Anaesthetic management of a patient with carcinoma larynx for laryngectomy

1
Anaesthetic management of a patient with
carcinoma larynx for laryngectomy
Dr Poonam Bhadoria Professor Department of
anaesthesia and intensive care Maulana Azad
Medical College Lok Nayak hospital New
Delhi-110002
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2

• Identify
• Clinical presentation
• investigation-IL
• airway evaluation
• essential monitoring
• anaesthetic concerns
• unexpected problems - after extubation in MLS
• - during laryngectomy

• spot

3
History

• Age, Sex 60 years male
• Present history c/o
• hoarseness, dyspnoea, stridor, cough,
  haemoptysis, dysphagia, referred pain to ear
  anorexia, mass in neck
• Treatment history
• Radiation - glottic oedema
• trismus
• fibrosis
• stiff larynx epiglottis
• Chemotherapy
• Surgery - scarring

4

• Past history
• Medical (COPD, CVS aspirin)
• Surgical (previous interventions)
• Personal history smoke, alcoholic
• Dietary history
• Occupational history industrial and textile
  worker (air pollution and chronic inflammation of
  larynx)

5
Examination

• GPE
• Built / nutritional status
• Vitals
• Oral cavity
• Jugular venous pressure
• Respiratory system wheeze
• Airway examination distorted upper airway and
  obstructed, because of friable growth
  with or without tracheostomy.

6
Investigations

• Routine
• Haemogram , blood glucose, KFT, LFT, SE
• Urine routine,
• ECG
• Specific to assess extent, invasion, destruction
• Chest Xray PA
• Xray neck AP / Lateral
• Indirect laryngoscopy
• PFT (COPD)
• Laryngogram filling defect
• CT scan, barium swallow
• MRI

7

• Major ? Plan ? MLS or D/L
• Short case
  long case

Short case
Long case
8

• Preoperative preparation
• Optimize lung functions
• antibiotics, bronchodilators, corticosteroids,
  chest physiotherapy including breathing exercises
• Care of nutrition, hydration
• Removal of bad teeth
• Indirect laryngoscopy - review again
• Treatment of associated medical disorders and age
  related problems
• Counseling-post operative speaking
• Care of tracheostomy

9
Preoperative preparation

• Cessation of smoking
• Time course beneficial effects
• 12-24 hours ?CO and nicotine levels
• 48-72 hours ?COHb levels normalizes
  and bronchociliary functions improve
• 1-2 weeks sputum production
• 4-6 weeks PFT improves
• 6-8 weeks immune function and drug
  metabolism normalize
• 8-12 weeks ?overall PO morbidity

10

• Preoperative preparation
• Cessation of alcohol
• effect on liver, gastric irritation, CVS,
  therefore pre-medication with antacids and
  metachlorpromide
• Effects Acute Chronic
• inhalational agents, ? need ?MAC
• barbibenzoopioids more sensitive
  cross-tolerance
• suxamethonium - ?effect
• relaxants rely on hepatic clearance
• drug of choice atracurium

11

• Preoperative advice
• NPO, continue bronchodilators morning dose of
  drugs, arrange blood, consent
• Pre-medication Glycopyrrolate 0.2 0.3 mg i/m,
  nasal drops FOB, IL, sedatives
• If with tracheostomy steam, nebulisation,
  encourage cough, suction,

12
Surgical plan

• Direct laryngoscopy and biopsy (day care)
• Major surgery
• Partial / total laryngectomy
• Laryngo-pharyngectomy
• RND
• Flap surgery
• Besides normal routine check for Int.
• Stylet , MLS tube
• Tracheostomy set
• Local 2, 4, 10 for awake intubation
• Availability of defibrillator
• Other type and size of laryngoscope
• check the equipment like FOB
• Ready ENT surgeon

13
Major surgery

• Preoperatively arrange
• Blood, Ryles tube CVP line, Foleys catheter
• If already tracheostomised
• Care of tracheostomy tube
• Montendo tube / Montgomery T tube
• I/V access
• Premedication
• Preoxygenation
• Induction
• Propofol / Thiopentone
• Suxamethonium after mask ventilation
• Maintenance on O2, N2O , Halothane or Isoflurane

