03 anaesthetic considerations in maxillofacial trauma surgery
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Transcript of 03 anaesthetic considerations in maxillofacial trauma surgery
Dentoalveolar surgery Maxillofacial trauma Orthognathic surgery Temporomandibular Joint disorders Salivary gland surgery Head and Neck tumours Reconstructive surgery
SYNDROME DESCRIPTIONDown Large tongue, small mouth make laryngoscopy difficult;
small subglottic diameter possibleLaryngospasm frequent
Goldenhar Mandibular hypoplasia and cervical spine abnormality make laryngoscopy difficult
Pierre Robin Small mouth, large tongue, mandibular anomaly; awake intubation essential in neonate
Treacher Collins (mandibulofacial dysostosis)
Laryngoscopy difficult
Turner High likelihood of difficult intubation
Major cases have a heavy reliance on GA
Shared operative site between the anesthesiologist and the surgeons
More challenging airways than any other specialty
Major cases require a precise and delicate anesthetic management
ABCDE of ATLS protocol Does not come in isolation Airway complicated by loose teeth,
oral / pharyngeal bleeding, foreign bodies, collapsed bones and anterior neck injuries
Associated C spine injuries very common; further complicate airway management
Things to look for› Mandibular mobility› Tongue mobility and size› Status and fragility of dentition› Amount of oral secretions› Hemorrhage, foreign body or a mass in
oral cavity / pharynx
1. Recognize airway obstruction2. Clear airway3. Reposition patient4. Utilize artificial airways
a. Oral airwayb. Nasopharyngeal airwayc. Other airway adjuncts
5. Perform endotracheal intubation6. Cricothyrotomy7. Tracheostomy
Rapid sequence intubation• Sellick maneuver• Pre oxygenation• No ventilation• Never nasal intubation
? Fiberoptic intubation Expertise required in emergency situation
Preferably nasal intubation; except• Nasal & BOS #
Be cautious about posterior pharyngeal lacerations Intra op Nasal Oral Nasal shift (panfacial #) Other possible routes; esp when post op IMF and nasal packing planned
• Submental• Retromolar• Buccal (cheek laceration)
PATHOLOGIC STATE DIFFICULTYLaryngeal fracture Airway obstruction may worsen during
instrumentationCervical spine injury Neck manipulation may traumatize spinal cordMaxillary/mandibular injury
Airway obstruction, difficult mask ventilation, and intubation; cricothyroidotomy may be necessary with combined injuries
Upper airway tumors Inspiratory obstruction with spontaneous ventilation
Lower airway tumors Airway obstruction not relieved by tracheal intubation
Radiation therapy Fibrosis may distort airway or make manipulations difficult
PATHOLOGIC STATE DIFFICULTYInflammatory rheumatoid arthritis
Mandibular hypoplasia, temporomandibular joint arthritis, immobile cervical spine, laryngeal rotation, cricoarytenoid arthritis all make intubation difficult and hazardous
Ankylosing spondylitis Direct laryngoscopy maybe impossibleSoft tissue, neck injury (edema, bleeding, emphysema)
Anatomic distortion of airway
Endocrine/metabolic acromegaly
Large tongue, bony overgrowths
Reassurance & confidence building Venous access Monitoring Warm fluids and Ensure availability of blood products
Thermal control Eye protection
› Keep them in surgical field Protective lubricant or tape
› If covered Thick padding Urinary catheterization
› > 4 hours› Urinary output monitoring
NG tube insertion
Pre medication• ‘Localized neurogenic shock’ Lesser pain after facial trauma• Sedation with Midazolam• Anti emetics• Anti cholinergic; Atropine or Glycopyrrolate
Induction• ? Barbiturates Hypotension• Ketamine increases catecholamine levels & maintain BP and cardiac output• Etomidate (0.3 – 0.5 mg/kg)• Propofol
• 20-30 % decrease in BP• Decreases heart rate
Surgical position• Ideal
Longer circuit RAE (Ring-Adair-Elwyn) tube Machine away from head; ? Foot end Secure tube and connections Suture tube columellar suture
Intra operative• LA delivery; Surgeon informs anaesthetist• Adequate muscle relaxation• Orbital # Forced duction test Oculocardiac reflex Vagally mediated bradycardia• Panfacial #; nasal oral nasal (Bottom – top approach)
Previously trachys or other routes IMF + nasal packing Trachy
• Current ORIF techniques Post op IMF not common
Pre requisites• Good health• Hematocrit at least 34 %• Hb at least 11 g / dL
Fe sulphate 150 mg OD; 2/52 before donation• Continue till day of surgery• After hospital discharge
Careful estimate of blood loss Autologous blood transfusion Hemodilution Aprotinin
• Serine protease inhibitor• Inhibits plasmin, and plasminogen• Anti fibrinolytic No evidence of thrombosis• 200 mL stat (2,000,000 KIU)• Continuous infusion. 50 mL (500,000 KIU)
Deeper anaesthesia• Narcotics, e.g. morphine, pethidine, nalbuphine,
fentanyl, sufentanyl• Inhalational agents, e.g. Isoflurane, Sevoflurane• Relaxants
Pharmacological• Adrenergic blockers, e.g. Labetolol, Esmolol, Atenolol• Ganglion blockers, e.g. guinethidine, Trimethaphan• Direct acting vasodilators, e.g. Nitroprusside,
Nitroglycerine, • Calcium channel blockers, e.g. Nicardipine
Head-up posture Minor degree of reverse Trendelenburg tilt (10 – 15 degrees) 1 cm rise in surgical area 0.77 mm Hg fall in BP 10 degrees tilt = 6 inches = 15 cm = Decrease of 11.5 mm Hg
Rewarming Post op transfusion
› Haemorrhage› Hb <9 g/dl
ICU / HDU essential Accurate physiologic monitoring Elective post op ventilation Analgesia & Sedation
› Nalbuphine / Ketorolac› PCA
Prolonged surgery
Intensive monitoringExhaustive vigilance
Concealed patient
Blood loss
Difficult airways
Anesthetic choiceRecovery problems
Surgeon’s expertise
Financial issues