oral and maxillofacial surgery and anaesthesia implications

maxillofacial surgery and anaesthesia

1. Maxillofacial Surgery & Anaesthesia THE INTERFACE Dr. Rehana Sultana MDS

2. Objectives Identify Salient Pre Operative Anaesthetic Considerations for Patients Undergoing Oral and Maxillofacial Surgery Discuss on Common Intraoperative Problems associated with Anaesthesia and their Management in Various Maxillofacial Surgeries Post Operative Measures To Be Taken In this Group of Patients

3. Why Do Maxillofacial Surgeons Need To Know? Many Critical Incidents Involved OMFS Cases Numerous Cases Where AFOI was Indicated But Was Not Used Aspiration Highest Cause Of Death Cannula Cricothyrodotomy Failed In 60% Of Cases

4. Anaesthesia is……..

5. Stages

6. Issues

7. Issues Associated Defects/Injuries Cervical Spine Injury Head Trauma Subcutaneous Emphysema Haemorrhage Trismus Requires multidisciplinary approach

8. Difficult Airway Clinical Condition Where In Conventionally Trained Anaesthesiologist Experiences Difficulty With Face Mask Ventilation Of Upper Airway, with Tracheal Intubation Or Both Practice guidelines for the management of the difficult airway ;anaesthsiology2003;98;1269

9. Causes & Predictors

10. Difficult Airway Cart Oropharyngeal Airways Nasopharyngeal Airways

11. Difficult Airway Cart

12. Other Methods Retromolar Intubation Submental Intubation Submandibular Intubation

13. Flexible Fiberoptic Intubation Safest Mode of Intubation with High Success Rate

14. Inadequate Seal- Cuff Leak Over Inflation Of Cuff Decreases Mucosal Perfusion Leading To Necrosis And Nerve Palsies Under Inflation Leads To Microaspiration Cuff Pressure Should Be 20-30cms Of Water Changes In Cuff Pressure Occur With Change In Position Of Head And Neck Careful Monitoring Of Cuff Pressures Should Be Done To Prevent Any Leak Endotracheal cuff pressure changes with change in position in neurosurgical patients Int J Crit Illn Inj Sci .  2015 Oct-Dec; 5(4): 237–241.

15. Problems During Intubation Avulsion Of Mobile Teeth, Rupture Of Abcess If Unnoticed Epistaxis Due To Trauma Poor Visibility Due To Bleeding And Oedema In Maxillofacial Trauma Cases Dislodgement Of Fragile Tissue From Cancer Growth Tube Should Not Interfere With Surgical Landmarks In Cleft Surgery

16. Management Prior Discussion With Anaesthetist Regarding, Method to Be Used For Intubation Site Of Surgery Should Be Known To Anaesthetist Awake Fibre Optic Intubation Preferred Loose Teeth Must Be Extracted Prior Nasal Packing If Necessary

17. Shared Airway Common Site Of Work Preop Discussion & Planning Helpful Extra Vigilance For Tube Dislodgement & Kinking

18. Tube Related Factors Tube dislodgement Tube damage Epistaxis Bacteremia From Trauma To Nasal Mucosa Damage To Turbinates And Retropharynx Pressure Sore Of Ala Nasi Alar Necrosis

19. Tube Dislodgement Common in orthognathic surgery Laryngeal nerve paralysis & accidental extubation Continous Breath Sound Method To Assess The Depth Of Tracheal Tube Damage to the pilot balloon of the nasotracheal tube during orthognathic double-jaw surgery: A case report J Dent Anesth Pain Med. 2015 Jun;15(2):101-103

20. Flexion of the neck results in increase of 2 cm in the insertion depth of tracheal tube. Conversely, extension of the neck results in decrease of 2 cm in the insertion depth of tracheal tube. *Extension and rotation of the neck results in decrease of 2.5 cm in the insertion depth of tracheal tube

21. Securing The Nasotracheal Tube Adhesive Tapes Suturing To Pericranium Disposable Catheter Strapping Ligatures Custom Made Splints Supporting The Tube By Mayo Table

22. The difficult airway in maxillofacial trauma,operative techniques in otolaryngology-head and neck surgery volume31,issue2,june2020