14
Monitoring

• Routine
• HR, ECG
• SpO2, EtCO2
• NIBP
• Temperature (rectal axillary probes)
• In addition
• CVP (towards higher side)
• Urine output
• Blood loss
• Arterial line for serial estimation of blood gas
  and hematocrit
• Airway pressures
• Positioning head up tilt (15 to 20 degree)

15
Intra-operative problems

• Bleeding (hematocrit 0.25 to .0.27)
• ?by positioning of patient (pillow under knees,
  reversed Trendelenburgh position), 2 mmHg fall in
  BP for each 2-5 cm rise in head position above
  the heart level.
• Induced hypotension inhalational, i/v (NTG, SNP
  etc).
• Early, accurate assessment of blood loss Timely
  replacement with blood / colloid.
• Compromised cerebral circulation
• carotid artery infiltration ??cerebral arterial
  pressure
• jugular vein infiltration ??cerebral venous
  pressure
• rotation of neck ??carotid blood flow
• Contd

16

• Induced hypotension
• Inhalational
• Isoflurane
• dose dependent hyotensive effect by
  vasodilatation
• up to 40mmHg in 6 minutes, little change in CO
• Halothane/enflurane
• ? BP, CO, Stroke volume ??right heart filling
  pressure
• IV agents
• fentanyl 1-3mcg/kg
• propofol 100mcg/kg/minute
• NTG 0.5-3mcg/kg (BP 80-90mmHg)
• SNP 3mcg/kg/minute, ?es dias. by 30 to 40
• Contd

17

• During opening of neck veins
• Rapid fall in EtCO2, BP ? Air embolism
• ECG inverted T, tall P, RBBB, RHS?VF
• Treatment
• Stoppage of surgery
• Flood with saline/fluid
• 100 O2 , stop N2O- why?
• Durhants position
• Aspiration of air through CVP catheter
• PPV
• Contd

18

• Carotid sinus stimulation ? cardiac dysrhythmias,
  bradycardia, Hypotension
• Denervation of carotid sinus body? hypertension
  and loss of hypoxic derive.
• Ablation of rt sympathetic ganglion-?QT interval
  and malignant arrhythmias ? cardiac
  arrest
• Treatment LA infiltration of carotid bulb /
  vagolytic agents
• cessation of pressure
• Hypotension
• Hypothermia
  Contd

19

• Intra-operative maintain adequate analgesia
• When trachea is transected, tube is replaced by
  non kinkable tube (confirmed by capnography and
  auscultation)
• ? airway pressure malpositon of tube,
  bronchspasm, debris
• Loss of airway at induction, midway, extubation,
  postoperative

20

• In microvascular flap reconstruction
• avoid vasoconstrictor
• Avoid induced hypotension techniques
• Maintain hematocrit 0.30
• No diuresis
• Avoid hypothermia
• forced air warming blankets
• IV warm fluids
• Inspired anaesthetic gasses warm and humidified

21

• Postoperative problems
• Prolonged recovery ICU care preferably
• Ventilation care - pneumothorax, subcutaneous
  emphysema
• Speaking
• Postoperative care
• Monitoring of vital signs
• Care of tracheostomy
• Chest physiotherapy, suctioning ,
• head up 30 to help venous drainage
• Chest X ray, within 6 hours
• No tight bandage airway impingement
• Bronchodilation, nebulisation
• Oxygen and analgesia

22
(No Transcript)
23
Rehabilitation

• Vocal
• Oesophageal speech
• Artificial larynx (electro-larynx and trans-oral
  pneumatic device)
• Tracheooesophageal speech (Blom-singer and Panje
  prosthesis)
• Other rehabilitation procedure
• Social
• Psychological
• Vocational

24
Patients limitations

• Swimming
• Cannot call aloud
• Climbing up the stairs,
• Strenuous work
• High altitude

