Preoperative anesthesia consideration for ENT.pptx

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1. 5/7/2022 BCD @ DTU 1 ENT procedures will challenge the anesthetist; Diagnosis alteration due to; Infection trauma Establishing & maintain AW in a patient whose anatomy is distorted. Creating shared operative field Selecting appropriate anesthetic compatible with the procedures. Defining the appropriate moment of extubation.

2. Anesthesia for Ear ,Nose and Throat surgery 5/7/2022 BCD @ DTU 2 Basazinew C.

3. Objectives 5/7/2022 BCD @ DTU 3 At the end of this course you will able to; Assess the airway Explain anesthesia for ear surgery Explain the concerns of anesthesia and ear surgery Explain lefort classification Explain anesthesia for nasal deformity Discuss adenotonsillar procedures and their management Describe the anesthesia goals for Bronchoscopic procedures Identify foreign body aspiration Discuss the management of foreign body aspiration Discuss Ludwig’s angina Manage different types of ENT surgery Apply practically on patients.

4. Introduction 5/7/2022 BCD @ DTU 4 ENT surgery encompasses a range of operations varying in duration, severity, & complexity. Airway problems are a major concern in ENT procedures. The provision of clear, unobstructed,& free airway is the principal concern for all ENT procedures. Cooperation and communication with surgeon: the surgeon and a nesthetist plan together. Children account for approximately one-third of all patients undergoing ear, nose, and throat (ENT ) surgery. Procedures range from simple day-case operations, such as myringotomy, to complex airway reconstruction surgery undertaken in specialist centres

5. 5/7/2022 BCD @ DTU 5 Airway problems are the major concern in E NT surgery, related to both the underlying clinical problem and the shared airway. Presenting pathology may: Produce airway obstruction Make access difficult or impossible. Surgeons working in, or close to, the airway can: Displace , obstruct, or damage airway equipment Obscure the anesthetist’s view of the patient Limit access for the anesthetist during operation Produce bleeding into the airway (intra- and post-operatively).

6. 5/7/2022 BCD @ DTU 6 Understanding of the surgical procedure is important. It’s important to appreciate that manipulation of the larynx, pharynx, and neck may precipitate cardiac dysrhythmias. Blood loss can be underestimated as a result of hidden losses with in the surgical drape and blood swallowed in to the stomach.

7. Issues common to many ENT surgeries 5/7/2022 BCD @ DTU 7 If patient has suspected airway compromise, be careful using sedation …… obstruction Antisialogogue (anti-saliva medication) may be useful pre-operatively Surgeon and anesthesiologist share airway…. cooperation essential Anesthetist may be distant from the airway Required head positions and/or intraoperative instrumentation can affect/compromise airway Abrupt variations in level of surgical stimulation can make maintaining hemodynamic stability a challenge

8. Issues common to many ENT surgeries… 5/7/2022 BCD @ DTU 8 Positioning the patient somewhat head-up and permitting a certain amount of hypotension can limit bleeding and protect delicate repairs Stimulation and/or drainage in or near airway…. laryngospasm more commonly than in other surgeries Instrumentation in or near ear can…. nausea and vomiting Gentle wakeup – without coughing, gagging, etc. – may be essential due to delicate surgical repairs Throat packs, blood clots, etc., left in airway at end of surgery can lead to disastrous consequences!

9. Assessment of the problem 5/7/2022 BCD @ DTU 9 Hoarseness of voice? Muffled voice? Recent voice change? Difficulty swallowing? Does patient have to be in a certain position to be able to breathe easily? What position? Difficulty breathing during sleep? Stridor? Is it inspiratory? Expiratory? Are there any relevant studies? Bronchoscopies? X-rays? CTs? MRIs? Remember – clinical upper airway obstruction is a LATE sign – patients may have obstruction with NONE of the above signs

10. Airway evaluation 5/7/2022 BCD @ DTU 10 Evaluation of location, size & extent of lesion. The effect of laryngeal function & airway patency must be investigated. Previous anesthetic and surgical findings are useful. Radiologic evaluation may provide insight to AW anatomy to help devise plan.

11. Factors affecting AW safety and maintenance 5/7/2022 BCD @ DTU 11 Patient factor : distorted upper AW anatomy or AW obstruction Surgical factor : positioning, instruments, aspiration Shared AW : surgery of glottis, subglottic & trachea Remote surgery : unreachable airway

12. Assessment of the airway: is mask ventilation difficult? 5/7/2022 BCD @ DTU 12 M – M ask seal, high M allampati score, M inimal jaw protrusion, M ale gender O – O besity or O bstructing lesions A – A ge >55 N – N o teeth or N eck radiation S – S nores or S tiff/constricted airway or lungs

13. Assessment of the airway: Will you be able to use an LMA? 5/7/2022 BCD @ DTU 13 R – R estricted mouth opening O – O bstruction/obstructing lesions D – D isrupted or D istorted airway S – S tiff lungs or S tiff cervical spine

14. Assessment of the airway: Will you be able to intubate? 5/7/2022 BCD @ DTU 14 L – L ook at the external anatomy E – E valuate airway geometry M – M allampati score O – O bstruction/obstructing lesions N – N eck mobility/stiffness

15. Management of airway problems 5/7/2022 BCD @ DTU 15 It can be life threatening emergency or planned The main problems in securing airway access are: Airway obstruction likely to be worsened by supine position, GA (all techniques), or instrumenting the airway ( laryngospasm, bleeding ) Identifying the laryngeal inlet may be difficult because of anatomical distortion (especially supraglottic lesions) Severe stenosis may make passage of the tube difficult ( particularly glottic or subglottic tumours ).

16. Management… 5/7/2022 BCD @ DTU 16 There is little evidence to support any one particular anesthetic technique. The use of IV induction agents or NMB carries the catastrophic risk of ‘cannot intubate/cannot ventilate’ (CICV) in a patient unable to breathe spontaneously. The three main options for establishing secure airway access are: Direct laryngoscopy and intubation under deep inhalational anesthesia Awake intubation using fibreoptic laryngoscopy under  LA Tracheostomy under LA (or deep inhalational GA with face mask or LMA in less severe cases). Whichever technique is used, a full range of equipment should be prepared , including different laryngoscopes, cricothyroidotomy kit, and tubes in various sizes. a small E TT kept in ice will be stiffer, useful to get past a tight stenotic lesion . F ibreoptic intubation under LA is generally most useful for supraglottic lesions; for stenotic lesions of the glottis/ subglottis , the scope may block the airway completely

17. Airway management 5/7/2022 BCD @ DTU 17 Tracheal tube : Traditionally , an E TT has been used for airway protection for the majority of E NT  work. Preformed Rae tubes provide excellent protection with minimal intrusion into the surgical  field. An oral (south-facing) Rae tube is used for nasal and much oral surgery, although a nasal tube (north-facing) allows better surgical access to theoral cavity. LMA or equivalent supraglottic airway, usually of the reinforced flexible type, is the alternative approach which reduces complications of tracheal intubation/ extubation . But It restricts surgical access to a greater degree More prone to displacement during surgery (with potentially catastrophic results).

18. Airway management… 5/7/2022 BCD @ DTU 18 Spontaneous ventilation Continuous NMB is not required for most E NT surgery. Many E NT anesthetists still favors SV, If SV is used via an E TT , mivacurium is preferable to succinylcholine for intubation, as myalgia is particularly troublesome in a population where early mobilization is likely. Alternatives include combinations of high-dose propofol and alfentanil / remifentanil , or deep inhalational anesthesia.

