ANESTESIA OTORRINOLARINGOLÓGICA I (1).pptx

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1. ANESTESIA OTORRINOLARINGOLÓGICA Hospital de Emergencias José Casimiro Ulloa CHICMANA ESPINOZA LUIS F. MR. 1. DE ANESTESIOLOGIA

2. ANATOMIA La laringe tiene un reflejo bilateral de cierre de la glotis mediado por los nervios laríngeos superiores. Este reflejo sirve para proteger de la aspiración. Laringoespasmo: espasmo mantenido de los músculos de la glotis que impide la respiración. Suele presentarse durante las anestesias superficiales y desencadenarse por irritación de las cuerdas vocales debida a sangre o secreciones. ( septoplastia y rinoplastia). La lesión N. recurrentes laríngeos: complicación temida, pero con frecuencia evitable de la cirugía de la tiroides y también de técnicas como la intubación traqueal. Daño unilateral: Ronquera por perdida de la capacidad de abducción de la cuerda vocal, mientras que su aducción, mediada por el músculo cricotiroideo, se mantiene intacta. Lesión de ambos nervios: puede provocar disnea, estridor e incluso una obstrucción. Estos pacientes pueden requerir una traqueotomía.

3. VALORACION PREOPERATORIA PARA LA CIRUGIA DE OTORRINOLARINGOLOGIA Antecedentes: neoplasias malignas de cabeza y cuello, tabaquismo, abuso de alcohol, obesidad, apnea obstructiva del sueño (AOS). Pacientes con una obstrucción crónica pueden desarrollar hipertensión pulmonar, que puede desencadenar una insuficiencia cardíaca derecha. Antecedentes de ronquera o estridor Antecedentes de radioterapia de cabeza y cuello para el tratamiento de neoplasias malignas suelen asociarse a intubación difícil, ya que las estructuras se vuelven duras y fibrosas (“como de madera”), Aunque a la vez son propensas a sangrar con la instrumentación. Los procedimientos de ORL implican un riesgo poco frecuente, algunas de las cirugías amplias de cabeza y cuello se consideran de riesgo quirúrgico intermedio. Estudios de imágenes Rx , TAC o RMN. Fibrobroncoscopia previa (puede cambiar el abordaje de la via aérea hasta en un 25 %) para determinar si existe alguna alteración problemática de la laringe, como lesiones supraglóticas no visibles con métodos convencionales.

4. Manejo de la vía aérea en otorrinolaringología En la mayoría de los pacientes que van a someterse a cirugía ORL, la vía aérea se controla mediante intubación traqueal. En circunstancias habituales la intubación traqueal resulta sencilla, por lo general es posible identificar previamente a aquellos pacientes que probablemente serán difíciles de intubar y emplear en ellos otras técnicas como la videolaringoscopia o la intubación con fibroendoscopio .} LA TÉCNICA DEPENDERÁ condiciones clínicas destreza del anestesiólogo preferencias sobre dispositivos consideraciones del cirujano equipos disponibles

5. CONSIDERACIONES INTRAOPERATORIAS Valoración por el algoritmo American Society of Anesthesiologists (ASA) Tipos de anestesia usados: A. general con intubación endotraqueal A. general empleando un dispositivo supraglótico para el manejo de la vía aérea (SGA) (p. ej., mascarilla laríngea) A. general empleando un laringoscopio de ORL (para exponer la vía aérea) asociado a ventilación con jet. Utilización de apnea intermitente. A. general empleando la vía aérea natural del paciente, con o sin el empleo de ayudas como dispositivos para la colocación de la mandíbula o cánulas nasofaríngeas. A. local asociada a sedación intravenosa con el paciente respirando espontáneamente. Que tubos usar: TET, TML, uso con láser o flexometalicos . Técnica con fibro despierto: Atropina + lidocaína VO y/o nasal Bloqueo del nervio laríngeo superior y el bloqueo transtraqueal Sedación adecuada. Tipo de anestesia TIVA: pacientes con masas colapsables si se usa ventilación jet o técnica apnea intermitente ( cx de laringe)

6. ANESTESIA PARA PANENDOSCOPIA Triple endoscopia: laringoscopia, broncoscopia y esofagoscopia. Se suele requerir laringoscopios específicos, frecuentemente asociados a TET de pequeño diámetro o a un tubo especialmente diseñado para su uso en cirugía láser. Otros usos de la panendoscopia : pacientes con neoplasias de cabeza y cuello para detectar lesiones de cuerdas vocales, obtener biopsias de tejidos, vigilancia de posibles recidivas tumorales, etc. Paciente no permita utilizar un TET y se precise una ventilación con jet o un broncoscopio rígido . La intubación traqueal con el paciente despierto es el método más habitual para los pacientes con vías aéreas difíciles. Además, cuando se emplea la ventilación con jet, se requiere una anestesia intravenosa total (TIVA).

