Term
| Patients with head and neck cancers usually smoke and drink and have other health issues. List 3 other related comorbidities that Gayle has listed in her notes. |
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Definition
- Emphysema
- Chronic bronchitis
- CAD
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Term
| If your patient with pharyngeal cancer has a huge tumor obstructing their oro/laryngopharynx, what implications does this have that may impact your anesthesia? |
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Definition
The tumor likely affects their intake and they may suffer from the following:
- Dehydration
- Malnourishment
- Anemia
- Electrolyte imbalances
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Term
| Fill in the blank: "The elderly head/neck cancer patient carries a _____greater mortality rate than the younger patient." (I'm not sure if the younger patient refers to someone who also has cancer or not) |
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Definition
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Term
| The head/neck cancer patient often tries other treatment modalities in addition to surgery. If they get radiation what danger might this pose to the anesthetist? |
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Definition
friable/scarred/immobile tissue with a propensity to bleed!!! Intubation near or through this tissue can lead to significant bleeding or edema causing airway compromise.
The tumor itself may interfere with intubation or immobilize neck structures making intubation difficult. |
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Term
| Patients with head/neck cancer may be on chemotherapy. Should this start turning some cogwheels within the skull of the savy anesthetist? |
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Definition
Indeed! The anesthetist should be thinking:
Is the chemo hepatotoxic? (Will drug metabolism be affected?)
Is the chemo cardio toxic? (Might the patient's EF be down as a result?)
Is the chemo toxic to the lungs? (For example, if the patient is on bleomycin, a reduced FiO2 may be necessary) |
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Term
| What are some things that should be done pre-operatively regarding the airway management of patients with head and neck cancer? |
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Definition
Check out CTs and x-rays to familiarize yourself with what structures may be involved or invaded.
Consult with the surgeon - determine whether a tracheostomy under local anesthetic is necessary prior to induction. An armored tube is often placed. |
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Term
| What might you do (besides a tracheostomy) to ensure that an airway is safely placed? |
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Definition
| Awake fiberoptic intubation. If there is serious doubt regarding potential airway problems, IV induction should be avoided. If IV induction is chosen, equipment and personnel should be available for an immediate emergency trach. |
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Term
| List several reasons why an artertial line may be necessary for head and neck surgeries? |
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Definition
- Big potential for blood loss
- Patients often have other comorbidities
- Frequent blood draws
- hypotensive technique may be used
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Term
| If your patient has a central line in place prior to his/her surgery, do you still have to worry about access? |
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Definition
You may. Subclavian and jugular lines may not be a good choice because of their proximity to the surgical field.
You should always have at least two large bore IVs for these types of cases. Make sure you're not doing a forearm flap or the IVs will be no good! |
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Term
| If you're doing a long head/neck case you should have a urinary catheter, warming blanket, and a fluid warmer...what is one other major consideration for these procedures? |
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Definition
| EYEBALLS!!! use lacrilube, extra tape and/or goggle shields. |
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Term
| Head and neck surgeons must retract on some critical nervous structures...what are the anesthetic implications? |
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Definition
The surgeon may use nerve stimulators to determine nerve patency--> may not be able to paralyze the patient (inhalation agents and supplemental narcs are commonly used)
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Term
| If the surgeons are working on the head/neck and you don't have easy access to the ulnar nerve, where might you put the PNS to check a TOF? |
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Definition
Tibial n. (little more resistance to TOF - not as sensitive as other nerves)
Aside: You might start out with an NDMR and then reverse it during critical points in the procedure so that nerve monitoring can be utilized. |
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Term
| What do you think about procedures involving the carotid body? |
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Definition
Well, you better be thinking about:
1. Changes in baroreceptor activity
2. Changes in PaO2 sensitivity
3. Blood flow through the circle of Willis (if the common or IC has to be clamped during the procedure) - will the patient have "mush head" post-op? Will they wake up slower? |
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Term
| Review: T or F: If the right recurrent laryngeal nerve is damaged during surgery the patient will require intubation post-opoeratively? |
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Definition
| Probably NOT. Unilateral RLN damagel is characterized by horseness and a paralyzed chord that assumes an intermediate position. |
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Term
| The head/neck surgeon you're working with requests a hypotensive technique. You should make sure your patient doesn't have risky co-morbidities that would make this technique dangerous...what are these conditions? |
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Definition
CAD
Neurovascular disease where a high CPP needs to be maintained. |
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Term
| The surgeon says, "please use a hypotensive technique." What does he want you to do? |
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Definition
Here's some of the criteria Gayle said in class (I don't think there's necessarily a "right" answer):
- 80 systolic BP
- 20-25% decrease in BP from baseline
- MAP around 55mmHg
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Term
| What can happen when the carotid sinus or stellate ganglion are manipulated? |
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Definition
| Vagal reflex (wide swings in BP, bradycardia, asystole) |
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Term
| When your patient's head is above his/her heart (as it oft is in H&N surgeries) you need to worry about what? |
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Definition
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Term
| You think your patient has a VAE, what the best modality for diagnosing this? |
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Definition
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Term
| A long surgery with interruption of venous flow precludes the patient to _____. |
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Definition
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Term
The surgeon is about to retract the carotid sinus. What can they do to help prevent a vagal response?