19. Recovery 5/7/2022 BCD @ DTU 19 Many E NT procedures create bleeding into the airway. Suction (and pack removal) under direct vision before extubation is essential by minimizing trauma to surgical  sites. One particular danger site for blood accumulation is the posterior nasopharynx Blood pooling here can be aspirated following extubation, with fatal results (‘coroner’s clot’). It is best cleared using either a nasal suction catheter or a Yankauer sucker Laryngospasm due to instrumentation or irritation by blood. The risk is minimized by extubating either deep or light (not in between). Deep extubation is best suited to SV . After careful suction, insert a Guedel airway; turn the patient left lateral/head-down (tonsil position); Check respiration is regular then extubate .

20. Recovery… 5/7/2022 BCD @ DTU 20 In the early recovery period, continuous low suction can be done via a catheter just protruding from the Guedel airway. Light extubation: Best suited to IPPV after careful suctioning, and laryngeal reflexes have returned. Often produces a brief period of coughing/restlessness initially . This is less frequent with the use of opioids. Recommended in all patients with a difficult airway or significant respiratory compromise.

21. Recovery… 5/7/2022 BCD @ DTU 21 Throat pack A  throat pack(wet gauze or tampons) is often used around the ETT/LMA to absorb blood that might otherwise pool in the upper airway . It is particularly useful during nasal operations where bleeding can be significant and is not cleared during surgery. The pack must be removed before extubation, as it can lead to catastrophic airway obstruction if left. Systems to ensure removal include : Tie or tape the pack to the E TT Place an identification sticker on the E TT or patient’s forehead Include the pack in the scrub nurse’s count Always perform laryngoscopy prior to extubation.

22. G. Summary 5/7/2022 BCD @ DTU 22 Protect the airway from contamination by blood, secretion, or pus by (for GA): Using a cuffed endotracheal tube. Using a pharyngeal pack. Ensuring the rapid return of reflexes at the end of the operation. Nursing the patient in the tonsillar position post-operatively. Avoiding use of local anesthetic solutions in the respiratory tract as this interferes with the cough reflex post-operatively .

23. G. Summary… 5/7/2022 BCD @ DTU 23 Prevent airway obstruction Use a RAE or non- kinkable armoured endotracheal tube. Choose the largest tube which can be used safely. Ventilate by hand, rather than mechanically Reduce bleeding to a minimum Good anesthetic techniques such as a smooth induction and intubation , maintaining a clear airway and IPPV Use a slight head-up tilt. Use vasoconstrictor agents.

24. G. Summary… 5/7/2022 BCD @ DTU 24 Post-operative complications are serious Airway obstruction Bleeding Aspiration into the respiratory tract of blood, pus or secretions Vomiting (common after middle-ear operations)

25. 5/7/2022 Obstructive sleep apnea BCD @ DTU 25

26. Introduction 5/7/2022 BCD @ DTU 26 Sleep disordered breathing describes a continuum of disorders ranging in severity from primary snoring which is seen in 20% of children, to obstructive sleep apnea which is seen in 2% of children. Primary snoring : noisy breathing during sleep without desaturation or obstructive episodes and daytime symptoms. Upper airways resistance syndrome ( UARS): snoring associated with sleep disruption and arousal, with daytime symptoms but no abnormalities of gas exchange at night. Obstructive hypoventilation (OH ): occurs when upper airway resistance is increased sufficient to cause paradoxical ventilation, with desaturation and or carbon dioxide retention. Obstructive sleep apnea (OSA ): is the most severe form of SDB when children demonstrate cessation of nasal/oral airflow during sleep with preserved thoracic and abdominal respiratory effort and oxygen desaturation.

27. Obstructive sleep apnea(OSA) 5/7/2022 BCD @ DTU 27 Obstructive Sleep Apnea (OSA) is a sleep-related breathing disorder characterized by repeated episodes of apnea and hypopnea during sleep. Apnea is defined as complete cessation of airflow for more than 10 seconds. Hypopnea as airflow reduction more than 50% for more than 10 seconds.

28. OSA… 5/7/2022 BCD @ DTU 28 ‘OSA syndrome’ refers to the clinical entity of OSA resulting in excessive daytime sleepiness and other symptoms such as; Un refreshing sleep, Poor concentration, Fatigue and morning headaches.

29. 5/7/2022 BCD @ DTU 29 One useful and easy to remember screening tool is the STOP-BANG model, consisting of 8 items. S : do you snore loudly, enough to be heard through closed doors? T : Do you feel Tired/fatigued during daytime almost every day? O : Has anyone Observed that you stop breathing during sleep? P : Do you have a history of high BP , with or without treatment? B : Body mass index ( BMI ) greater than 35 kg/m2 A : Age over 50 years N : Neck circumference greater than 40 cm G : Male Gender High risk three or more of the STOP-BANG criteria, Low risk if they have less than three of the items.

30. Epidemiology 5/7/2022 BCD @ DTU 30 In middle age, prevalence 4% male & 2% woman. Predisposing conditions include: Obesity (40% of female and 50% of male) Age>50 yrs. Male Neck circumference >40cms Nasal/pharyngeal/laryngeal obstruction Craniofacial abnormalities Neuromuscular disorders & the use of alcohol, sedatives, & cigarettes. It is estimated that 80% of patients are undiagnosed , with sleep study data estimating sleep disordered breathing having a prevalence of 24% in men and 9% in women.

31. Pathophysiology 5/7/2022 BCD @ DTU 31 Apnea occurs when the pharyngeal airways collapse. The body is in its most relaxed state during rapid eye movement sleep, which is when there is decreased tone of the pharyngeal dilator muscles , ( musculus genioglossus and musculus geniohyoideus ). A irway obstruction; arterial oxygen desaturation; inspiratory efforts increases, leading to a partial arousal from sleep and a sudden opening of the airway; short period of hyperventilation The result is blood gas oscillation and sleep fragmentation.

32. OSA cont….. 5/7/2022 BCD @ DTU 32 In OSA patients, neural control mechanisms generating pharyngeal dilator muscle tone are active in the awake state to overcome the relatively smaller upper airway. Sleep and anesthesia substantially attenuate pharyngeal dilator muscle activity. A combination of anatomical structure and neural compensatory mechanisms that is responsible for the development of OSA.

33. 5/7/2022 BCD @ DTU 33 In obese patients, increased adipose tissue in the neck and pharyngeal tissues narrows the airway further, predisposing to airway closure during sleep. In non-obese patients, tonsillar hypertrophy or craniofacial skeletal abnormalities may lead to airway narrowing and sleep apnea. The common cause of OSA in pediatrics is tonsillar hypertrophy.

34. Clinical features of OSA in children and adults 5/7/2022 BCD @ DTU 34

35. Risks associated with Anesthesia 5/7/2022 BCD @ DTU 35 OSA is associated with increased peri -operative morbidity and mortality. The peri -operative risk ↑ es in proportion to the severity of OSA. Patients with OSA are at high risk of developing a range of complications when they receive sedation, analgesia or anesthesia.

36. 5/7/2022 BCD @ DTU 36 Preoperative Screening Numerous clinical screening tests have been developed and validated for this purpose, including the Berlin questionnaire, the ASA checklist, Flemons criteria and the Epworth Sleepiness Scale . Evaluate if the patient have: Excessive daytime sleepiness and other symptoms such as; Un refreshing sleep, Poor concentration, Fatigue and morning headaches. STOP BANG

37. 5/7/2022 BCD @ DTU 37 Preoperative diagnostic workup The gold standard for the diagnosis of OSA is an overnight sleep study ( polysomnography ). Full polysomnography includes monitoring of; chest movement airflow dynamics heart rate, blood pressure, SaO2, and the electroencephalogram during sleep.

