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Dental & MAXILLOFACIAL SURGERY
SAAD A. SHETA
MBChB, MA, MD
Associate Professor, Anesthesia Dental College KSU
Dental Anesthesia
I. Out-Patient anesthesia II. Day-Case anesthesia III. In-Patient anesthesia V. Emergency Surgery
Intravenous Induction
Less hypotension less bradycardia However high risk of aspiration high risk of Airway obstruction
Left lateral position 100% O2 Suction Observation & monitoring Discharge criteria Instructions Analgesia (NSAIDs)
Respiratory Complications
Airway Obstruction
Respiratory Depression
Cardiovascular Complications
Hypotension Bradycardia
Dysrhythmias
(Tachy-arrhythmias)
Aetiology
(Tooth extraction)
High preoperative catecholamines Light anesthesia Airway obstruction & hypoxia Halothane & local anesthesia Local anesthesia with vasopressors
Syncope
Causes Previous factors (CV, allergic,..) Emotional factors (more common)
Aetiology
Allergic Reaction
Incidence Very rare More commonly (vaso-vagal, toxic reaction, epinephrine) Aetiology Ig E-mediated reaction Easter-linked: p-amino benzoic acid Amide-linked: preservatives (Paraben) Manifestations Management
Rapid Recovery
Minimal Postoperative Morbidity Remote Location
Minor oral surgery and conservative dentistry Limited surgery No significant risk of complications Standard criteria of patient selection (ASAI&II)
Intubation
Ventilation
Extubation Throat pack removed Very light anesthesia (recommended) Patient turned to one side
Recovery& PO
Minimum 2 hrs Pain Control
NSAIDs (IM diclofenac) Short acting opioids Local analgesic block (2Quadrants only ) Preoperative Dexamethazone Assessment (Morbidity) Written instructions Contact telephone number Possible overnight admission
Discharge
Tumor Surgery
Palate Surgery
Altered Airway Anatomy Shared Operative Field Anesthetic Drugs Choice Appropriate Time for Tracheal Extubation
Airway Management
Airway Management
Choice of the technique depends on several factors: Patient safety Experience of the anesthetist Known difficult airway Requirement: nasal or oral Post operative jaw wiring
Airway Management
History Physical Examination Further Evaluation Difficult Airway & Algorism Airway Strategies
History
Documented History of Difficulties with general anesthesia or, more specifically, mask ventilation or endotracheal intubation
Congenital Syndromes Associated With Difficult Endotracheal Intubation
Klippel-Feil
Pierre Robin Treacher Collins (mandibulofacial dysostosis) Turner
Airway obstruction, difficult mask ventilation, and intubation; cricothyroidotomy may be necessary with combined injuries Airway obstruction may worsen during instrumentation Neck manipulation may traumatize spinal cord
Ankylosing spondylitis Soft tissue, neck injury (edema, bleeding, emphysema) Laryngeal edema (postintubation)
Management
PATHOLOGIC STATE Angioedema DIFFICULTY Obstructive swelling renders ventilation and intubation difficult
Endocrine/metabolic Large tongue, bony overgrowths acromegaly Diabetes mellitus Hypothyroidism Thyromegaly Obesity Reduced mobility of atlanto-occipital joint Large tongue, abnormal soft tissue (myxedema) make ventilation and intubation difficult Extrinsic airway compression or deviation Upper with loss of consciousness airway obstruction Tissue mass makes successful mask ventilation unlikely
Physical Examination
Inspection (Obvious Problems) Mouth Opening (3 4cm) Oral Cavity Examination Mallampati Score Thyromental Distance (3 large fingers = 5 cm) Neck Movement
Further Evaluation
PRE-OPERATIVE ASSESSMENT OF THE AIRWAY
Indirect or Fiberoptic Laryngoscopy X ray: Chest , Cervical Spine CT or MRI Flow- Volume Loops Pulmonary Function Tests
Difficult Airway
Difficult airway
The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both
Difficult Airway
Difficult Laryngoscopy
Not being able to see any part of the vocal cords with conventional laryngoscopy
Difficult Intubation
Proper insertion with conventional laryngoscopy requires either : a) > 3 attempts b) > 10min
Airway Management
Normal Airway Difficult Airway
Awake or Sedated Under GA
Difficult Airway
Awake Under GA/Sedation
Different Laryngoscopes, Stylets
Awake Laryngoscopy
Awake Fiberoptic
LMA/ I LMA/FO
Tracheostomy
Fiberoptic
Retrograde Intubation
Tracheostomy
AWAKE TECHNIQUES
Difficult Airway
Awake
Awake Laryngoscopy
Awake Fiberoptic
Tracheostomy
Retrograde Intubation
AWAKE TECHNIQUES Glosso-Pharyngeal Nerve IX Nerve Posterior pharyngeal fold at its midpoint, 1 cm deep to the mucosa of the lateral pharyngeal wall
AWAKE TECHNIQUES Superior Laryngeal Nerve Pyriform Fossa External :1 cm medial to the superior cornu of the Hyoid Bone to pierce the thyrohyoid membrane
AWAKE TECHNIQUES
Laryngoscope Blades
AWAKE TECHNIQUES
McCoy
AWAKE TECHNIQUES
AWAKE TECHNIQUES
GA TECHNIQUES
Laryngoscope Blades
GA TECHNIQUES
McCoy
F.O. + LMA
90% successful but may need several attempts Contraindicated in fractured base of skull Cervical collar in situ
GA TECHNIQUES
Rigid Fiberoptic laryngoscope
Retromolar Fiberscope
Limited
Retrograde Intubation
Extremely limited
Awake Intubation with F.O.