23. Tube Damage Maxillofacial Surgery In Particular Orthognathic Surgery More Prone To Cause Tube Damage Due To Close Proximity Complete Transection Of Nasotracheal Tube Is Rare Sharp Instruments, Pterygomaxillary Dysjunction , Lateral Nasal Osteotomy Cuts More Common Causes Oropharyngeal packing may be helpful Surgical airway ready Patel K, Morris DE, Gassman A. Complications of orthognathic surgery. J Craniofac Surg 2007; 18: 975–85

24. Measures To Prevent Pre Planning Essential Peizotome Much Safer Instrument Use Of Reinforced NET Over Soft NET 3D Planning For Proper Visualisation Of Osteotomy Cuts Use Of A Guarded Osteotome With Lateral Stops That Is Thinner Than The NET 

25. Management Use of a gum-elastic bougie or a specialized airway exchange catheter, which has the advantage of providing ventilation during the exchange process . Jain M, Garg M, Gupta A. Accidental perforation of endotracheal tube during orthognathic surgery for maxillary prognathism - a case report. Indian J Anaesth 2008; 52: 205-7. Using a nasogastric tube as a conduit to deliver oxygen and guide ETT exchange Baker CS, Kora S, Abadir AR. Management of a perforated endotracheal tube during orthognathic surgery. Anesth Prog 1988; 35: 158-9. MacGrath video laryngoscope, direct laryngoscope, and fiberoptic bronchoscope to safely exchange damaged ETTs Koyanagi Y, Yokota E, Iwata M, Shimazaki R, Misaki T, Oi Y. A case of successful tracheal tube exchange with McGrath MAC for tube damage during oral surgery. Anesth Prog 2020; 67: 174-6.

26. Placing a smaller, lubricated ETT in the lumen of a damaged tube and exchanging the damaged ETT with a stylet Peskin RM, Sachs SA. Intraoperative management of a partially severed endotracheal tube during orthognathic surgery. Anesth Prog 1986; 33: 247-51.

27. Alar Necrosis Nasal ala pressure sores following head and neck reconstructive surgery: A retrospective analysis from a tertiary cancer hospital Indian J Anaesth Volume 61(1); 2017 Jan Columellar Necrosis and Alar Notching-Prolonged Nasal Intubation Small Amount Of Pressure Maintained For A Long Period Might Induce More Tissue Damage Than A Large Amount Of Pressure Applied For A Short Period

28. Nasal Pressure Sores Prevalence: 0.59% To 24.48% Stage I: Nonblanchable Erythema Stage II: Partial Thickness Skin Loss Stage III: Full Thickness Skin Loss Stage IV: Full Thickness Tissue Loss >32mm of Hg pressure on soft tissue leads to pressure sore Nasal ala pressure sores following head and neck reconstructive surgery: A retrospective analysis from a tertiary cancer hospital Indian J Anaesth  , v.61(1); 2017 Jan

29. Risk Factors Gender Prolonged Duration Of Surgery ( Risk Increased 4.8% For Every 10 Min Of Anaesthesia Time) Type And Material Of Endotracheal Tubes Bare Contact Surface Sharp Angle Between Tube & Nose Underlying Conditions Which Cause Poor Skin Elasticity Lower Incidence In Patients With High BMI Use of a hydrocolloid dressing to prevent nasal pressure sores after nasotracheal intubation Br J Oral Maxillofac Surg 2011 Oct;49(7):e65-6.

30. Measures for Prevention Barrier To Attach Between The Nasal Alar And The Tube, For Example; Polyvinyl Alcohol Foam, Hydrocolloid Flexible silicon putty Modified nasotracheal tube Duoderm adhesive patch over alar base Using A Modified Nasotracheal Tube To Prevent Nasal Ala Pressure Sore During Prolonged Nasotracheal Intubation

31. Reflex Bradycardia Incidence :1.6% Manipulation Of Mid Face Fractures, Zygoma Fractures, maxillary Osteotomies Sudden Onset Of Sinus Bradycardia, Bradycardia Terminating In Asystole, Asystole With No Preceding Bradycardia, Arterial Hypotension, Apnea , And Gastric Hypermobility Beta blockers, calcium channel blockers precipitate