38. Cont… 5/7/2022 BCD @ DTU 38 Polysomnography provides classification of severity of patients with OSA based on an apnea-hypopnea index (AHI). This refers to the average number of obstructive apnea and hypopnea episodes measured per hour. A score of 5-15 is ‘mild OSA 15-30 ‘moderate’, and ‘ severe OSA’ is over 30.

39. OSA cont… 5/7/2022 BCD @ DTU 39 Preoperative treatment and planning The gold standard of treatment for OSA is the nocturnal use of nasal continuous positive airway pressure ( nCPAP ) delivery devices. A nasal mask provides positive airway pressure to the pharynx. Pressure requirements range from 5 to 20 cmH2O. Preoperative use of nasal CPAP. Elective surgery should be postponed until the patient has been fully investigated and treated.

40. OSA, intra operative management 5/7/2022 BCD @ DTU 40 Premedication Ideally all sedative pre medications should be avoided, or used extremely cautiously. Choice of anesthetic technique All central depressant drugs diminish pharyngeal tone predisposing to upper airway collapse. Ketamine & halothane less effect of collapse Anticipate difficult MV & intubation Regional anesthesia is preferable

41. OSA, Extubation 5/7/2022 BCD @ DTU 41 Extubation Tracheal extubation should be carried out with the patient conscious, communicative, and breathing spontaneously with an adequate tidal volume and oxygenation. Extubation should be performed in the semi-upright or lateral position, after complete reversal of NMB. Non-supine positions should then be maintained throughout the recovery period.

42. OSA postoperative care 5/7/2022 BCD @ DTU 42 Adequate pain relief remains a priority in OSA. Patients are best managed in HDU or ICU. Continuous pulseoximetry in the ward Supplemental oxygen should be administered continuously to all OSA patients until they are able to maintain their baseline oxygen saturation whilst breathing room air.

43. Nasal and sinus surgery 5/7/2022 BCD @ DTU 43

44. 5/7/2022 BCD @ DTU 44 Nasal surgery can involve Procedures on the external aspect of the nose Procedures within the nasal cavity, Surgery involving the nasal bony structures, and Nasal sinus surgery.

45. Nasal Surgeries 5/7/2022 BCD @ DTU 45 Nasal pathology may produce difficult mask ventilation. Have oral airways available Bleeding problems and/or aspirin/NSAID/anticoagulant ( patient shouldn’t take at least for 1- 2 weeks.) Nose is full of blood vessels! Proximity of brain, may mean that muscle paralysis is key Eye injury is a risk in these surgeries. Assess vision post-op and address any changes immediately.

46. Pre-op consideration 5/7/2022 BCD @ DTU 46 The possibility of undiagnosed OSA, The potential presence of the Samter triad Nasal polyps, asthma, and a sensitivity to aspirin and NSAIDs that may produce deadly bronchospasm ). Pt. may have nasal obstruction Face mask ventilation may difficult

47. Anesthetic choice 5/7/2022 BCD @ DTU 47 The choice of anesthesia depends on pt. factor, duration, site, & complexity of the procedure. Many nasal procedures can be satisfactorily performed under local anesthesia with sedation . Local anesthesia may be suitable for simple procedures such as Cauterization, Simple polypectomy, Turbinectomy, & reduction of simple nasal fracture. Packing the nose with gauze or cotton-tipped applicators soaked with local anesthetic +/- sub mucosal injection. LA + sedation for uncooperative pt.

48. 5/7/2022 BCD @ DTU 48 GA may be needed immobility, airway protections, or to provide amnesia. Procedures such as sinus surgery, rhinoplasty , septorhinoplasty , nasolacrmial surgery, anterior skull base surgery & craniofacial surgery.

49. Nasal vasocontrictors 5/7/2022 BCD @ DTU 49 Commonly used vasoconstrictors Cocaine Epinephrine Phnylephrine oxymethazoline

50. ETT Vs LMA 5/7/2022 BCD @ DTU 50 Choice depends on experience, duration of surgery, & pt. factor. A south facing or reinforced tracheal tube (RAE )with throat pack often used to reduce blood contamination to lower AW. Correctly sited flexible LMA covers & protects the SGAW better than ETT.

51. 5/7/2022 BCD @ DTU 51

52. RAE Tubes left side oral right side nasal 5/7/2022 BCD @ DTU 52

53. Emergence & E xtubation 5/7/2022 BCD @ DTU 53 Gentle awakening Nose is unstable for application of a face mask Nasal packs obstructed nasal passages unless nasopharyngeal airways used Compared to ETT fLMA has better extubation profile. Suctioning

54. Corner’s clot 5/7/2022 BCD @ DTU 54 In addition to suctioning, many clinicians follow throat pack removal with pre- extubation laryngoscopy and a neck flexion-extension maneuver to encourage any residual clot (the so-called “coroner’s clot”) to fall past the soft palate into a position where it can be removed under direct vision.

55. Post op considerations 5/7/2022 BCD @ DTU 55 Left lateral with Gudel AW Postoperative pain in these procedures usually does not require opiates, only pcm & NSAIDs suffice. IV cannula in-situ until nasal pack removal in case un expected bleeding

56. Summary 5/7/2022 BCD @ DTU 56 Despite d/t procedures, principles of Anesthesia mgt is the same for nasal & sinus surgery. Practical techniques for GA South facing RAE tube or LMA SV or IPPV Throat pack Nasal vasoconsrictor Face mask ventilation with gudel AW Un tap the eye for polpectomy Suck out pharynx(corner’s clot) before extubation

57. Ear surgery 5/7/2022 BCD @ DTU 57

58. Anatomy 5/7/2022 BCD @ DTU 58

59. 5/7/2022 BCD @ DTU 59

60. External ear procedures 5/7/2022 BCD @ DTU 60

61. External ear procedures 5/7/2022 BCD @ DTU 61 Can be done either local or general anesthesia. The procedures include : Removal of simple lesion Foreign body in the external auditory ear canal Pre-auricular abnormalities Reconstruction of external auditory ear canal

62. Middle ear 5/7/2022 BCD @ DTU 62 It is an air filled space Connected with naso -pharynx by eustachian tube. Close to temporal lobe, cerebellum, & jugular bulb Contains three ossicles (malleus, incus & stapes)

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64. Middle ear surgery 5/7/2022 BCD @ DTU 64 Myringotomy : an incision of tympanic membrane. Myrigoplasty : closure of perforation of tympanic membrane. Tympanoplasty : is more extensive, repair of TM and reconstruction of damaged ossicles . Stapedectomy : removal of damaged stapes Mastoidectomy : removal of damaged mastoid bone

65. Middle ear surgery… 5/7/2022 BCD @ DTU 65 The most frequent of these procedures, myringotomy with tube placement, is most commonly performed in children by using simple sevoflurane mask anesthesia, in conjunction with acetaminophen or (less commonly) fentanyl to treat postoperative pain. The procedure can usually be safely accomplished without establishing intravenous access.

66. Inner ear surgery 5/7/2022 BCD @ DTU 66 Includes operation on the cochlea, endolymphatic sac, etc Patients are more prone to NV with all ear procedures

67. Anesthesia for middle and inner ear surgeries 5/7/2022 BCD @ DTU 67 The choice of anesthesia depends on; Type, duration & technique of surgery. You can use GA with FM, LMA or ETT LA infiltration Topical EMLA cream application General anesthesia for surgery of the ear has its own set of unique considerations.