25

• D/L BIOPSY or MLS
• Day care surgery
• Goals COMPLAINTS
• Clear view Hoarseness,
• Immobile field stridor
• Sufficient space to work haemoptysis
• CVS stability
• Etiology
• Benign growth
• Vocal cord dysfunction
• Foreign body aspiration
• Obstructed tumour
• Papillomatosis

26

• How to proceed ?
• Airway concerns
• Anaesthetic concern

27

• Airway concerns
• Mask ventilation?
• Intubation with laryngoscopy ?
• Any doubt - secure airway before induction by
  FOB or by tracheostomy ? LA
• -airway evaluation for type of lesion
• (95 ant. 5 post.)
• -i/l d/l (laryngeal inlet), CT, MRI
• -discuss with surgeon for size of tumor

28

• LA
• Topical, oral lignocaine lozenges
• Oral 4 lignocaine gargles, spray
• Nerve block (SLN and glossopharyngeal)
• Nebulization with 4 xylocaine

29
landmarks SLNB (ext)
30
Nebulisation

• 4-6 ml 4 lignocaine
• Particle size gt100 microns-oral
• 60-100 microns-trachea
• 30-60 microns-larger bronchi
• 10-30 microns-small bronchi
• lt5 microns-alveoli
• gt50 loss during spont resp

31

• Anaesthetic concerns (MLS)
• What are they ?
• Rapid awakening return of protective airway
  reflexes
• Minimize secretions and reflexes
• Protection to trachea
• Ensure good ventilation oxygenation
• -Review on table
• -Pre-oxygenation
• -Glycopyrrolate 0.2-0.3mg IM
• -no premed. If any s/o UAO

32

• Intubation depending on spread of growth
• Small routine paralysis, tracheal intubation
• Mod. Large awake intubation / tracheostomy ?
  LA as airway obstruction may
  worsen after anaesthesia. -If
  ventilation- yes intubation ? VA and S/R
  -If ventilation- no -
  intubation awake block IV sedation
• -limited pre-medication
• Large, impinging on upper airway stridor at
  rest preoperative tracheostomy, no pre-medication
  
• No BNI if friable lesion

33

• Methods for ventilation
• (Manual and automated)
• Ventilation with ETT
• Venturi jet ventilation (supraglotic)
• Intermittent apnea technique
• HFPPV

34
Ventilation oxygenation

• A). ETT 5mm ID, long with standard cuff (Micro
  laryngeal tube) low pressure high volume tube
• Control ventilation-
• advantages
• - prevent aspiration
• - maintain inhalation anaesthesia
• - monitor ETCo2
• disadvantages
• - limited access to surgeons
• - possible distortion of tissue during
  intubation

35

• Alternatives techniques (post. commi. lesion)
• (balanced technique-injector below vocal
  folds/lx)
• B). Jet ventilation
• ETT not required
• Unobstructed view (profound messeter relax)
• Alignment of laryngoscope tracheal axis.
  (pneumatic knife)
• Full relaxation of V.C.
• Free egress of gas
• Monitor chest wall motion
• contd

36

• Ventilatory rate 6-7 bpm at 30-50 PSI I/E 1.56
  sec (Saunders jet injector)
• Cuffed Carden tube.
• Contraindicated in children, obese bullous
  emphysema.
• Risks -barotrauma, stomach dilatation, forcing of
  blood tumour in lungs, pneumothorax,
  hypotension.
• C). Intermittent intubation and apneic period.
• D). HFPPV, less risk of barotrauma. (80-300/min)
• - 2-3 ml/kg ? T.V

37
(No Transcript)
38

• Reflex responses -HT, tachycardia, arrhythmia
• -Use topical lignocaine,
• or I/V (1-1.5mg/kg)
• -I/V fentanyl, esmolol (200-
  400mcg/minute)
• Anaesthesia -Propofol (2mg/kg), fentanyl
  (1-2mcg/kg)
• -topical anaesthesia of larynx
• -appropriate muscle relaxation
• -suxamethonium,
  intermediate acting
• -Ensure adequate depth
• -remifentanyl -potent rapid recovery profile
• -thorough suction before extubation
• Remember if difficult intu then difficult
  extubation

