are open to atmosphere, air is sucked in
causing air embolism.
Diagnosis
Early Detection
Hypoxia
Hypotension
Hypocarbia
INTRAOPERATIVE MANAGEMENT
Venous Air Embolism
Treatment
Compression of neck veins
Positive pressure ventilation
Place the patient in the left lateral position
Aspiration of air through the central venous
catheter
Ionotropes
POST-OPERATIVE CARE
I. ROUTINE CARE
II. SPECIAL CONSIDRATIONS
ICU care & Possible mechanical Ventilation
Hemodynamic Instability
Analgesia
Tracheostomy
POST-OPERATIVE CARE
ICU Care & Possible Mechanical Ventilation
Patient should be kept in the intensive care unit for
24-48 hours
Prolonged Surgery
Airway Oedema
Co-existing diseases
Risk of bleeding and/or neck hematoma
POST-OPERATIVE CARE
Haemodynamic Instability
As bilateral neck dissection may result in post-operative
hypertension and hypoxic drive because of the denervation
of the carotid sinus and carotid body
POST-OPERATIVE CARE
Analgesia
Non Steroidal Anti-inflammatory Agents should be
used as opioids cause respiratory depression in
spontaneously breathing patients
When patient is on ventilator opioid analgesia can
be given
POST-OPERATIVE CARE
Tracheostomy Care
Humidified Oxygen
Intermittent Suction
Sterile Precautions
Adjustment of cuff pressure to15-
20 mmHg
Complications
THANK
YOU