68. General Anesthesia 5/7/2022 BCD @ DTU 68 Most ear surgeries requires the use of an operating microscope, where movement, coughing, and straining are greatly affected the procedure. Access to airway during the procedure is limited. A through pre operative assessment should be undertaking.

69. 5/7/2022 BCD @ DTU 69 Specific issues relating to general anesthesia: The choice of airway Use of nitrous oxide Facial nerve monitoring Hemostasis Nausea and vomiting

70. The choice of airway 5/7/2022 BCD @ DTU 70 Facemask Historically FM was used for simple, short ear procedures such as myrigotomy and tube insertion. But latter obscure surgical access Most of these short duration procedures are now undertaken with LMA.

71. The choice of airway con…. 5/7/2022 BCD @ DTU 71 LMA The flexible LMA is designed for ENT procedures. For minor ear surgery, the flexible LMA has a flexible shaft and is better suited tolerant to head rotation flexion and extension but tap it well. For longer duration procedures a proseal LMA with a gastric drain tube and superior airway seal characteristics has allowed major ear surgery.

72. The choice of airway con…. 5/7/2022 BCD @ DTU 72 ETT For most long duration procedures a reinforced or armored tracheal tube is used to prevent kinking or partial compression with head rotation. Alternatively south facing preformed tracheal tubes are used.

73. Nitrous Oxide 5/7/2022 BCD @ DTU 73 Nitrous oxide is more soluble than nitrogen in blood and diffuses into air-filled cavities quicker. Using of N2O can increase middle ear pressure 300-400mmhg in 30 minutes, conversely acute cessation can result negative pressure in the middle ear which causes altered middle ear anatomy , tympanic membrane rupture, and disruption of tympanoplasty grafts. N20 is related to a high incidence of PONV; which is a direct result of negative middle ear pressure. Due to this problems; Avoid to use N2O or Decrease the concentration lower than 50% or Discontinue 15-30 minute before grafting

74. Facial Nerve Monitoring 5/7/2022 BCD @ DTU 74 Facial nerve monitor is used to identify the facial nerve and reduce the incidence of iatrogenic facial nerve injury. The general principle involves an audible and visible signal on the monitor identify when surgical movement or stimulation close to or at the facial nerve. When the nerve is stimulated, electrodes attached to the face detect nerve activity, and monitor signal. Complete paralysis by neuromuscular blocking drugs can inhibit facial nerve monitor function. So complete muscle relaxation be avoided. It is not mandatory to avoid NMBs when monitoring of facial nerve function is necessary.

75. lustration of facial nerve and monitoring electrodes. 5/7/2022 BCD @ DTU 75

76. HEMOSTASIS 5/7/2022 BCD @ DTU 76 Bleeding must be kept to a minimum during surgery of the small structures of the middle ear, even small bleeding can obscure the surgical field. Epinephrine usually used to ↓ bleeding in the surgical filed. But Close attention should be paid to the volume of injected epinephrine so that dysrhythmias and wide increase in blood pressure may be avoided. Techniques to minimize blood loss include: mild (15°) head elevation, infiltration or topical application of epinephrine (1:50,000-1:200,000), and Controlled hypotension(deliberate hypotension)

77. Postoperative Nausea and Vomiting 5/7/2022 BCD @ DTU 77 PONV is common after middle and inner ear surgery. It is particularly common after inner ear surgery involving the labyrith and vestibular nerve. Because a signal from vestibular apparatus can stimulate the emetic center. Retching and vomiting increase venous pressure, ICP, and bleeding, and dislodge surgical graft and prosthesis. So take measurement to decrease PONV.

78. Positioning 5/7/2022 BCD @ DTU 78 Rotation of head and neck extension are common. So care the AW. Lateral tilt of the table to prevent extreme head & neck rotation & which ↓ venous compression and improve arterial blood supply. Arms should placed in neutral position & padded.

79. Summary 5/7/2022 BCD @ DTU 79 Most patients under go ear surgery are healthy A through pre-op ass’t either LA/GA Primary concerns for anesthetists Use of N2O Facial nerve monitoring Hemostasis (bleeding control) Positioning Antiemetics

80. Awake Fiber Optic Intubation Basazinew c BCD @ DTU

81. Introduction 5/7/2022 BCD @ DTU 81 Awake fibreoptic intubation (AFOI) is an essential skill in the management of: Patient with a known difficult airway (who has previously required AFOI or other procedures and adjuncts aside from normal airway adjuncts for ventilation and intubation), An anticipated difficult airway as found during the airway assessment preoperatively It is important to know the anatomy of the normal airways , from the nasal passage to the carina/bifurcation of the trachea. It is also essential to have a good knowledge of the mechanisms of action and maximum dosages of various local anesthetic agents and vasoactive drugs, Recognition of the signs, symptoms and treatment of local anesthetic toxicity is essential . (AAGBI guideline…??)

82. Definition and Terminology 5/7/2022 BCD @ DTU 82 AFOI is a technique which allows a flexible oral or nasal route to provide clear vocal cord visualization. Passage of ETT in to trachea under direct vision Management of difficult AW Endoscopy Use of instrument to look into various parts of the body to diagnose various diseases or explain certain conditions Bronchoscopy Procedure that allows visualization of the airways below the larynx

83. Indication 5/7/2022 BCD @ DTU 83 Anticipated difficult tracheal intubation    Anticipated difficult mask ventilation, including sleep apnea    Anticipated difficult rescue technique    Confirmation of tracheal tube position    Diagnosis of malfunction of a supraglottic airway device Previous difficult airway or AFOI Previous difficulty in mask ventilation   

84. Indication 5/7/2022 BCD @ DTU 84 Positioning of a double-lumen tube and bronchial blocker    Assessment of swelling or trauma after difficulty with airway management    Tracheal tube change (between the nasal and oral routes)    Intensive care use, including aspiration of secretions and confirmation of the dilatational tracheotomy site

85. 5/7/2022 BCD @ DTU 85 Anticipated difficult airway as found on preassessment, with other complicating factors such as contraindications to the use of Suxamethonium and Inhalational anaesthetic agents, aspiration risk, inability to access the pre-cricoid or pre-tracheal region To avoid iatrogenic injury – such as patients with unstable C-spine as result of trauma, rheumatoid arthritis etc

86. Contraindications 5/7/2022 BCD @ DTU 86 Lack of AW skill Allergy to local anesthetics Patient refusal Fractured base of skull (especially nasal route) Lack of time Severe maxillofacial trauma Grossly distorted anatomy Infection/contamination of the upper airway – blood, friable tumor, open abscess Penetrating eye injuries

87. Innervation of the Airway 5/7/2022 BCD @ DTU 87 The airway is divided into: Nasal cavities Oral cavities Pharynx ( consisting of the naso -, oro -, and hypopharynx ) Larynx Trachea Innervation of the airway can be separated into three principal neural pathways: trigeminal, glossopharyngeal, and vagus ( superior and the recurrent laryngeal nerves & t he recurrent laryngeal nerve).

88. 5/7/2022 BCD @ DTU 88

89. Innervation of the Airway 5/7/2022 BCD @ DTU 89 Nose: The nasal cavity is entirely innervated by fibers carried by branches of the trigeminal nerve . Ant. Parts of the nasal cavity and the septum – ant. ethmoidal nerve ( a br. of the ophthalmic nerve) The remaining parts of the nasal cavity and the septum – br. of the maxillary nerve, including lateral posterior superior, inferior posterior, and naso -palatine nerves .