39

• Monitoring ECG-essential as sym stimulation ,
  
• BP, Oximetry, ETCo2
• Post op risk -MI or Ischemia 1.5-4
• -laryngospasm,
• -laryngeal edema
• -strider
• -restlessness (hypoxia, pain)
• barotrauma and pneumothorax
• Aspiration / seeding of polyp into trachea

Laryngospasm
40
Laryngospasm

• Reflex closure of upper airway from spasm of
  glottic
• musculature
• Mechanism
• False cords and epiglottic body come together
• Extrinsic muscles of larynx create ball valve
  mechanism
• Reflex apnea d/t stimulation of SLN
• Etiology
• Stimulation by blood, vomitus , secretions
• Light planes of anaesthesia
• Chemical irritation of laryngeal , pharyngeal
  mucosa
• Can persist even after irritation ceases
• Visceral pain reflex
• Negative pressure pulmonary edema (as a result)

41

• Treatment
• Removal of stimulus
• 100 oxygen
• Lifting the mandible up and maintain sniffing
  position
• Sustained positive pressure ? bulge in pyriform
  fossa
• Low dose Suxa (10 20 mg i/v)
• If fails , 100 mg Suxa and intubate
• i/v lidocane
• Propofol and ketamine ? inhibit the N-methyl-D
  aspartate receptor

42
Our role

• Pro active approach to prevent or terminate the
  laryngospasm and thus preventing hypoxemia is the
  mark of a seasoned anaesthesiologist

43
Stridor

• Immediate attention, establish cause,
  intubation , assess severity situation and
  clinical details
• Treatment
• Heliox helium 70 30 O2
• Full monitoring head end of bed up by 45 to 90
  degree
• Nebulize epinephrine
• Dexamethasone 4-8mg/8-12 hourly if oedema is the
  casue

44
Laser surgery

• Light amplification by stimulated emission of
  radiation useful tool in modern surgery
• CO2 laser -
• Invisible infra red light
• Absorbed by tissue water
• is used for treatment of early carcinoma of
  larynx
• Beam focused to small spot-precise controlled
  coagulation.
• Incision or vaporization of tissue, suitable for
  vocal cord laryngeal surgery (10 W power with
  0.1 sec pulses a small spot)

45

• LASER
• Advantages Disadvantages
• No bleeding Lack of pathology specimen
• No oedema, scarring Damage to surrounding
  tissue
• Rapid healing Risk to eyes
• 
  ETT damage and Intratracheal fire
• Hazards
• To staff, patient and theatre
• Eyes are vulnerable
• Fire explosion (thermal effect)
• Noxious fumes
• Ignition of inflammable materials

46

• Safety considerations
• OT warning signs for laser use.
• Restrict entry into OT
• Wear protective eye glasses (wave length
  specific).
• Avoid flammable materials (drapes, plastic tubes
  etc.).
• Patient's eyes taped closed cover with wet
  pads
• Wet towels to drape.
• Competent personnel for equipment use
• Avoid misdirection of beam
• Avoid ETT in short procedures use venturi
• Ready bucket of clean water for dipping the tube
• Smoke evacuators at surgical site

47

• Metal endotracheal tube
• Nortons stainless steel spiral coil without cuff
  
• (Walls not air tight)
• Laser flex tube air tight stainless steel spiral
  with two distal cuffs
• Bivona foam cuff aluminum spiral tube with outer
  silicone Coat and self inflating foam sponge
  filled cuff

48

• Airway fire (0.1) protocol
• Fatal due to
• Thermal injury, Chemical burn brochospam
  edema, melting burning ETT lead to obstruction
• Management
• -use of special tubes
• -stop O2, remove ETT, flood with saline
• -bag mask/venturi ventilation
• -if difficult airway, remove ETT on guide wire
• -check bronchoscopy
• -post operative sitting position, X-ray chest
  , antibiotics, humidified O2, steroids

49

• careful thought ahead of time by anaesthetist
  can prevent such complications

50

• GOOD LUCK

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om