Term
| Explain why nitrous is not a preferred anesthetic agent for tympanoplasty. |
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Definition
| During the procedure the middle ear is open to atmosphere (and nitrous can therefore escape). However, when the graph is in place, nitrous can diffuse into the middle ear space (which is now closed due to the graph) and lead to bulging (inward or outward bulging) and possible tearing. If it's DC'd while the graph is in place it can bulge inward and tear. |
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Term
| If nitrous is used during tympanoplasty, when should it be DC'd? |
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Definition
| 15 mins prior to complete placement of the graph. |
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Term
| Microsurgery of the ear requires a clear surgical field. What can the anesthetist do ensure that the surgeon doesn't turn into a cry-baby bitch who's always whining about a dirty or obstructed surgical field? |
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Definition
- 10-15 degree head up position increased venous drainage.
- Deliberate hypotension with SHORT acting agents (esmolol, nipride).
- The surgeon may inject the ear (near the tympanic vessels) with an epinephrine containing solution. (If it goes systemic you may see changes in your vital signs.
- DON'T USE NITROUS
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Term
| Why would a competent CRNA be wary of giving too much/many opioids to an OSA patient presenting for tonsillectomy? |
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Definition
| They can be very sensitive to opiates. OSA patients typically have a blunted response to arterial hypoxemia/increased PaCO2 levels. Opiates can exacerbate this making it harder to wake them up from anesthesia. |
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Term
| In addition to nitrous, what is else should be avoided in the tympanoplasty patient that might undo the exquisite work of the of the super-human surgeon? (HINT: think post-op) |
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Definition
| PONV (orad projection of stomach contents). PONV incidence is high in middle ear surgery and it can undo the "delicate graft". |
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Term
| Usually people don't get their tonsils taken out for the hell of it. Think of the anesthetic challenges associated with huge, purulent tonsils. |
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Definition
1. Hypertrophic tonsils - Creates difficulties with VENTILATION and INTUBATION.
2. Infected tonsils - May lead to SYSTEMIC COMPLICATIONS
3. The condition is often associated with childhood obesity and OSA - This may lead to Pickwickian syndrome (obstructive sleep apnea syndrome) and V/Q mismatching, enlargement of the right heart structure and CHF. |
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Term
| Based on all the clinical conditions associated with large tonsils, what are 5 possible scenarios/considerations for a safe anesthetic regime that Gayle lists on her slide? |
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Definition
1. Mask induction v. IV induction
2. Adjunct equipment for potential difficult intubation
3. Awake intubation
4. Tracheostomy under local
5. Use of optiods (related to sensitivity of OSA patients) |
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Term
| What kind of NDMR should be used (if any) for a tonsillectomy? |
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Definition
| A short-acting one. The cases are typically short. |
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Term
What are the two most commonly used types of ETT tubes used for tonsillectomy and adenoidectomy?
At what age should a cuff be used? |
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Definition
1. Oral RAE
2. Reinforced ETT
>8 yrs old |
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Term
| If using a non-cuffed tube, how much air leak should be allowed to prevent post-extubation problems such as croup and edema? |
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Definition
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Term
Where should the ETT be taped for a tonsillectomy (ie. to the right or left)? |
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Definition
MIDLINE (I'm assuming this allows for the best surgical access if you're taking both tonsils out). |
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Term
Tonsillectomies can be very stimulating. What is considered to be one of the most STIMULATING points in the procedure? |
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Definition
When the mouth gag is placed. The gag is designed to open the mouth wide and retract the tongue. Its stimulation level rivals that of micro-ma-bone wearing a bananna hammock.
Don't forget to evaluate the airway after mouth gag placement! You want to make sure that the ETT is not compressed and that its placement is still intact. |
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Term
| Anesthetic technique should account for what 5 factors related to tonsillectomy? |
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Definition
1. Adequate depth for the VERY STIMULATING procedure.
2. Rapid return of reflective reflexes - you don't want them aspirating on some drizzly throat blood.
3. Good post-operative analgesia
4. Reduced post-op bleeding
5. Reduced post-op nausea |
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Term
| Gayle talked about the "damned if you, damned if you don't" situations regarding extubation technique in the tonsellectomy patient. Don't know if it'll be on the test but here's what she said: |
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Definition
Fully awake extubation: may cough and bite and cause bleeding of the surgical site
Deep extubation: protective airway reflexes may not be fully functional and the patient may bleed and aspirate |
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Term
| What is the most SERIOUS complication of tonsillectomy? |
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Definition
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Term
What is the most COMMON reason for post-op hospital admission following tonsillectomy?