90. Innervation of the Airway – 5/7/2022 BCD @ DTU 90 Pharynx: Mainly innervated by glossopharyngeal nerve Visceral fibers – posterior third of the tongue, the fauces , tonsil and epiglottis Special visceral sensation – posterior third of the tongue and soft palate Sympathetic fibers – derived form the carotid plexus and the cervical sympathetic trunk Efferent motor fibers – innervate the stylopharyngeus muscle and join the pharyngeal plexus.

91. Innervation of the Airway – 5/7/2022 BCD @ DTU 91 Larynx: The superior laryngeal nerve dividing into internal and external branch. Internal br. – through a foramen in the thyrohyoid membrane and provides visceral sensory and secretomotor innervation to the larynx above the true cords. External br. – supplies with motor fibers of the cricothyroid muscle .

92. Larynx… 5/7/2022 BCD @ DTU 92 Recurrent laryngeal nerve Providing both structures with fibers for visceral sensation, motor and secretomotor innervation, and sympathetic branches. It enters the larynx by passing the lower border of the inferior constrictor m. of pharnyx . It supplies all muscle of the larynx except cricothyroid and conveys visceral sensation to the cords and infraglottic regions.

93. The airway reflexes 5/7/2022 BCD @ DTU 93 The aforementioned nerves participate in several brainstem-mediated reflex arcs. Gag reflex – triggered by mechanical and chemical stimulation of areas innervated by the glosso -pharyngeal nerve, and the efferent motor arc is provided by the vagus nerve and its branches to the pharynx and larynx. Glottic closure reflex – elicited by selective stimulation of the superior laryngeal nerve, and efferent arc is the recurrent laryngeal nerve.– exaggeration of this reflex is called laryngospasm Cough – the cough receptors located in the larynx and trachea receive afferent and efferent fibers form the vagus nerve.

94. Requirements for the procedure 5/7/2022 BCD @ DTU 94 Ensure that you are familiar with using the fiberoptic scope Resuscitation equipment Monitoring = blood pressure, pulse oximetry, ECG Calculation of your local anesthetic dose Maximum safe dose 9mg/kg for topical anesthesia application Concentration - 4% and 10% Lignocaine , and Co- phenylcaine (5% Lignocaine with 0.5% Phenylephrine ) Xylometazoline or Oxymetazoline nasal spray (or any other available topical vasoconstrictors )

95. 5/7/2022 BCD @ DTU 95 Glycopyrronium 3-4mcg/kg IV to minimize the airway secretions (alternatively, Atropine can be given) Administer Oxygen 4L/min to the opposite nostril using a nasal cannula ( sponge plug with a central orifice for oxygen tubing, or cut nasopharyngeal airway/small endotracheal tube with 15mm connector, connected to oxygen supply) Communication with your patient throughout the procedure is of vital importance.

96. Anesthetizing the AW 5/7/2022 BCD @ DTU 96 Position the pt. semi-recumbent or supine Identify patient’s patent nasal passage for nasal route. Spray nasal mucosal with vasoconstrictor Nebulize 2ml of 4% lignocaine (80mg of which 25% is topically absorbed=20mg)

97. 5/7/2022 BCD @ DTU 97 If nasal intubation is planned, anesthetizing the maxillary branches from the trigeminal nerve will need to be carried out. As our manipulations involve the pharynx and posterior third of the tongue, glossopharyngeal block will be required. Structures more distal in the airway to the epiglottis will require block of vagal branches .

98. 5/7/2022 BCD @ DTU 98 Nose and naso -pharynx: sock cotton bud (cotton applicator mounted on stick)/pus swab sticks/ribbon gauze in measured dose of either Co- phenylcaine (5% Lignocaine + 0.5% Phenylephrine) (2.5ml = 125 mg) or Xylocaine (2% Lignocaine + 1:200000 Adrenaline ) (5ml = 100mg ) or “ home made” solution of 4% Lignocaine + 1:200000 or 1:100000 Adrenaline (3ml = 120mg)

99. 5/7/2022 BCD @ DTU 99 Insert the cotton buds/pus swab/ribbon gauze into the nasal cavity (inferior nasal meatus) and posterior nasal space, ensuring that the anterior part/entrance of the nostril is also anesthetised , leaving it in situ for around 3 minutes .

100. 5/7/2022 BCD @ DTU 100 Alternatively, if Co- phenylcaine and mucosal atomiser device (MAD ) are available, administer to selected nostril via MAD ( 125mg) Tongue and oropharynx : 4 puffs 10% Lignocaine to throat (2 each side, tonsillar pillows and back of throat – 40mg). Alternatively Benzocaine 100mg can be sucked half an hour beforehand.

101. 5/7/2022 BCD @ DTU 101 Pharynx and Larynx above cords : can be anesthetised by 1-4% Lignocaine via metered spray or soaked swabs at increasing depths into the mouth, using a spatula or laryngoscope. 4 puffs 10% Lignocaine to nose and post nasal space (40mg) Total dose so far = 225mg

102. 5/7/2022 BCD @ DTU 102 Subtract this from the total maximum dose (9mg/kg), and allocate the remaining 4% Lignocaine in 1 ml aliquots to anesthetise the larynx below the vocal cords, and tracheo -bronchial tree, using: spray as you go

103. 5/7/2022 BCD @ DTU 103 Cricothyroid (trans-tracheal) injection , to anesthetise subglottic region, vocal cords and trachea . A 21-23G needle is used to pierce the crico -thyroid membrane, aspirating whilst inserting, to confirm position. The patient is told to exhale prior to the injection of 3-5ml of 1% - 4% Lignocaine.

104. 5/7/2022 BCD @ DTU 104 Remove the needle immediately following injection, to prevent trauma of the airway when the patient coughs . The resultant inspiration and cough aids the spread of the local anaesthetic within the tracheo -bronchial tree. Various nerve blocks can be performed – glossopharyngeal, superior laryngeal and recurrent laryngeal nerve blocks

105. Endoscopy and Intubation 5/7/2022 BCD @ DTU 105

106. Endoscopy and Intubation… 5/7/2022 BCD @ DTU 106 Lubricate the fiberscope with aqueous gel/KY jelly, and load it with the uncut Endotracheal Tube (ETT) (size 6.0 to 7.0), securing it to the fibrescope with tape. Ensure that it can be released easily and quickly.

107. Tips for performing endoscopy 5/7/2022 BCD @ DTU 107 Orientate the fiberscope and white balance before starting Keep the air cavity (the dark space ) constantly in the centre of your visual field. The awake patient can assist in opening the airway by protruding the tongue (opens oropharynx), saying “ eeh ” (opens pharynx, and epiglottis comes into view), deep inspiration (opens glottis)

108. 5/7/2022 BCD @ DTU 108 A good view may be spoilt by Blood = red out, Secretions = white out, No cavity = pink out, moving target, reduced air space If an area is not anesthetized, pull the fiberscope back by 1-2cm, advance the epidural catheter, and anesthetise the area

109. Endoscopy 5/7/2022 BCD @ DTU 109 Introduce the fibrescope through the nostril, into the lower nasal meatus (inferior, largest). Identify nasal septum medial, floor of nose superior, turbinate lateral. Beyond the nasal septum, enter the nasopharynx.

110. 5/7/2022 BCD @ DTU 110 Steer the fibrescope into the oropharynx. Once in the oropharynx, you may see the epiglottis, the 1st landmark . Advance the fibrescope into the laryngeal opening. Here you will require the first dose of topical anesthetic. Alert the patient that they may cough at this point. Wait a few minutes.

111. 5/7/2022 BCD @ DTU 111 Advance the fibrescope until it enters the subglottic space, and identify the trachea, 2nd landmark . Apply your 2nd dose of local anaesthetic. This again may cause the patient to cough. Retract to just before the laryngeal opening. Advance the fibrescope again into the trachea, identifying the carina, 3rd landmark .