What can you do? |
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Definition
Surgeon: inject small doses of local near the carotid sinus
You: administer an anticholinergic (remember: atropine is much faster than glycopyrrolate so you may want it as your first line agent) |
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Term
Surgeons do regional "free flaps" with all kinds of different body parts. All of the following regions may be used EXCEPT:
- trapezius
- forehead
- radial forearm
- pec major
- taint
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Definition
| All can be used, however, patients frequently become upset when their friends call them "taint face" following the procedure. That, and their face smells like ass. |
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Term
| There are three major things to avoid when doing H&N flap cases. List'em. |
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Definition
1. Avoid HYPOTENSION
2. Avoid HYOTHERMIA
3. Avoid FLUID OVERLOAD |
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Term
| It's bad to have a positive fluid balance on your flap patient. What might you do to avoid this? |
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Definition
| Integrate BLOOD or COLLOIDS. Remember, crystalloids stay intravascular for a short time (15-30 mins depending on the crystalloid) so you will keep that reconstructed vasculature flowing longer by using products that stay in the vascular space longer. |
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Term
| The force required to produce facial trauma is considerable. What should this tell you? |
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Definition
| Your patient is likely to have other inuries (head injury--> maybe some elevated ICP) as well. Think about how they will affect your anesthesia. |
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Term
| What are "battle signs" and what implicatioins do they have for anesthesia? |
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Definition
| Battle signs = ecchymosis behind ear, racoon eyes, CSF from nose, blood behind a tympanic membrane. These are signs of cribiform plate disruption so DO NOT NASALLY INTUBATE unless absolutely necessary. |
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Term
What structures are involved in a le fort I fracture? Does it make the anesthetists job more difficult?
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Definition
Maxilla thru the hard palate and nasal septum.
Little difficulty. Can intubate nasally or orally. |
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Term
| Structures involved in a lefort II facture? Hard on the anesthetist? |
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Definition
triangle shaped fracture running from the bridge of the nose thru the medial walls of the orbit beneath the zygoma and thru the lateral maxilla.
I don't know. Gayle didn't say. |
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Term
| Structures involved in a lefort III fracture? Implications for the anesthetist? |
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Definition
separates the upper skull from the face. The fracture runs through the nose, ethmoid bone, orbits and sphenopalatine fossa. Disrupt the cribiform plate.
If you've got CSF coming from the nose, blood behind the tympanic membrane, periorbital edema or racoon eyes a nasal tube should not be attempted. |
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Term
| Prevention of N&V is especially important for the maxillofacial trauma patient. What are you going to do about this? |
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Definition
Put an OG tube down to empty the stomach.
Give antiemetics:
- Serotonin inhibitor: Zofran
- Muscarinic blocker: scopolamine or glycopyrrolate
- Dopamine blocker: Reglan
- Histamine blocker: Benadryl
- Prostaglandin: Decadron
You don't have to give them all, I'm just listing the targets of a "multimodal" approach. |
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Term
Your maxillofacial trauma patient seems like they need some sedation for an elective trach. Run through a few of the drugs you might use and the pros and cons of each.
(This is not in the notes but Gayle discussed it for a while with us) |
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Definition
- Midaz and Fentanyl - watch out for too much of a synergistic effect
- Ketamine - good analgesia. Probably should give some midaz with it to prevent untoward emergence side effects. Good hemodynamics and pulmonary profile
- Precedex - Produces sedation and a little analgesia. Alpha-2 CNS agonist--> may not want to use it if BP is already low.
(These are not "right" answers but are things we talked about in class. Intepret however you want) |
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Term
| Where is the chemotrigger zone? |
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Definition
| 3rd ventricle of the brain - OUTSIDE the BBB |
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