32. Lubbers Et Al Classified Various Facial Surgery Into Low (TMJ Surgeries , Le Fort I Osteotomy, Elevation Of Zygoma) , Medium (Skull Base Surgeries) , High Risk Surgeries (Ophthalmic Surgeries, Orbital Exenteration And Fracture In Children With Cardiac Disease). Lu¨bbers HT, Zweifel D, Gra¨tz KW, Kruse A (2010) Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg 68(6):1317–1321

33. Preventive measures Abrupt And Sustained Traction Of Craniofacial Structures Should Be Avoided Administration Of Regional Nerve Block In The Operating Site Especially If Hypotensive Anaesthesia Is Planned Administration Of Glycopyrolate ( Vagolytic Agent) + Lignocaine Prophylactically Continuous Cardiac Monitoring, Adequate Oxygenation And Watching For Additional CO2 Waves Devakumari S, Vijhayapriya T (2013) Trigemino cardiac reflex and its importance in maxillofacial surgery—a review. IOSR J Dental Med Sci 12(2):7–11

34. Hemorrhage /Bleeding Face Has Rich Vascular Supply Patients On Anticoagulants - Caution Risk Of Peri-operative Bleeding Versus Thrombosis On Discontinuation Of Anticoagulants Should Be Stratified

35. Methods To Control Blood Loss Reverse Trendelenburg (Anti-gravity) Positioning. Ensuring Adequate Venous Drainage. Antifibrinolytics - Tranexamic Acid. Infiltration Of The Tissues With Vasoconstrictors Like Adrenaline. Controlled/Induced Hypotension. Intermittent Positive Pressure Ventilation And Maintenance Of Mild Hypocarbia.

36. Induced Hypotension Can Reduce Blood Loss, Transfusion Rate & Operating Time, Not Without Risks!! No more than 30 % Reduction with an absolute lower limit of 55 mm of Hg Caution in CAD, Uncontrolled Hypertension, CVD, Hepatic/Renal Impairment Risks & benefits of induced hypotension in anaesthesia: A systematic review .Int J Oral Maxillofac Surg2008;37:687-703

37. Hypotensive Anaesthesia Can Reduce The Extent Of Intraoperative Bleeding& Can Potentially Improve The Quality Of Surgical Field Carries Risk Of Hypoperfusion In Vital Organs & Is Unsafe In Certain Patients Appropriate Patient Selection, Careful invasive arterial blood pressure Monitoring & Adequate Intraoperative Volume Replacement Are Mandatory Hypotensive anaesthesia versus normotensive anaesthesia during major maxillofacial surgery: a review of literature The scientific world journal;2014 Induced Hypotension

38. Carotid Sinus Reflex Controls Heart Rate & Blood Pressure Three Types Of Response Cardioinhibitory Vasodepressor Cerebral Pressure On Neck/ Tumors Compressing Sinus/Neck Dissection Anticholinergic Medications And Cardiac Pacing.  Weiss S, Baker JP: The carotid sinus reflex in health and disease: its role in the causation of fainting and convulsions. Medicine. 1933, 12: 297-354.

39. Aspiration Accidental Aspiration Of Loose Teeth, loose Dentures, Foreign Bodies Can Occur During Intubation Foreign Body Enters Trachea-bronchi- Lung Bronchiectasis- Lung Abcess Retrieval Using Fibreoptic Bronchoscope Dormia Basket – Device To Hold Firmly

40. Chest Xray To Confirm The Position Removal Done Using Fibreoptic Bronchoscope Dormia Basket Tooth aspiration following emergency endotracheal intubation Respir Med Case Rep.  2016; 18: 85–86 n

41. Throat packs?? A TP Acts A Pharyngeal Tampon And Is Placed In The Posterior Pharynx After Endotracheal Intubation To Prevent Secretions/Blood/Tissue Debris From Trickling Down Into The Stomach Or Trachea A Retained TP May Lead To The Dangerous Complication Of Airway Obstruction In Immediate Post- extubation Period. Joint Decision Between Anaesthetist & Surgeon Removal Of TP – Include In Swab Count Current practices and beliefs regarding the use of oropharyngeal throat pack in India: A nationwide survey Indian J Anaesth .   2021 Mar; 65(3): 241–247

