Anaesthesia for Oncological ENT Surgeries

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Anaesthesia for Oncological ENT Surgeries

• Moderators
• Prof Chandralekha
• Dr V Darlong
• Presenters
• Rakesh Garg
• Prabhu

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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Head and Neck Surgery

• Laryngectomy
• Hemimandibulectomy
• Maxillectomy
• Angiofibroma
• Glossectomy
• Pharyngectomy
• Radical neck dissection

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Cont

• Tracheostomy
• Diagnostic
• Endoscopic examination
• Therapeutic
• Definitive oncological surgery
• Reconstructive surgery

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Conclusion

• Duration of anesthesia and ASA class- significant
  predictors of major complications
• Comorbidity - established important factor
• 3 significant risk factors
• site of primary tumor
• adjunctive treatment
• low hemoglobin

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Perioperative Concerns

• Prolonged surgery and its complications
• Blood loss and its conservation strategies
• Sharing of airway
• Surgery related implications

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Indicators of Difficult Airway

• Changes in the voice
• H/o dyspnoea, dysphagia or inability to handle
• oro-nasal secretions
• Radiation to head and neck
• H/o difficult airway
• Previous head and neck surgery
• Tumors and edema of pharynx and hypopharynx

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Airway examination

• Examination of the oral cavity-site, size and
  friability of the tumor- indirect laryngoscopy
• Mouth opening
• Mallampati grading
• Mandibular space
• Assessment of sniffing position.
• Adequacy of mask placement.

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Investigations

• Hematological
• Biochemical
• Chest X-ray
• ECG
• STN X ray
• CT
• MRI
• Laryngoscopy / endoscopy
• PFT / FV loops

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Premedication

• Cancer emotional and psychological state
• Cautious premedication
• Avoid sedative drugs
• Analgesics

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Anaesthetic Management

• Selecting the appropriate anesthetic technique
  compatible with the surgical procedure

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LMA in ASA DA algorithm
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260 patients review
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Airway Management

• Awake Oral FOB
• Awake Nasotracheal intubation
• Inhalational induction
• Tracheostomy under LA
• Acute airway compromise - Transtracheal Jet
  Ventilation
• Tracheal extubation and Jet Stylet
• Retrograde Tracheal Intubation - awake patient

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Cont

• ETT and connectors
• nonkinking and properly secured
• Breathing circuit - secured to patients head
• Constant vigilance -prevent the breathing circuit
  from pulling downward on the tubes adapter

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Cont

• The lengthy surgical procedure near the airway
  and bulky flap reconstruction may cause oedema
  around the airway making extubation even more
  challenging than the intubation

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Cont

• Nerve blocks contraindicated- tumour
• Coughing and straining awake intubation - trauma
  and bleeding
• Pectoralis major flap tunnelled through the neck-
  risk of airway obstruction (bulk) than does a
  free flap.
• Postoperative local oedema

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Monitoring

• Routine
• Capnography
• Invasive monitoring - arterial BP and CVP
• Arterial line and cannulas
• Central line - antecubital, subclavian or femoral
  
• Two large bore cannulas
• Urinary catheterization
• Temperature monitoring

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Intraoperative Tracheostomy

• 100 oxygen
• Suction
• Tube pulled just above the tracheal incision
• TT inserted
• Ventilations checked
• Observe breath sounds, capnography, airway
  pressure, compliance

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Extubation

• Extubation
• degree of edema and
• upper airway distortion produced by the surgery
• Lengthy procedure, free flap reconstruction-
  intubated, sedated overnight in the ICU
• Others extubated in the OT or PACU when they are
  fully awake
• Equipment for securing the airway
• readily available

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Intraoperative and Postoperative Complications

• VAE
• Carotid sinus manipulation
• Stellate Ganglion injury
• Positioning- neck torsion
• Airway compromise edema, hematoma

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Maxilla Cancer

• Concerns
• Difficult Airway
• Bleeding
• CSF leak/ pneumocephalus
• Infection
• Visual impairment
• Enopthalmos

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Mandible cancer

• Concerns
• Tumour
• Primary
• Infiltration from adjoining structures
• Resection segmental/hemimandibulectomy
• Osteocutaneous flap/plates

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Reconstructive surgery

• Flaps
• Skin grafting
• Local flaps
• Pedical fasciocutaneous flap
• Musculocutaneous flap
• Osteocutaneous flap
• Evaluated invidualized

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Intraoperative Considerations

• Avoid cannula/monitoring devices at flap donor
  sites
• Secure monitoring/airway devices change of
  position
• Blood loss
• Hemodynamics
• Hypotension
• Avoid vasoconstrictors
• Decrease inhaltional agents
• Fluids
• Avoid shivering/pain - vasoconstriction

