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General anesthetic concerns of head and neck cancer surgery

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General anesthetic concerns of head and neck cancer surgery Moderators: Prof.Chandralekha Dr.Darlong Presentors: Dr.Rakesh Dr.Prabhu.R www.anaesthesia.co.in ... – PowerPoint PPT presentation

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Title: General anesthetic concerns of head and neck cancer surgery


1
General anesthetic concerns of head and neck
cancer surgery
  • Moderators
  • Prof.Chandralekha
  • Dr.Darlong
  • Presentors
  • Dr.Rakesh Dr.Prabhu.R

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
m
2
Surgeries
  • Tracheostomy
  • Diagnostic
  • Endoscopic examination
  • Therapeutic
  • Definitive oncological surgery
  • Reconstructive surgery

3
Anesthetic concerns
  • Problems related to age
  • Problems related to cancer
  • Securing an airway
  • Recovery

4
Age related problems
  • Generally older patients
  • Age related changes
  • Cardiac - CO ? 1 per year
    after 30 yrs.
  • - Ability to ?
    in response to stress is
  • diminished.
  • Pulmonary - PaO2 ? by 0.5 mm Hg per
    year
  • after 20 yrs.
  • - Rapid
    hypoxemia
  • Hepatic - Drug clearance is
    impaired.

5
Contd..
  • Renal function
  • - Cr CL ? by 1
    ml/min/year after the
  • age of 20 yrs.
  • - S. Cr remains
    normal even in
  • decreased
    clearance because of
  • parallel ? in
    muscle mass.
  • - High normal S.
    Cr? underlying
  • severe
    impairment in clearance .
  • Tobacco and alcohol use

6
Problems related to cancer
  • Chemotherapy
  • For tumor reduction
  • Toxicities
  • Depends on specific agents, cumulative dosages,
    drug toxicity
  • Cardiac
  • Pulmonary
  • Hematological, bone marrow suppression
  • GI
  • Renal

7
Anthracyclin cardiotoxicity
  • Doxorubicin (adriamycin)
  • Acute
  • ECG- ST-T changes
  • Reduction in R wave
  • Chronic
  • Diastolic dysfunction? CHF

8
Risk factors
  • Cumulative dose risk lt1 for
    doseslt300mg/m2
  • 5-10 for
    doses350to 450 mg/m2
  • 30 for doses
    gt550mg/m2
  • Schedule greater risk with
    bolus
  • less risk with
    continuous infusion
  • less risk with
    dexrazoxone
  • Mediastinal irradiation
  • Cardiac disease CAD, HTN, Valvular
    disease
  • Age young children,
    adultsgt70
  • Von Hoff
    et al Risk factors for doxorubicin induced CHF.
    Ann Int Med 91710,1979.

9
Contd..
  • Cyclophosphamide Hemorrhagic myocarditis
  • 5-FU Coronary
    ischemia(1.6)
  • Cytosine
  • arabinose Acute pericarditis
  • Paclitaxel Asymptomatic
    bradycardia(30)
  • high incidence
    with cisplatin
  • combination

10
Contd
  • Radiotherapy
  • Airway fibrosis
  • Lung toxicity
  • Restrictive cardiomyopathy
  • Metabolic abnormalities
  • Tumor produced factors
  • Tumor cells destruction
  • Electrolyte imbalance

11
Preoperative evaluation
  • History
  • To determine the degree of
    compromise and risk.
  • Physical examination
  • Focused on CVS, Pulmonary and
    Airway.
  • Relevant laboratory data.

12
Pulmonary system
  • H/o pulmonary disease- higher incidence of

  • perioperative complications.
  • Important predictor - Pre operative abnormal
    PFT.
  • Other predictors - obesity,
  • -
    smoking
  • - agegt60

13
Contd..
  • FEV1 lt 2 L
  • Maximum breathing capacity lt 50 of predicted.
  • PaCO2 gt45 mm Hg.
  • Tsi EM Preoperative evaluation of
    pulmonary function Validity, indications, and
    benefits. Am Rev Respir Dis 119293-310,1979.

14
Contd..
  • Preoperative preparation of the
    patient with pulmonary disease can significantly
    reduce perioperative morbidity and mortality.
  • Stein M, Cassar EL Preoperative
    pulmonary evaluation and therapy for surgery
    patients. JAMA 211787-792,1970.