112. Intubation 5/7/2022 BCD @ DTU 112 Lubricate the tip of the ETT, and the fibrescope , so as to ease the passage of the ETT over the fibrescope and the ETT through the nasal passage and vocal cords. At this point, ask your assistant to hold fibrescope in position, as you perform intubation. Release the ETT and advance it with a gentle rotating motion through the nose, naso / oropharynx , pharynx and larynx.

113. 5/7/2022 BCD @ DTU 113 Alert the patient of discomfort as the tube is passed through the nose. If any resistance is felt, do not force the tube, but withdraw slightly, rotate the ETT 90 degrees anti-clockwise, and advance gently again. Keep the carina in the field of vision at all times to prevent dislocation of the fibrescope out of the larynx into the oesophagus

114. 5/7/2022 BCD @ DTU 114 Remove the fibrescope whilst visualising , to ensure tip of the ETT is in the trachea, and maintaining the ETT in place, with the tip at 3-5cm above the carina. Fix the ETT in place and connect to the anesthetic breathing circuit Confirm the ETT position Induce the patient using appropriate anesthetic agents (intravenous, inhalational, neuromuscular blockers), and inflate the ETT cuff.

115. Recommendations 5/7/2022 BCD @ DTU 115 When FOI thought to secure the AW awake technique should considered unless contraindicate. GA should only be induced after tube has been railroaded and its position checked and the cuff has been inflated. AFOI may fail, back up plan

116. Anesthesia for Throat surgery Anesthesia for T onsillectomy Basazinew C. BCD @ DTU

117. Introduction 5/7/2022 BCD @ DTU 117 Tonsillectomy is a surgical procedure that was first described in India in 1000 BC. Although not performed as often as previously, it remains a common procedure particularly for children. The indications and methods of surgery remain a controversial issue. Tonsils and adenoids appear in the second year of life, are largest between 4 and 7 years of age and then regress .

118. Anatomy and function 5/7/2022 BCD @ DTU 118 Tonsillectomy is defined as the surgical excision of the palatine tonsils, which are lymphoid tissue covered in respiratory epithelium and invaginated to create crypts. The tonsils are 3 separate pieces of tissue: the lingual, the pharyngeal (adenoid) and the palatine tonsil. The tonsils are located in the lateral oropharynx. The tonsillar branch of the facial artery forms the main arterial blood supply. The venous drainage is via a plexus surrounding the tonsil, which drains into the pharyngeal plexus.

119. 5/7/2022 BCD @ DTU 119 The external palatine vein enters the tonsillar bed from the soft palate. This large vein is usually responsible for the venous haemorrhage following tonsillectomy The sensory supply is from the glossopharyngeal and lesser palatine nerves. Important structures deep to the inferior pole of the tonsil are the glossopharyngeal nerve, the lingual artery and the internal carotid artery. The tonsils are lymphoid tissue and are therefore involved in lymphocyte production. And are also active in immunoglobulin synthesis. They are believed to play a role in immunity though when diseased.

120. Indications for surgery 5/7/2022 BCD @ DTU 120 The indications for surgery may be absolute or relative. The absolute indications for surgery are: Upper airway obstruction, dysphagia and obstructive sleep apnea. Peritonsillar abscess, which is unresponsive to adequate medical management and surgical drainage. Recurrent tonsillitis with associated febrile convulsions. The requirement for biopsy to confirm tissue pathology.

121. 5/7/2022 BCD @ DTU 121 The relative indications include: Recurrent tonsillitis that is unresponsive to medical treatment. The Royal College of Surgeons, UK suggest the following criteria need to be met prior to tonsillectomy secondary to tonsillitis: Sore throat secondary to tonsillitis. More than 5 episodes of tonsillitis in one year. To have had the symptoms for more than one year. The episodes of sore throats are significantly disabling. Persistent bad-breath and taste in mouth due to chronic tonsillitis. Persistent tonsillitis in streptococcus carrier, which is unresponsive to beta-lactamase- resistent antibiotics.

122. 5/7/2022 BCD @ DTU 122 Contraindications for surgery are Bleeding diathesis. Acute infection. Anemia. Significant anesthetic risk.

123. Pre-operative assessment 5/7/2022 BCD @ DTU 123 A full history and examination is mandatory. In all children the presence of heart murmurs must be excluded. Particular attention should be paid to detect any evidence of obstructive sleep apnea. Exclude evidence of active infection and consent.

124. Anesthetic considerations 5/7/2022 BCD @ DTU 124 The main areas of anesthetic concern are airway management, provision of analgesia, and prevention of PONV. Sharing the airway with the surgeon, remote access, and the need to prevent soiling of the respiratory tract are factors that need to be taken into consideration in airway management. Two techniques are commonly used: the tracheal tube and the reinforced LMA. Adequate postoperative analgesia is best provided with a combination of simple analgesics and small doses of opioids. p aracetamol and NSAIDs have a morphine-sparing effect . The incidence of PONV can be as high as 70% after adenotonsillectomy and a multimodal approach is indicated to combat this

125. Intra-operative management 5/7/2022 BCD @ DTU 125 Induction of anesthesia may be either intravenous or inhalation. Inhalation induction is often challenging due to the high incidence of obstruction of the naso -pharynx by the adenoids. An intravenous induction agent of choice may be used, such as propofol or thiopentone . The airway may be managed with either an ETT, or preferably a pre-formed or reinforced tube, or a reinforced LMA.

126. 5/7/2022 BCD @ DTU 126 Insertion of the airway may be done under deep anesthesia or using a muscle relaxant. The choice of muscle relaxant must consider the duration of surgery and t he form of ventilation that will be used. Ventilation may be either spontaneous or controlled. Most children can be intubated using suxamethonium or a short-acting non-depolarizing agent such as mivacurium and then allowed to breath spontaneously via the endotracheal tube or on control ventilation .

127. 5/7/2022 BCD @ DTU 127 The positioning of patient and the surgical access The patient is supine, the neck is extended and a roll is placed under the shoulders. Surgical access is improved with the use of a mouth clamp, commonly the Boyle-Davis gag. Tonsillectomy involves a shared airway therefore always ensure that the endotracheal tube is secured in the midline. Ensure that the airway is not obstructed or displaced by the surgeon particularly when inserting and opening or removing the Boyle-Davis gag.

128. Post-surgery and the emergence from anesthesia 5/7/2022 BCD @ DTU 128 Careful suction of the oropharynx under direct vision, and limits damage to the tonsillar bed. Adequate spontaneous respiration is essential prior to extubation. Extubate in the left lateral position with slight head down tilt. Extubation should be considered once the airway reflexes have returned i.e. a wake extubation and the patient is appropriate for the available skills of the recovery staff.

129. Post-operative management 5/7/2022 BCD @ DTU 129 Administer oxygen until fully recovered. Post-operative analgesia Opiates in recovery if required. Ideally using the same drug used intra-operatively. Regular paracetamol. Regular NSAIDs. Observation for evidence of post-operative bleeding. Routine observations of pulse, blood pressure, respiratory rate and pain

130. 5/7/2022 BCD @ DTU 130 Complications Pain Nausea & vomiting Bleeding

131. Post-tonsillectomy bleeding 5/7/2022 BCD @ DTU 131 This is a serious complication, which can present in recovery or occur hours later. Persistent swallowing is an early indicator of bleeding from the tonsil bed. The volume of blood loss cannot be measured and the patient may be hypovolemic and need fluid resuscitation prior to induction.