7. Cuando la panendoscopia se combina con cirugía láser, se suele emplear un TET compatible. La panendoscopia suele realizarse con el paciente bajo anestesia general, con el cuello flexionado y la cabeza extendida, general mente empleando un rodillo para el hombro y un soporte circular para la cabeza (posición de Jackson). Habitualmente se emplea un laringoscopio para la comisura anterior, que se mantiene sus pendido en posición fija. Esta técnica permite al cirujano tener las manos libres y utilizar el microscopio quirúrgico. Otros laringoscopios quirúrgicos especializados de ORL de uso frecuente, generalmente en combinación con un microscopio para realizar microcirugía laríngea, son el laringoscopio Dedo y el Universal Modular Glottiscope . ANESTESIA PARA PANENDOSCOPIA

8. técnicas anestésicas para la panendoscopia El método más habitual es realizar el procedimiento bajo anestesia general con relajación muscular y un tubo traqueal de tipo TML. Los anestesiólogos están familiarizados con esta técnica, que proporciona protección de la vía mediante capnografía fiable del dióxido de carbono (CO2) y posibilita el uso de anestésicos volátiles sin diseminarlos al quirófano. Desventajas: Presiones de ventilación superiores a las habituales por el menor diámetro del tubo empleado, Dificulta el acceso quirúrgico y aumenta el riesgo de combustión del tubo cuando se utiliza un láser. La necesidad de una técnica de TIVA de ciclos repetidos de intubación-extubación (que pueden provocar un edema de glotis), la realización discontinua del acto quirúrgico dentro de los períodos breves de apnea y la interrupción repetitiva de la ventilación y la oxigenación. La pan-endoscopia suele realizarse mediante ventilación jet supraglótica.

9. CIRUGIA NASAL Valoración preoperatoria: Vasoconstrictores nasales por vía tópica La posible existencia de AOS no conocida Tríada de Samter (poliposis nasal, asma y sensibilidad al ácido acetilsalicílico y los AINE que puede provocar un broncoespasmo mortal). Sangrado postoperatorio es una complicación habitual tras la cirugía nasal, los pacientes que van a someterse a ella no deben tomar AINE ni ácido acetilsalicílico desde 1 o 2 semanas antes. Elección del tipo de anestesia: Anestesia local puede resultar adecuada para procedimientos sencillos como cauterización o una polipectomía o turbinectomía simple en adultos, con frecuencia se precisa anestesia general. Mascarilla facial convencional (que puede resultar adecuada para realizar una miringotomía en pacientes pediátricos), un dispositivo SGA (p. ej., ML flexible) o un tubo traqueal (p. ej., tubo flexometálico que no pueda acodarse). A general empleando por lo general un TET reforzado colocado en la línea media sujeto al mentón con cinta adhesiva : Rinoplastias, septo plastias, lesiones neoplásicas, reducción de fracturas nasales.

10. En muchas de estas cirugías se emplea un vasoconstrictor tópico como fenilefrina que reducen el sangrado y mejoran la visualización durante las intervenciones de cirugía nasal y endoscópica, en ocasiones producen toxicidad cardiovascular. La fenilefrina es un vasoconstrictor tópico con efecto agonista α-adrenérgico que se administra solo o en combinación con lidocaína. La dosis inicial no debe superar los 500 µg. Puede producirse una hipertensión grave tras la administración de fenilefrina, por lo que resulta especialmente importante la monitorización de la presión arterial. CIRUGIA NASAL

11. Amigdalectomía y adeneidectomía Los adenoides hiperplásicos, puede provocar una obstrucción de la nasofaringe y diversos problemas requiriendo su extirpación quirúrgica ( adenoidectomía ). Cuando se extirpan, se suelen extirpar también las amígdalas. Otras indicaciones: hiperplasia amigdalina, la amigdalitis recidivante y su degeneración maligna. La obstrucción crónica de la vía aérea en la nasofaringe, secundaria a una hipertrofia amigdalina, puede provocar AOS y sus complicaciones asociadas (somnolencia diurna, cor pulmonale , hipertensión pulmonar, hipertrofia del ventrículo derecho, cardiomegalia). La presencia de fiebre o tos productiva pueden ser motivos para posponer la cirugía o para que la atención postoperatoria se realice con mayor vigilancia.

12. La inducción de la anestesia en adultos generalmente implica la administración de fármacos por vía intravenosa, mientras que la inducción por vía inhalatoria es bastante popular en niños. Se prefiere utilizar tubos traqueales orales de tipo RAE (denominados así en honor de sus inventores, Ring, Adair y Elwyn ) o tubos flexometálicos sujetos con cinta adhesiva en la línea media a la mandíbula, siendo estos tubos menos propensos a acodarse tras la colocación de un separador. Cuando existe un absceso amigdalino o parafaríngeo puede ser una vía aérea complicada por la existencia de trismo y edema faríngeo. Se realiza la descompresión de un absceso en el paciente despierto mediante aspiración con aguja antes de la inducción. Amigdalectomía y adenoidectomía

13. bibliografía Miller, Ronald D. Miller Anestesia 9º Edición. Editorial Elsevier 2020