42. Use it or not?? May Not Be Effectively Prevent Patients From Ingesting Blood During Surgery Or Improve Post Op Nausea And Vomiting Use Of Throat Packs Not Effective For Patients So Its Use Is To Be Reconsidered Randomised Controlled Trial , IJOMS 2021

43. Endotracheal fire Hazards Of Fire While Using Co2 Laser For Resection Of Head And Neck Cancer The Laser-flex Tracheal Tube (Stainless) And Aluminum Foil Wrapped PVC Endotracheal Tube Are The Best Ones Laser Consumables Wet Throughout The Procedure Is Highlighted As Laser Fails To Penetrate Need To Cover The ET Tube With Damp Swabs Or Neuropatties When Possible. Laser safety in head and neck cancer surgery Eur Arch Otorhinolaryngology 2010 Nov;267(11):1779-84

44. Post Operative Nausea & Vomiting H igh Incidence Of PONV After Orthognathic Surgery Caused By The Emetic Properties Of Volatile Anaesthetics And The Opioids Administered This Can Be Explained By Swallowed Blood, An Altered Diet, And Hypotension In The Perioperative Period  Blood Loss During Surgery Has A Major Impact On PONV Postoperative nausea and vomiting after oral and maxillofacial surgery: a prospective study IJOMS; VOLUME 47, ISSUE 6, P721-725, JUNE 2018

45. Risk factors Management Antiemetics Dexamethasone Analgesics Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth .  2012; 109: 742-753

46. Post Operative Bleeding Haematoma-related Airway Obstruction Nasal Haemorrhage Is One Of The First Signs Of Massive Bleeding Following Le Fort I Osteotomy Prevalence of postoperative secondary bleeding and its relationship with intraoperative massive bleeding in patients undergoing orthognathic surgery Journal of Stomatology, Oral and Maxillofacial Surgery Volume 122, Issue 1, February 2021, Pages 29-32

47. Management Posterior And Anterior Nasal Packing Packing Of The Maxillary Antrum Re-operation With Clipping Or Electrocoagulation Of Bleeding Vessels Application Of Haemostatic Agents In The Pterygomaxillary Region External Carotid Artery Ligation

48. Issues During Extubation Discussion With Anaesthetist While Extubation Check for Bleeding Cuff Leak Test Jaws Wired- Awake Extubation Jaws Open- Nasopharyngeal Airway Stop Induced Hypotension Keep Difficult Airway Cart Ready Avoid Tight Face Mask Ventilation Avoid pressure on surgical site Extubation criteria for oral and maxillofacial surgery patients J Oral Maxillofac Surg 1989 Jun;47(6):616-20

49. References Anaesthesia for maxillofacial surgery,oral and maxillofacial surgery for the clinician,2021 The Anaesthetic management of facial trauma and fractures,BJA volume 1 ,2001 Anaesthetic challenges and management of maxillofacial trauma J Anesth Surg4(2) 2017;134-140 Anaesthesia for cosmetic and functional maxillofacial surgery, continuing Education in Anaesthesia Critical Care & Pain ,BJA Volume 14, Issue 1, February 2014, Pages 38–42 Nasal Retrograde Intubation in Oromaxillofacial Surgery Patients with Limited Mouth Opening: A Cross-sectional StudyInternational Journal of Scientific Study | June 2018 | Vol 6 | Issue 3 Airway management in patients with deep neck infections Anaesthesi a for head and neck cancer surgery, BJA Education, 17 (12): 383–389 (2017) Anaesthesia for cleft lip and palate surgery continuing education in critical care and pain, BJA volume5,2005

50. "The collaboration of a Surgeon and A nesthetist leads to The Finest Surgical Outcomes. "

51. "The True Concern Lies Not In The Operation Itself, But In The Anesthesia , For It Poses A Greater Risk Than The Procedure." "Harmonious Understanding Between The Anaesthetist And Surgeon Orchestrates Medical Excellence." THANK YOU