132. Types of hemorrhage 5/7/2022 BCD @ DTU 132 Primary : bleeding occurs at the time of operation due to injury to vessels Reactionary : approximately 75% of the post tonsillectomy bleeding occur in the 1 st 6hrs after surgery and the remaining 25% in the 1 st 24hrs. Could be due to slipping of ligature or dislodgement of clot due to retching and vomiting. During anesthesia, a slight hypotension can cause collapse of blood vessels during recovery and post OP period when BP will return to normal, on increase opening up the collapsed vessel may cause bleeding.

133. 5/7/2022 BCD @ DTU 133 Secondary : occurs after 24hrs and with in 28 days. May be caused by secondary to infection of the tonsillar fossa or sloughing of eschar , usually around 5 th postoperative period.

134. Management plan for post-tonsillectomy bleed: 5/7/2022 BCD @ DTU 134 The anesthetist must consider: The patient may have a full stomach and risk of aspiration The intubation may be difficult by obscuring the view by blood. Hypovolemia A second general anesthesia increase stress for the child and the parents Blood loss is because of venous or capillary ooze from the tonsillar bed and is difficult to measure, as it occurs over several hours and is partly swallowed

135. 5/7/2022 BCD @ DTU 135 Fluid resuscitation may be necessary. The fluid status of the patient must be assessed prior to induction by: Capillary refill time Pulse rate Respiratory rate Urinary output Conscious level/Glasgow coma score

136. 5/7/2022 BCD @ DTU 136 Induction of anesthesia in a hypovolemic child can precipitate cardiovascular collapse. Hemoglobin and coagulation variables should be checked. Blood and blood products should be immediately available and transfused as necessary. Before induction , in addition to the standard equipment, a selection of laryngoscope blades, smaller than expected tracheal tubes, and two suction catheters should be immediately available

137. 5/7/2022 BCD @ DTU 137 Intravenous access and fluid resuscitation prior to induction. A rapid sequence induction with slight head-down positioning of the patient ensures rapid control of the airway and protection from pulmonary aspiration . During induction some anesthetists prefer an inhalation induction performed on the left side, in the head-down position. Consideration should be given to adopting the left lateral position if bleeding is excessive. Controlled ventilation provides good conditions for hemostasis.

138. 5/7/2022 BCD @ DTU 138 Once hemostasis is achieved, a large-bore stomach tube is passed under direct vision to e nsure the stomach is empty prior to Extubation. Extubate awake in left lateral position with slight head down tilt. Patient must remain in recovery for an extended period to ensure the bleeding has stopped. Post-operative hemoglobin and coagulation screen must be checked.

139. Inhaled Foreign Body Basazinew C. BCD @ DTU

140. 5/7/2022 BCD @ DTU 140 Foreign body aspiration (FBA ) one of the leading cause of accidental child death. Occurs commonly 1-3 year of age groups. Inhalation of FB is a potential life threatening event. Small reduction in airway radius in a child result larger resistance to air flow.

141. 5/7/2022 BCD @ DTU 141 Patient with FBA may develop hypoxia rapidly. Most death occur at the time of aspiration. The most common aspirated matter are: Coins Small toys Beads Peas, beans, nuts, candies, raisins, grapes, seeds, etc.

142. 5/7/2022 BCD @ DTU 142 Partial obstruction of a lower airway may cause : Air trapping behind the foreign body with a possibility of pneumothorax, surgical emphysema, and Pneumomediastinum The usual inspiratory chest X-ray can appear normal An expiratory film may reveal air trapping. Without a clear history of choking, the symptoms can be difficult to differentiate from acute asthma.

143. Diagnosis 5/7/2022 BCD @ DTU 143 The diagnosis of FBA can be difficult: The inhalation event is not witnessed The history is not clear Young children are pre-verbal

144. Presentation 5/7/2022 BCD @ DTU 144 The presentation is variable depends on: Early vs late presentation Size and shape of the object Site of the object Time of presentation since event

145. History 5/7/2022 BCD @ DTU 145 Sudden onset of choking followed by coughing and wheezing. Type of object give useful information The presentation may be acute with signs and symptoms of laryngeal or tracheal obstruction: Cough, choking, resp ’ distress, cyanosis, stridor, tachypenia . Or signs of main bronchus obstruction: Respiratory distress, tachypnoea , wheeze, or absent breath sound

146. Special investigations 5/7/2022 BCD @ DTU 146 X-ray: Many Airway FB’s are radiolucent Many CXR’s are normal, especially in first 24 hours Secondary Evidence on CXR: Atelectasis, Air Trapping with mediastinal shift Pneumonia Lobar collapse

147. Management principles 5/7/2022 BCD @ DTU 147 Immediate Basic life support(BLS) mgt. If the child is acutely unwell managed as chocking child from BLSA. Does the child have effective cough? Is the child conscious?

148. 5/7/2022 BCD @ DTU 148 Does the child has an effective cough? Crying, talking, can take breath b/n cough, not cyanosed If so encourage to cough by themselves Physiotherapy/interventions such as back blows or chest/abdominal thrust

149. 5/7/2022 BCD @ DTU 149 Is the child conscious? If conscious , the rescuer may with back blow or chest/abdominal thrust If not conscious? The child should have assessed with ABC of life.

150. Airway FB obstruction management (ERG) 5/7/2022 BCD @ DTU 150 Visualize  remove No finger sweep Infant: 5 back blow follow 5 chest thrusts Child Conscious  Heimlich maneuver Unconscious  ABC If cyannose & cannot ventilate & cannot intubation  Consider needle/surgical cricothyrotomy

151. 5/7/2022 BCD @ DTU 151

152. 5/7/2022 BCD @ DTU 152

153. Chest compressions and CPR (in unconscious FBAO) 5/7/2022 BCD @ DTU 153 1. Airway opening Open the mouth and look for any obvious object. 2. If one is seen, make an attempt to remove it with a single finger sweep. 3. Attempt five rescue breaths and if there is no response (moving, coughing, spontaneous breaths) proceed to chest compressions without further assessment of the circulation. 4. Follow the sequence for single rescuer CPR for 5 cycles of 15 compressions to 2 ventilations.

154. Subsequent management 5/7/2022 BCD @ DTU 154 Most children who reach hospital have effective cough. Skilled personnel for bronchoscopy under GA. Initially flexible bronchoscope for diagnosis. Communication b/n staff for planning and equipment The anesthetist should check the bronchoscope attached with breathing system. Experienced senior staff should perform the procedure Two anesthetists should be present

155. Techniques of Anesthesia 5/7/2022 BCD @ DTU 155 Pre-Operative Preparation Fasting if patient stability permits Anticholinergic medication Sedative premedication- relatively contraindicated IV access Antibiotics Steroids Preparation of OR Anesthesia equipment Endoscopy equipment and Endoscopist

156. Induction of Anesthesia 5/7/2022 BCD @ DTU 156 Inhalation induction with halothane or Sevoflurane in 100% O 2 Avoid N 2 O May induce sitting up if patient very agitated or in severe respiratory distress The cords and the trachea sprayed under direct vision.

157. Rigid bronchoscopes 5/7/2022 BCD @ DTU 157

158. How to ventilate ? 5/7/2022 BCD @ DTU 158 Advantage of spontaneous ventilation It reduces distal movement of the FB. Improved ventilation when the bronchoscope passed more distally Once the FB is removed, airway may be rapidly assessed. Advantage of PPV Decrease episode of coughing and desaturation Reduced atelectasis to distal airway Overcomes the resistant to breath through the bronchoscope. Anesthesia can be also maintained with repeated boluses of IV anesthetic agents.