15
Contd..
  • Reversible aspects of pulmonary disease
  • Bronchospasm
  • Bronchitis with purulent sputum
  • Nutritional deficiency
  • Effects of cigarette smoking
  • Chronic hypoxemia
  • Corpulmonale
  • Tenacity of secretions

16
Contd..
  • Educate - use of incentive spirometer
  • - techniques of coughing and
    deep breathing
  • - importance of early
    ambulation.
  • Preoperative bronchodilator therapy in COPD.
  • Smoking cessation
  • PFT normalise by 8
    wk.
  • Reduction in COHb-
    12hrs
  • Warner MA, Divertie MB Preop cessation of
    smoking and pulmonary complications in CABG
    patients. Anesthesiology 60380-383,1984.

17
Contd..
  • Intraoperative
  • Hydration
  • Humidified respiratory gases
  • Limit the use of respiratory depressants.
  • Prevent alveolar collapse - adequate Vt
  • -
    avoid high FiO2

18
Contd..
  • Post operative
  • Prevent alveolar collapse
  • - Early
    ambulation
  • - Chest
    physiotherapy

19
Cardio vascular system
  • According to ACC/AHA 2007 guidelines.
  • Head and neck surgery - intermediate risk
  • HTN, CAD.
  • Continue cardiac medications -ß blockers, CCB
  • Fluid Mx
  • Rehydration
  • Maintenance
  • Replacement

20
Airway
  • Information needed for evaluation
  • H/o surgery in or near the airway.
  • H/o radiation in or near the airway
  • Previous anesthetic records documenting airway
    difficulty and methods utilised.
  • Physical examination
  • Radiological examinations
  • Laryngologic examinations- latest IDL

21
Recognition of difficulty
  • Difficult mask ventilation
  • - Age gt55 yrs
  • - Presence of beard
  • - BMIgt26 kg/m2
  • - Edentulousness
  • - H/o snoring

  • Langeron et al prediction of difficult mask
    ventilation.Anesthesiology921229-1236,2000.
  • - Masive jaw
  • - Poor atlanto-occiptal extension
  • Large tongue
  • Pharyngeal pathology
  • - Facial deformities
  • - Facial dressings

22
Difficult intubation
  • H/o difficult intubation
  • Length of upper incissors
  • Inter incisor length
  • Overbite
  • Shape of palate
  • TMJ translation
  • Mandibular space
  • Cervical vertebral ROM
  • TMD
  • MMP
  • Neck

Anethesiology 981269,2003.
23
Options
  • Tracheal intubation after induction of General
    Anesthesia.
  • Examination of the airway in the awake patient.-
    check DL
  • Tracheal intubation in the awake patient.
  • FOB guided
  • Tracheostomy with local anesthesia

24
Difficult or failed intubation
  • Unanticipated difficult or failed intubation
    after induction of GA.
  • Options if MV adequate
  • -Holinger anterior
    commissure laryngoscope
  • -Fiberoptic guided
    laryngoscopy
  • -Allow awakening

25
Holinger laryngoscape
26
  • Options if MV not adequate
  • -Follow ASA algorithm
  • -Consider/attempt LMA
  • -If not adequate follow the
    emergency pathway.
  • Cricothyrotomy
  • Surgical
  • Needle- for TTJV
  • Tracheostomy

27
Intra op airway management
  • Positioning of ETT
  • Protect ala nasi from
    necrosis
  • Direct tracheal operations
    need a change over to reinforced ETT.
  • Surgical field requirement
  • Accordingly secure the
    ETT, circuit and connections
  • Tracheostomy

28
Extubation
  • Supraglottic, glottic edema- Post RND pts
  • Can be reduced by- Dexamethasone
  • - Minimising
    movement of ETT
  • - Elevation of
    head slightly
  • Lengthy/reconstructive procedures-keep intubated
    overnight.
  • Be ready with equipment to secure airway
  • Tube exchange catheter- reintubation guide
  • - jet
    ventilation
  • - both

29
JUVENILE NASOPHRYNGEAL ANGIOFIBROMA
  • Anesthetic concerns

30
JNA
  • The juvenile nasopharyngeal
    angiofibroma (JNA) is a highly vascular and
    histologically benign neoplasm.