What should you incorporate into your anesthetic plan to fix this problem? |
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Definition
NAUSEA AND VOMITTING!!! Incidence of PONV may be as high as 70% during the first 24 hrs.
- Use a soft catheter to get the blood out of them guts and to decompress the stomach (Surgeons will often do this for you).
- Give them some anti-nausea medication!
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Term
| What drug is commonly used to treat edema associated with tonsillectomy? |
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Definition
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Term
| What might a surgeon do at the end of a tonsillectomy that would have implications for the anesthetist? |
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Definition
| Inject local anesthetic. Know your doses! |
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Term
| If your CRNA tells you to put your patient in the "tonsil position" following extubation s/p tonsillectomy what would you do to avoid looking like a dipshit? |
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Definition
| Place the patient in a LATERAL position with the HEAD SLIGHTLY DOWN. |
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Term
| If I were to tell you that the incidence of post-operative bleeding s/p tonsillectomy is 0.3-0.6% would you believe me? |
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Definition
You should cuz that's what it is.
75% is within the first 6 hours. However, it can occur up to the 6th post-op day (when the scab usually falls off). |
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Term
| If your post-op tonsillectomy patient is bleeding what are the two main problems associated with this? |
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Definition
1. You can't determine the extent of the blood loss (cuz they swallow it).
2. Lots of nausea and vomitting occurs when people swallow large amounts of blood. |
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Term
| So your post-op tonsillectomy patient is bleeding; what are six things you need to consider regarding your anesthetic plan? |
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Definition
1. FLUID RESUSCITATION (hypovolemia may be profound - do it before induction)
2. Get necesarry labs (H&H, T&S, or T&C).
3. Decide whether you need to do an awake intubation or an RSIV induction.
4. If your patient is hypovolemic make sure you use the appropriate induction agent (consider etomidate or ketamine)
5. Place an OG or NG ASAP after induction (or before if possible)
6. Place the patient's head down prior to induction.
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Term
| What is the major indication for uvulopharyngopaltoplasty (UPP)? |
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Definition
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Term
If your patient is getting a UPP is it cool to assume that you can easily place an ETT? If it's not cool, what should you do?
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Definition
It is way not cool to assume that. You better check yo'self fool. You better:
1. Do a complete and thorough airway assessment.
2. Carefully develop an airway management plan.
(In severe cases where even awake fiberoptic intubation is difficult you may have to do a trach under local) |
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Term
| What's the most frequent complication of a UPP? |
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Definition
| Swelling. Usually give intra-op steroids. |
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Term
| What are the steps of emergence in the typical UPP patient? |
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Definition
- Insert soft catheter to suction out stomach.
- Gentle suctioning (I'm assuming she's referring to oropharyngeal)
- Place airway
- Ensure protective airway reflexes are intact
- Use xylocaine 1-1.5mg/kg to reduce coughing and bucking
- Completely reverse NDMRs
- Consider how post-op pain meds might affect ventilation (Remember that these patients get a UPP for sever OSA).
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Term
| Cleft lip and palate deformaties have varying degrees of structureal involvement (lip, hard palate, soft palate). What implications might these deformities have on intubation? What might you do to correct this? |
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Definition
| 1. It usually makes intubation more difficult because the blade slips into the defect. Packing the defect with gauze may help prevent this. |
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Term
| Cleft lip/palate patients have a higher incidence of what conditions? What should you always be checking if they do have these defects? |
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Definition
congenital heart anomalies (atrial or ventricular defects)
Check your IV lines to make sure that there are no bubbles (in case the have ASDs OR ISDs).
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Term
| What do surgeons typically do to patient's with cleft lip/palate that makes an oral airway obsolete? |
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Definition
| They put a suture through the patient's tongue and tape it to the cheek. If airway obstruction occurs on emergence , tugging on the suture usually alleviates the problem. Don't forget to use gentle suctioning on emergence! |
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Term
| If your cleft palate patient has a URI should you proceed with the case? |
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Definition
| No. postpone until better. |
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Term
| Should you extubate your cleft palate patient deep or fully awake? |
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Definition
Awake (I'm not exactly sure why)
Don't forget to apply hand mittens and arm restraints, your patient may even have a Logan's bow, to prevent them to ruining the surgical site. |
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Term
| What are your cleft palate patients typically intubated with? |
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Definition
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