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Anesthetic management of maxillofacial surgery. By: Alaa Samir El Kateb Lecturer of anesthesia and intensive care Ain Shams university. Objectives:. - Preoperative airway assessment. - Learn how to perform awake intubation. - How to draw a fluid chart. - PowerPoint PPT Presentation
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Anesthetic management of
maxillofacial surgery
By:
Alaa Samir El KatebLecturer of anesthesia and intensive care
Ain Shams university
Objectives:
- Preoperative airway assessment.
- Learn how to perform awake intubation.
- How to draw a fluid chart.
- What is massive blood transfusion and its
complications.
- Know complications and prevention of
hypothermia.
Le fort classificationTransverse crossing
floor of nose, separating of the palate from the
maxilla.
Fracture of maxilla, where body of the maxilla is
separated from the facial skeleton (pyramidal in
shape)
The entire maxilla and one or more facial
bones are completely separated from the craniofacial skelton
Anesthetic consideration
Airway management (intubation &
extubation)
Blood loss
Hypothermia
Eye protection
Airway management
!
Airway Anatomy
Airway assessment
1- HISTORY: *Rheumatoid - *Morbid obese
*Submandibular abscess *Retropharyngeal abscess
*Neoplasm, Radiation, *Scleroderma
*Previous tracheostomy *Prolonged intubation
*Bleeding lesions *Syndroms e.g. Down
*Mandibular, maxillary &/or cervical spine fractures
*History of difficult intubation
Cont. Preoperative airway evaluation
2- PHYSICAL EXAMINATION:
Thick , short & muscular neck
Receding or hypoplastic mandible
Edentulous, prominent incisors
High arched palate, large tongue
Presence of ear or hand deformities
Cont. Preoperative airway evaluation
Hyomental distance: 2 fingers
Thyromental distance: 6.5 cm
Mouth opening: (TMJ) 3-4 cm
Neck Movement: 35 degree flexion at
lower cervical and 80 degree
extension at atlanto-occipital
Cont. Preoperative airway evaluation
Mallampati’s : sitting, vocalizing, tongue protruded
- Cormack and Lehane scale
The vocal cordsvisible
The vocal cordspartially visible (posterior commissure)
Only epiglottisEpiglottisNot seen
El-Ganzouri risk index+0 +1 +2
Mouth opening cm ≥4 <4
Thyromental distance cm >6.5 6-6.5 <6
Mallampati class I II III-IV
Neck movement >90° 80°-90° <80°
Ability to prognath Yes no
Body weight Kg <90 90-110 >110
History of difficult intubation none ?? yes
Awake intubation
preparation
Innervation of nasal, oropharyngeal & laryngeal
cavitiesNasal/Nasopharyngeal Cavity –Trigeminal Nerve (CN V)
Oropharynx-Glossopharyngeal Nerve (CN IX)
Larynx & Trachea – Branches of the Vagus Nerve (CN X)
I. Anesthesia of the Nasal Mucosa and Nasopharynx(Sphenopalatine ganglion and
ethmoid nerve) - Lidocaine + epinephrine or lidocaine + phenylephrine
- Long cotton-tipped applicators: 1st: 45 degree to the hard palate 2nd: parallel to the dorsal surface of the nose
- Left in place for 5 minutes
- Should be done bilaterally
II. Anesthesia of the mouth, oropharynx
and base of tongue (Glossopharyngeal & superior
laryngeal nerves) - Lidocaine gel on tongue blade and
patient "sucks“. Peak on set 15 min.
OR Lidocaine can be placed in a
nebulizer for 5-7 min
OR The tongue and posterior pharynx
are sprayed with the atomizer.
Glossopharyngeal nerve
block
Superior laryngeal nerve block
III. Anesthesia of the hypopharynx, larynx and
trachea Transtracheal block (RLN)
After anesthetizing the airway you may use:
Direct laryngoscopy
Blind intubation
Retrograde intubation
Fiberoptic intubation
PLEASE
Maintain spontaneous breathing
ctrachcombitube
ILMA
COPA
LMA_supreme2
AIRtraq
glidescope video assessted
TruView
Nasal intubation
- Vasoconstrictor 30-45 minutes earlier.
- Insert ETT parallel to hard palate.- Bevel is medial (turbinates are lateral)
- During blind nasal:
_ Introduce the ETT during inspiration
_ You may use capnography
Fiberoptic bronchoscopy- May turn to be an emergency situation.- If to be used, use it as the first choice.- Pull the tongue forward, jaw thrust.- Put the patient in sitting position.- Keep the midline against hard palate.- You may dim room light and use it as illuminating stylet.
Retrograde intubation
- For nasal intubation!!
Submental intubation
Safe extubation
“air leak test” is done to evaluate whether or not the patient is capable of breathing spontaneously
You may use a hollow introducer or a tube-exchanger, bronchoscope or NGT
Blood loss
- Wide pore canula / central venous access
Fluid therapy
Deficit
Hourly maintenance * fasting hours
Maintenance
- 4 cc/Kg for 1st 10 weight- 2 cc/Kg for 2nd 10 weight- 1 cc/Kg for remaining weight
Losses- Ryle- UOP- Bleeding- 3rd space loss
Gross’s simplified formulaAllowable blood loss =[(Starting Hct – target Hct) / Starting Hct]X Estimated blood volume.
Estimated blood volumeAdults: 65-75 cc/kgInfants: 80 cc/kgNeonates: 85 cc/kg
Newborn: 100-120 cc/Kg
Amount to be transfuse (ml)=[Target haemaglobin – Current haemaglobin]X 4 X weight (kg)
Massive blood transfusion
American Association of Blood Banks definition:
10 units of blood in 24 hrs
or 5 units of blood in 4 hrs
Complications of massive blood transfusion
1- Coagulopathy: At least 1.5 times blood volume to become a clinical problem.
2- Hypothermia.
3- Citrate toxicity: > unit/5 min
4- Hyperkalemia
Hypothermia
Complications of hypothermia:1- Arrhythmia: PVC (<30°C) – VF (<28°C)
2- ↓ O2 delivery to tissues: O2 dissociation curve, VC, ↑ blood viscosity.3- ↓ GFR and UOP stops at 20°C4- ↑ blood viscosity, ↑ rouleaux formation, coagulopathy (depressed clotting mechanism and platelets function).5- Metabolic acidosis.6- Post-operative shivering.
How to prevent?
- ↑ ambient air temperature.
- Humidify inspired air
- Warm mattress
- Plastic or cotton wraps
- Warm fluids
Eye protection
Any questions??
THANK YOU
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