  • It causes severe recurrent epistaxis
  • It Involves of endocranial structures .
  • There is high incidence of recurrence.
  • So JNA is clinically malignant.

31
Epidemiology
  • JNA accounts for 0.05 of all head and neck
    tumors.
  • 15,000-160,000 in otolaryngology patients.
  • Sex JNA occurs exclusively in males. Females
    with JNA should undergo genetic testing.
  • Age Onset is most commonly in the second decade
    range is 7-19 years. JNA is rare in patients
    older than 25 years.

32
Etiology
  • Hormonal
  • dependency
  • - Most prevalent theory.
  • - Occurrence exclusively
    in
  • adolescent males
  • - Alteration of the
    pituitary androgen-
  • estrogen axis
    contributes to the
  • pathogenesis of JNA.

33
Symptoms
  • Nasal obstruction (80-90) - Most frequent
    symptom, especially in initial stages
  • Epistaxis (45-60) - Mostly unilateral and
    recurrent usually severe unprovoked epistaxis
    that necessitates medical attention.
  • Headache (25) - Especially if paranasal sinuses
    are blocked
  • Facial swelling (10-18)

34
Contd..
  • Other symptoms - Unilateral rhinorrhea
  • - anosmia
  • - hyposmia
  • - rhinolalia
  • - deafness
  • - otalgia
  • - swelling of the
    palate
  • -deformity of
    the cheek

35
Signs
  • Nasal mass (80)
  • Orbital mass (15)
  • Proptosis (10-15)
  • Other signs
  • Serous otitis- due to eustachian
    tube blockage
  • Zygomatic swelling- trismus
    that denote spread of the tumor to the
    infratemporal fossa
  • Vision impairment- due to
    optic nerve tenting (rare)

36
Pathology
  • Histopathology
  • Vascular component- Single layer of
    plump endothelial cells without the surrounding
    smooth muscle.
  • lack of muscle- contributes to the
    tumors capacity for massive hemorrhage following
    minimal manipulation.
  • It was recently suggested that JNA is
    not a true neoplasm but rather a vascular
    malformation

37
Point of origin
38
Growth pattern
  • Medial extension
  • Lateral extension
  • Intra cranial 20-30
  • Orbital

39
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42
Blood supply
  • External carotid artery (most often the internal
    maxillary artery and the ascending pharyngeal
    artery).
  • Blood vessels of the contralateral side.
  • Internal carotid system- in IC extension.

43
Natural history
  • Not well understood.
  • spontaneous regression (without therapy?)
  • Increase in fibrous elements of the tumour after
    20 years of age.
  • Small residual tumours tend to involute.

44
Investigations
  • Hemogram, platelet count, prothrombin time, and
    partial thromboplastin time.
  • X-ray
  • PNS - opacity in the nose and
    sinus areas.
  • Skull lateral - mass inside the nasopharynx

45
  • CT scan
  • clinch the diagnosis.
  • reveals the extent of the lesion.
  • helps in staging of the disease.
  • MRI
  • reveals the precise extent of the
    mass.
  • Carotid angiogram
  • feeding vessel

46
Staging
  • Andrews staging classification Stage I Tumor
    limited to the nasal cavity
  • Stage II Tumor extension into the
    pterygopalatine fossa, or maxillay, sphenoid or
    ethmoid sinuses.
  • Stage IIIa Tumor extension into the orbit
    without intracranial involvement.
  • Stage IIIb Stage IIIa with extradural
    (parasellar) intracranial involvement
  • Stage IVa Intradural without cavernous sinus,
    pituitary, or optic chiasm involvement
  • Stage IVb Involvement of the cavernous sinus,
    pituitary, or optic chiasm

47
Treatment
  • Surgery treatment modality of choice.
  • Primary surgical cure rates
    for
  • extracranial JNA are near
    100.
  • Aproaches -transpalatal
  • -transnasal (endoscopic)
  • -lateral rhinotomy
  • -midfacial degloving.