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Laryngeal cancer

• Conservative laryngeal procedures ? total
  laryngectomy
• Laser surgery
• Vertical hemilaryngectomy
• Supraglottic laryngectomy
• Supracricoid partial laryngectomy
• tracheostomy

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Direct LaryngoscopyMicrolaryngoscopyLaser
LaryngoscopyMicrolaryngeal Endoscopic Surgery

• Goals
• Dry immobile field
• Securing Airway and protection
• Oxygenation and ventilation
• Anaesthetic technique short, rapid and full
  recovery
• Hemodynamic stability

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Anaesthesia

• No airway compromise premedication, standard
  induction
• Antisialagogue, sedation
• Vigilant inadveretent extubation, kinking,
  disconnection
• Cardiac monitoring
• Induction and maintenance short acting agents,
  muscle relaxant, narcotics, beta blockers

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Cont

• Posterior commissure MLS tube
• Protection of eyes/teeth
• Anaesthesia machine and monitors side of
  patient, head end free

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Other Ventilatory Strategies

• Supraglottic jet ventilation
• Subglottic jet ventilation
• Transtracheal jet ventilation
• Free access to expiration
• Intravenous anaesthesia, unpredicted inhalation
• Pneumothorax, pneumomediatinum, submucosal
  emphysema
• Blood, debris tracheal ingress
• Postoperative CxR
• Apneic ventilation
• Tracheostomy

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• MAC
• In selected patients, high risk patients
• Topical, regional anaesthesia

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Neck Dissection

• Lymph node and fibrofatty tissues
• Therapeutic neck dissection
• Elective neck dissection
• Radical neck dissection
• Modified neck dissection
• Selective neck dissection

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Laser and Anaesthesia

• Light amplification by stimulated emission of
  radiation

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• Laser beam is intense light, emitting identical
  coherent, excited photons in one direction
• Beam focused to small spot precise controlled
  coagulation
• Incision or vaporization of tissue

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Types

• Solid ruby, YAG, xenon
• Gas co2, argon, krypton, excimer
• Liquid - liquid dyes

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Laser Hazards

• Misdirected burn eyes are vulnerable, CO2
  corneal burn tissue / vessel perforation
• Fire explosion (thermal effect)
• Ignition of inflammable materials ETT,
  breathing circuits, drapes
• Atmospheric contaminations

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Safety Considerations

• OT warning sign for laser use
• Restrict entry into OT
• Protective eye glasses (wave length specific)
• Avoid flammable materials
• Patient eye care taped closed covered
• wet pads
• protection glass
• Wet towels for draping

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Cont

• Competent personal for equipment use
• Avoid misdirection of beam
• Avoid ETT in short procedure, use venturi
• Use fire proof tubes with saline filled cufffs
• Cover visible cuff area with moist cotton
  pledgets
• Ready bucket of clean water
• Smoke evacuators at surgical site

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Special ETT Protection

• Wrapping with wet muslin, dental acrylic coating
  (disadv mucosal trauma)
• Wrapping with metalised foil tape Al, Cu,
  plasticmetal
• Solid copper foil or aluminium (protect from
  NdYAG laser for 60 sec)
• Cuffs unprotected fill with saline / dye

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FDA approved Material ETT

• Merocel laser guard (tube wrap) metal foil with
  sponge surface
• Xomed laser shield tube for co2 laser (silicone
  with outer aluminium powder coating)
• Laser shield II (silicone tube with cuff)

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Metal Endotracheal Tube

• Nortens tube stainless steel spiral without
  cuff , walls not air tight
• Laser flex tube air tight stainless steel
  spiral with two distal cuffs
• Bivona fome coff aluminium spiral tube with
  outer silicone coat self inflating foam sponge
  filled cuff

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Anesthetic Technique

• Sharing of airway use microlaryngeal ETT,
  ventilating bronchoscope, jet ventilation
• Irregular respiratory movement use muscle
  relaxant
• Postoperative laryngeal edema use adrenaline,
  steroids, head up position, remove stimulus

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Airway Fire - Protocol

• Fatal due to
• Thermal injury, chemical burn,
  bronchospasm, edema, melting burning ETT lead
  to obstruction
• Management
• Use of special tubes
• Stop O2, remove ETT, flood with saline
• Bag and mask / venturi ventilation
• If difficult airway, remove ETT on guide wire
• Check bronchoscopy
• Post operative, head up, x-ray chest,
  antibiotics, humidified O2, steroids

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Thanks
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