Anaesthesia for FESS

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu),

Dip. Diab.DCA, Dip. Software statistics- Phd

Mahatma Gandhi Medical college and research institute , puducherry , India

• FESS is a nasal endoscopic technique that

allows visualization of the paranasal sinuses

and nasal cavity without a skin incision

History

• Described in the late 1970s by Messerklinger

and Stamberger, FESS has become increasingly

popular in the last 30 years and is now one of

the most commonly performed ambulatory

surgical procedures in otolaryngology

• Almost 350 cases / year in MGMC

Indications

• surgical treatment of sinusitis; nasal polyps; epistaxis;

• bacterial, fungal, recurrent, acute, and chronic sinus

problems.

• Extended

• skull base surgery, trans sphenoidal pituitary tumor

resection, and treatment of vascular malformations.

Complications- nose, orbit and brain

Intraoperative bleeding

• Intra operative bleeding and poor surgical

conditions not only increase complications but

also can prolong total surgical time and lead to

incomplete resection of tissue or tumors,

which may require reoperations.

Preoperative look out

Samter’s triad

• Samter’s triad, or aspirin-exacerbated respiratory

disease, is the combination of reactive airways

disease, chronic rhinitis and nasal polyps, and

sensitivity to aspirin.

• The disease is produced by an abnormality in the

arachidonic acid cascade resulting in overproduction

of leukotrienes.

Preoperative preparation

• NSAIDs ?? • Bronchial asthma but beta blockers Local adrenaline • Long term steroids

• Planning deliberate hypotension • Ask h/o CVS CNS diseases

• Helpful preoperative studies include

prothrombin time, activated thromboplastin

time, platelet count, and complete blood

count.

• ECG, ECHO, Xray, PFT

• In highly motivated patients with minimal or limited

sinonasal disease, simple sinus surgery can be

performed with infiltration of local anesthetic, nerve

blocks, and vasoconstrictors alone or with

monitored anesthesia care

• Combined with local anesthetics, vasoconstrictors

are frequently employed.

• Topical agents are also used in combination with

infiltration techniques.

• Oxymetazoline, phenylephrine, cocaine, and

epinephrine are the vasoactive agents most

commonly used in FESS.

• ENT surgeons pack ??

GA

• children, • developmentally disabled adults, • potentially difficult airways • have a risk of aspiration • require longer operative times• Concepts ?? • Motionless, bloodless field and a secure

airway

Anaesthetic technique

• Controlled GA – ETT routine tube or RAE

• LMA - throat pack !!

• In patients with a history of significant gastro

esophageal reflux disease, obesity, hiatal hernia, or prior

gastric surgery, use of LMAs should be discouraged.

• LMAs do not protect against aspiration as well as cuffed

ETTs -- but ?? Studies

Intraoperative

• Dexa and propofol • Steroids – wheezing and PONV • Propofol - hypotension and PONV

• Glyco, fentanyl, isoflurane, vec –

• No halo , no atracs

Deliberate hypotension • “Controlled” hypotension is an anesthetic

technique aimed at “deliberately” significantly

decreasing the MAP

• Advocated to aid in the reduction of blood loss

and improve visualization in sinus surgery.

Deliberate hypotension

• one can safely achieve a 30% decrease from baseline MAP or an absolute value of 50 mm Hg in healthy patients with ASA class I status

• But the definition is • Reduction of the systolic blood pressure to 80-

90mmHg• Reduction of mean arterial pressure (MAP) to 50-65

mmHg• 30% reduction of baseline MAP

Routine drugs

• Remifentanil- 1 µg.kg-1.min-1 and

0.05-2 µg.kg-1.min-1 infusionOne and one is OK

• Propofol 2.5 mg.kg-1 & 200 µg.kg-1.min-1

• Sevoflurane 2-2.5 %• Clonidine IV sos

How to give controlled hypotension

• the answer is -- VIAGRA• V – Vasodilators (SNP, NTG, Adenosine)• I - Inh. Agents , IV anaesthetics • A - Adrenergic blockers(labetolol,esmolol)• G – Ganglion blockers • R – Regional • A – Anaesthesia

Saudi Journal of Anaesthesia Vol. 7, Issue 2, April-June 2013

• Both dexmedetomidine or esmolol with sevoflurane

are safe agents for controlled hypotension and are

effective in providing ideal surgical field during FESS.

Compared with esmolol, dexmedetomidine offers the

advantage of inherent analgesic, sedative and

anesthetic sparing effect.

• Reduce BP • better fields

• Reduce complications

Other techniques

• Vasoactive medications are injected and infiltrated into the nasal sinuses to decrease mucosal congestion, reduce blood loss, and help achieve hemostasis

Maintenance of Anesthesia

• Remifentanyl propofol TIVA • Remi + isoflurane • Fentanyl + isoflurane • nitrous oxide (50%–75%) with remifentanil

(0.1–0.5 mg/kg/min)/propofol (25–50 mg/kg/min) infusions can be used.

Maintenance of Anesthesia

• mild degree of hypocapnia or hyperventilation has

long been advocated to induce vasoconstriction in

the nasal sinuses and minimize bleeding

• Hypercapnia and oozing is well known

• Controlled ventilation – must

• PEEP increased incidence of bleeds

What we use here – better field

• Propofol • Dexmed , clonidine • Fentanyl + iso • Local vasoconstrictors • Head up

• Preop beta blockers , captopril ??

Emergence

• Smooth • No cough• Neostigmine and spasms • So LMA is better !!

• NO NSAIDs for pain relief• Remove pack

Acta Anaesthesiologica ScandinavicaVolume 49, Issue 10, pages 1471–1476, November

2005

• Local anesthesia for functional endoscopic sinus surgery employing small volumes of epinephrine-containing solutions of lidocaine produces profound hypotension

• Nasociliary nerve block + infra orbital nerve block --- OK

The infraorbital nerve is located 1.5 cm lateral to the nasal bone and 1 cm below the orbital rim

Infraorbital nerve block

Maxillary nerve block

Nasociliary nerve blockade

Posteroinferior 1.5 cm- 2.5 cm depth 1.5 ml

Technique • To perform blockade of the nasociliary nerve, the

medial canthus is identified and a line is drawn superiorly to a point just below the eyebrow.

• The skin overlying this area is prepared with antiseptic solution, with care being taken to avoid spillage into the eye.

• A 22-gauge, 1½-inch needle is inserted at this point, and, with close contact kept with the bony surface of the orbit, the needle is carefully advanced posteroinferiorly approximately 35 degrees off the perpendicular to a depth of approximately 1¼ inches.

Srilankan journal of anaesthesiology

Coroner's Clot

• Any clot left behind can be inhaled after removal of a tracheal tube and lead to total airway obstruction and death—hence the term “coroner's clot.”

• Be more careful in OSA patients • IV cannula – be there till pack removal (nasal)• Post op pain relief - RA, narcotics , para ( oral !!)

Regional anaesthesia for FESS

• Maxillary nerve block + nasociliary nerve block

• Infraorbital nerve block + nasociliary nerve block

summary

• Definition • Indications • Preop • Anaesthetic technique • Deliberate hypo • Post op pain + PONV

Thank you all