Awake Intubation
Under Anesthesia
Blind Technique
Blind technique such as BNI, Light wand, Retrograde wire intubation, LMA, and Combi tube are C/I in tumor patients because of the risk of bleeding and tumor dislodgement.
Spontaneously Risk of apnea with breathing awake difficulty mask patient without the risk ventilation of apnea Suitable for patients Suitable for patients with no obstructive with obstructive symptoms symptoms Needs patients cooperation Success rate in good experienced hands Risk of complications from nerve block Incase of failure , can be postponed for reconsideration
Failure to intubate may result in fatal outcome Multiple attempts may lead to bleeding and/or aspiration
Awake Laryngoscopic
Fiberoptic
Intubation Under GA
Tracheostomy
Blind Techniques
Combi-Tube
Modified Techniques
Wu Scope
Bullard Laryngoscope
NEVER PARALYSE UNTILL POSSIBLE VENTILATION HAS BEEN ESTABLISHED RECENT SUCCESSFUL INTUBATION DOESNOT MEAN FUTURE POSSIBLE INTUBATION
ALL PHYSICIANS RESPONSIBLE FOR AIRWAY MANAGEMENT SHOULD BE PRACTICED IN AT LEAST ONE ALTERNATE TO BAG & MASK VENTILATION. THESE ALTERNATIVE INCLUDES THE FOLLOWING:
LARYNGEAL MASK AIRWAY COMBI TUBE TRANSTRACHEAL TECHNIQUES LMA PROVIDE RESCUE VENTILATION IN 94% OF CASES OF UNANTICIPATED DIFFICULT INTUBATION
HAVING DISCUSSED ALL THE MANAGEMENT STRATEGIES AWAKE TECHNIQUE IN GENERAL & AWAKE FIBER OPTIC TECHNIQUE ESPECIALLY, IS THE MOST COMMONLY USED & SAFE TECHNIQUE
ANESTHESIA MANAGEMENT
Special Consideration
Preoperative Management
PRE-OPERATIVE PROBLEMS
Elderly, Chronically Debilitated Patients Malnourished
PRE-OPERATIVE
MANAGEMENT
Adequate pre-operative work-up of Cardiac Status & Pulmonary Functions should be carried out using various diagnostic modalities with the objective of optimizing patients condition
INTRA-OPERATIVE
Routine Monitoring NIBP ECG SPO2 ETCO2 TEMPERATURE Choice of Volatile Agent Choice of Anesthesia
INTRA-OPERATIVE MANAGEMENT
SPECIAL CONSIDERATIONS
After induction of anesthesia, two large bore canulae can be put in large veins so that rapid fluid replacement can be carried out in case need arises.
INTRA-OPERATIVE MANAGEMENT
INTRAOPERATIVE MANAGEMENT
Induced Hypotension
Mild degree of hypotension is required during surgery to reduce the blood loss. This can be achieved by following:
15-30 degree head up tilt Increasing the conc. of volatile anesthetics Use of peripheral vasodilators Use of beta blockers
INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes
During radical neck dissection, the traction or pressure on the carotid sinus and / or stellate ganglion can cause following: Brady-dysrhythmias
INTRAOPERATIVE MANAGEMENT
POST-OPERATIVE CARE
I.
ROUTINE CARE
II. SPECIAL CONSIDRATIONS ICU care & Possible mechanical Ventilation Hemodynamic Instability Analgesia Tracheostomy
POST-OPERATIVE CARE
Analgesia
Non Steroidal Anti-inflammatory Agents should be used as opioids cause respiratory depression in spontaneously breathing patients
POST-OPERATIVE CARE
Tracheostomy Care
Humidified Oxygen Intermittent Suction Sterile Precautions Adjustment of cuff pressure to15-20 mmHg Complications
THANK YOU