48
  • Irradiation- For surgically inaccessible
    intracranial extension or for recurrences.
  • Hormonal
  • Estrogen
  • Associated side effects

49
Anesthetic concerns
  • Risk of aspiration of blood during induction of
    anesthesia.
  • Major surgical bleeding,
  • Upper airway obstruction after extubation because
    of traumatic edema from the surgery

50
Anesthesia
  • Arrange blood and blood products
  • Premedication?
  • Two large bore IV cannulae
  • Induction -RSI?
  • Maintenance - O2N2OIsoVec
  • Monitoring -ECG,IBP,CVP, SpO2, capnography,
    temperature, and urine output

51
Blood conservation
  • Physiological techniques
  • Reverse Trendelenburg position
  • Ventilation
  • Pharmacological techniques
  • Deliberate hypotension.

52
Deliberate hypotension
  • Intentional reduction of blood pressure
    below the level that is normally associated with
    a surgical plane of anesthesia.
  • Reducing mean arterial pressure to 50-75
    mm Hg.
  • Sollevi A. Hypotensive anesthesia
    and blood loss. Acta Anesth Scand
    198832(Suppl.89)39-43.

53
Methods
  • Inhalation agents
  • Isoflurane
  • Halothane
  • Enflurane
  • Intravenous medications
  • Esmolol
  • labetolol
  • a- adrenergic blocking agents
  • Phentolamine

54
Contd..
  • CCBs
  • Nicardipine
  • Diltiazem
  • Vasodilators
  • Arterial and venous
  • NTG
  • SNP
  • Arterial
  • Hydralazine

55
Contd..
  • Ganglionic blocking agents
  • Trimethaphan
  • Purine derivatives
  • Adenosine
  • Prostaglandins
  • PGE1

56
ANH
  • One of the measures to decrease allogenic blood
    transfusion and promote autologous transfusion.
  • Simultaneous removal of patients whole blood and
    replacing it with an acellular fluid product.

57
Patient selection
  • An estimated blood loss 1500 ml.
  • Preoperative Hb concentration 12 g per dl after
    correction of normovolumia
  • Normal cardiovascular function(i.e no ischemic
    signs)
  • Absence of restrictive or obstructive lung
    disease.

58
ANH contd..
  • Absence of renal disease
  • Absence of untreated hypertension and liver
    cirrhosis.
  • Absence of coagulation abnormalities.
  • Absence of infection.
  • Kreimeier et al. Hemodilution in
    clinical surgerystate of the art 1996.World J of
    Surg, 199620(9)1208-1217.

59
Contraindications
  • Anemia with Hb lt 7 g.
  • Hemoglobinopathy associated with hemolysis
  • Active ischemic cardiac disease(severe AS,
    unstable angina, or both),
  • Renal failure-ANH can be done with CVVH
  • Known Coagulopathy associated with active
    bleeding.
  • Severe COPD.
  • Hemodilution
    possibilities and safety aspects.Acta
    Anaesthesiol Scand Suppl.19888949-53.

60
Preoperative embolisation
  • Reduces blood loss and may lower recurrence rate.
  • Davis et al
    (1986),Lafjunias et al (1980)
  • Higher grade JNA surgery cause significant
    bleeding even after embolisation because of blood
    supply from Internal carotid system.
  • Performed 24 hrs prior to surgery.
  • Cerebral embolism high in ICA embolisation.
  • Minor side effects-head ache, fever, scalp pain

61
Comparison of blood loss
Moulin et al .JNA Comparison of blood loss
during removal in embolized group versus
nonembolized group. Cardiovasc Intervent Radiol
18 158-161, 1995
62
Post op
  • Propped up position
  • Adequate analgesia
  • Monitor HR,BP,SpO2,RR,Urine output
  • Awareness about rebleeding

63
Post op
  • Extubation after 24 -48 hrs.
  • Assess extent of edema in relation to airway-
    cuff leak test
  • Fisher MM, Raper RF. The
    cuff-leak test for extubation. Anaesthesia
    19924710 2.
  • Marik PE. The cuff-leak
    test as a predictor of postextubation stridor a
    prospective study. Resp Care 199641509 11.
  • Steroids
  • Discuss with surgeon.
  • Pack removal in OT before extubation
  • Use of exchange catheter/FOB if edema suspected

64
Extubation criteria
  • Severity of underlying pulmonary disease
  • Length and extent of surgery
  • Presence of significant edema in or about the
    airway
  • Ability to mobilize and remove secretions
  • Ability to protect airway from aspiration
  • Amount of residual respiratory depression from
    anesthetics

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