159. Complications 5/7/2022 BCD @ DTU 159 Unable to measure ETCO 2 - hypercarbia may develop Loss of airway Laryngospasm Bronchospasm Regurgitation Arrhythmias Fragmentation of FB Pneumothorax Loss of spontaneous ventilation Airway edema Airway trauma, bleeding, perforation . . . Hypoxic brain injury

160. 5/7/2022 BCD @ DTU 160 A common time for a serious complication is during removal of FB. The FB may become snagged and dislodged at the cords/ larynx causing complete airway obstruction. If the FB lodged in the trachea the object needs to be retrieved rapidly and must ventilate the patient.

161. Summary 5/7/2022 BCD @ DTU 161 Inhaled FB it is important cause of death in infants. Preventive methods e.g. toy safety & supervision. Expertise personnel Inhalational anesthesia with IV supplementation is most commonly employed. Removal of FB can be dangerous part of the procedure and can precipitate airway obstruction.

162. Epiglottitis Basazinew C. BCD @ DTU

163. Epiglotitis 5/7/2022 BCD @ DTU 163 Most feared pediatrics emergency. Can be infectious or non infectious Bacterial infection( hemophilius influenza), s. aureus , s. pneumonia. Affects epiglottis, adjacent pharyngeal tissue ‘ supraglottitis ’

164. Epiglottitis incidence 5/7/2022 BCD @ DTU 164 Common in ages 2-7 Previous H.influenza (HIB) Can occur in adults Mortality 7.1%

165. Signs and symptoms 5/7/2022 BCD @ DTU 165 Acute onset, rapid progression, tripod position, drooling, severe distress in hours High fever Stridor Speech may be muffled or lost Intense sore throat and difficulty in swallowing.

166. Respiratory distress + Sore throat+ Drooling = Epiglottitis 5/7/2022 166 BCD @ DTU Immediate Life Threat Possible Complete Airway Obstruction Tripod position of epiglotitis

167. Management 5/7/2022 BCD @ DTU 167 Placement of standard monitors High concentration of oxygen Classical Do n’ts No throat examination , No IV cannulations No X -rays Do not disturb the child Not relieved by administration of nebulized epinephrine.

168. Management… 5/7/2022 BCD @ DTU 168 Tracheal intubation and an appropriate antibiotics should be started and continue until the swelling subside. Secure the airway under inhalational anesthesia Experienced ENT surgeon stand by. Anesthesia should induced in sitting position and IV canulation attempted when calm. Muscle relaxation is contraindicated due to risk of pharyngeal muscle relaxation and complete airway obstruction.

169. 5/7/2022 BCD @ DTU 169 Visualization of laryngeal inlet may be difficult-bubble from the inlet may be used as a clue for laryngeal inlet. Use ETT half size smaller than calculated. Atropine should be given before laryngoscopy tried. At laryngoscopy epiglottis: Red and swollen arytenoids and other supraglotic tissues inflamed. Glottis opening difficult to visualize Use stylet ,and if difficult bougie .

170. 5/7/2022 BCD @ DTU 170 After intubation laryngeal and blood culture should obtained Antibiotic Rx. Should be commenced. The swelling usually improves one or two days after appropriate antibiotics therapy. Direct examination under anesthesia will confirm the presence of normal epiglotitis and pt. can be extubated .

171. Summary 5/7/2022 BCD @ DTU 171 Epiglottitis can be immediate life threat with possible complete airway obstruction. Severe in pediatrics than adults. Progress from mild symptoms to complete airway obstruction Symptoms are more severe than adults, intubate ASAP.

172. Abscess and Ludwig’s angina Basazinew C. BCD @ DTU

173. Abscess 5/7/2022 BCD @ DTU 173 Abscess around peri-tonsillar area lead to: Airway compromise with obstruction Dysphagia and severe pain Aspiration under LA may be possible. For patients w/o signs and symptoms of airway compromise, inhalational/IV induction can be done.

174. 5/7/2022 BCD @ DTU 174 If airway compromise or anatomic distortion is present: An awake fiber optic intubation technique or Tracheostomy under LA is indicated.

175. Ludwig’s Angina 5/7/2022 BCD @ DTU 175 Background Hippocrates in 1836, a postmortem findings, Karl Friedrich Wilhelm von Ludwig A rapidly progressive gangrenous cellulitis originating in submandibular gland . Inflammatory distention of the facial planes of the neck can lead to respiratory tract obstruction and death. It extends by continuity rather than lymphatic spread . Mortality rate exceeds 50% during the pre-antibiotic era, attributed to overwhelming sepsis . But in the early 1900s the deadly role of mechanical respiratory obstruction was realized.

176. Ludwig’s angina… 5/7/2022 BCD @ DTU 176 An acute odontogenic infection of deep tissues of; Floor of mouth and Adjoining parts of the neck, lower jaw i.e. marked by sever rapid swelling which cause obstruction rapidly. It’s usually bilateral , rapidly spreading usually arising from 2 nd or 3 rd molars.

177. Early appearance of patient who has Ludwig’s angina with characteristic submandibular ‘’woody’’ swelling 5/7/2022 BCD @ DTU 177

178. Presentation Neck swelling Tooth pain Protruding or elevated tongue Fever Dysphagia Difficulty breathing Asphyxia 5/7/2022 BCD @ DTU 178

179. Pathogens 5/7/2022 BCD @ DTU 179 Bacterial isolates are often mixed, comprising both aerobes and anaerobes. Mostly alpha-hemolytic streptococci, staphylococci and bacteroides .

180. Treatment Primary goal: Preserve the oropharyngeal airway. Secondary goal: Antibiotic agent or incision and drainage 5/7/2022 BCD @ DTU 180

181. Airway maintenance 5/7/2022 BCD @ DTU 181 The need for immediate artificial airway: Stridor Cyanosis Retractions Difficulty managing secretions. Rapid progression of edema Comorbid health problems, DM

182. Airway maintenance 5/7/2022 BCD @ DTU 182 Airway maintenance may be difficult: Endotracheal intubation with laryngoscopy: Supraglottic edema Nuchal rigidity Nasal intubation: Requires careful awake Patient in an upright position. Last resort: Airway must be maintained with: Awake fiberoptic intubation. Tracheostomy under LA.

183. Antibiotic agent 5/7/2022 BCD @ DTU 183 Early aggressive antibiotic therapy: Largely replaced surgical decompression Frequently circumvents artificial control of the airway. Determine the source of infection: High-dose penicillin G. Sometime combined with metronidazole . In penicillin-allergic patients, use clindamycin . IV dexamethasone , given for 48 h, has been beneficial in reducing edema.

184. Surgical intervention 5/7/2022 BCD @ DTU 184 Decompression sublingual and submandibular spaces. Incision and drainage Debridement

185. Complication 5/7/2022 BCD @ DTU 185 Deep neck infection Mediastinitis Sepsis Pneumonia Empyema Asphyxia Pneumothorax

186. Summary 5/7/2022 BCD @ DTU 186 The name angina, meaning spasmodic suffocative pain when not treated. Tracheotomy may eliminate the decision-making burden, but… Early aggressive antimicrobial therapy has reduced the need for airway intervention. The treatment plan for each patient should be individualized . Examinations performed at regular intervals allow the physician to monitor the progression of the disease or its response to therapy.

187. Reading assignment 5/7/2022 BCD @ DTU 187 Lefort classification with anesthesia management concerns …..??? Croup….??

188. 5/7/2022 BCD @ DTU 188 Thank you!!!