ANESTHESIA

for
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

Out-Patient Dental Anesthesia

Dental Chair Anesthesia

Out-Patient Dental Anesthesia

Dental Chair Anesthesia

Out-Patient dental extraction Children (4-10 years): URTI Steadily decreased

Out-Patient Dental Anesthesia

Induction

Inhalational (mask) induction

Intravenous Induction

Out-Patient Dental Anesthesia

Maintenance

Inhalational agents/N2O Maintain airway

Posture (Supine Position)

Less hypotension less bradycardia However high risk of aspiration high risk of Airway obstruction

Out-Patient Dental Anesthesia

Recovery

Left lateral position 100% O2 Suction Observation & monitoring Discharge criteria Instructions Analgesia (NSAIDs)

Out-Patient Dental Anesthesia

Complications

Respiratory Complications Cardiovascular Complications Syncope Allergic Reaction

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

limbic cortex-hypothalamus-reflex vasodilatation Increase parasympathetic activity-bradycardia

Management Head down-leg elevated 100% O2 Cessation of anesthesia

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

Day-Case Dental Anesthesia

Minor Oral Surgery& Conservative Dentistry

Day-Case Dental Anesthesia

Concerns

Rapid Recovery
Minimal Postoperative Morbidity Remote Location

Day-Case Dental Anesthesia

Minor oral surgery and conservative dentistry Limited surgery No significant risk of complications Standard criteria of patient selection (ASAI&II)

Day-Case Dental Anesthesia

Anesthetic Technique Induction
Inhalational (pediatrics) or Intravenous (propofol) Airway Nasal Endotracheal tube Oral intubation LMA Nasal mask& Nasophryngeal airway NDMR (short acting) Suxamethonium (Postoperative Mylegia) Deep Inhalational Anesthesia Propofol & Alfentanil

Intubation

Moist Pharyngeal Pack

Day-Case Dental Anesthesia

Anesthetic Technique Maintenance
Inhalational Sevoflurane Isoflurane Halothane

(slow recovery & cardiac arrhythmias)

Ventilation

Spontaneous (Short procedure) Controlled ventilation

Extubation Throat pack removed Very light anesthesia (recommended) Patient turned to one side

Day-Case Dental Anesthesia

Anesthetic Technique

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

In-Patient Dental Anesthesia

Major Oral & Fasciomaxillary Surgery

In-Patient Dental Anesthesia

Classifications:

Major Orthognathic Surgery

Tumor Surgery
Palate Surgery

In-Patient Dental Anesthesia

Concerns:

Altered Airway Anatomy Shared Operative Field Anesthetic Drugs Choice Appropriate Time for Tracheal Extubation

Airway Management Anesthetic Management

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

Pathologic States That Influence Airway Management

Selected Congenital Syndromes Associated With Difficult Endotracheal Intubation

SYNDROME Down DESCRIPTION Large tongue, small mouth make laryngoscopy difficult; small subglottic diameter possible Laryngospasm frequent Goldenhar Mandibular hypoplasia and cervical spine abnormality make laryngoscopy difficult

Klippel-Feil
Pierre Robin Treacher Collins (mandibulofacial dysostosis) Turner

Neck rigidity because of cervical vertebral fusion

Small mouth, large tongue, mandibular anomaly; awake intubation essential in neonate Laryngoscopy difficult

High likelihood of difficult intubation

Selected Pathologic States That Influence Airway Management

PATHOLOGIC STATE Infectious epiglottitis Abscess (submandibular, retropharyngeal, Ludwigs angina) Croup, bronchitis, pneumonia (current or recent) Maxillary/mandibular injury Laryngeal fracture Cervical spine injury DIFFICULTY Laryngoscopy may worsen obstruction Distortion of airway renders mask ventilation or intubation extremely difficult

Airway irritability with tendency for cough, laryngospasm, bronchospasm

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

Selected Pathologic States That Influence Airway Management

PATHOLOGIC STATE Upper airway tumors Lower airway tumors Radiation therapy Inflammatory rheumatoid arthritis DIFFICULTY Inspiratory obstruction with spontaneous ventilation Airway obstruction not relieved by tracheal intubation Fibrosis may distort airway or make manipulations difficult Mandibular hypoplasia, temporomandibular joint arthritis, immobile cervical spine, laryngeal rotation, cricoarytenoid arthritis all make intubation difficult and hazardous Direct laryngoscopy maybe impossible Anatomic distortion of airway

Ankylosing spondylitis Soft tissue, neck injury (edema, bleeding, emphysema) Laryngeal edema (postintubation)

Irritable airway, narrowed laryngeal inlet

Selected Pathologic States That Influence Airway

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

Cormack-Lehane Laryngeal View Scoring

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 mask ventilation

1) inability of unassisted anesthesiologist to maintain SpO2 > 90% using 100% oxygen and positive pressure mask ventilation in a patient whose SpO2 was 90% before anesthetic intervention; Or 2) inability of the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation

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

Blind Nasal Intubation

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 Trachea & Vocal Cord Atomizer Injection

AWAKE TECHNIQUES

Laryngoscope Blades

AWAKE TECHNIQUES

McCoy

AWAKE TECHNIQUES

AWAKE TECHNIQUES

FIBER OPTIC INTUBATION

AWAKE TECHNIQUES SURGICAL AIRWAY

Under General Anesthesia

Chidren / Uncoaperative Adults / Sepsis

Assess / Anticholinergic / Anxiolytic ( if any)

1) Inhalational / asses: Ventilation / Veiw

2) Stillete / Different Laryngeoscopes

(=/- short acting MR)

3) LMA / LMA + F.O.

Face Mask + F.O. + Modified Oral AW 4) F.O using Sedation Or light GA

5) Tracheosyomy under light GA

6) Blind Nasal Technique

GA TECHNIQUES

Laryngoscope Blades

GA TECHNIQUES

McCoy

GA TECHNIQUES Laryngeal Mask Airway (LMA)

GA TECHNIQUES LIGHTED STYLETS/LIGHTWAND

Well Circumscribed Glow

GA TECHNIQUES Unconventional LMA

F.O. + LMA

Fast Track LMA

GA TECHNIQUES Blind Nasal Intubation

90% successful but may need several attempts Contraindicated in fractured base of skull Cervical collar in situ

GA TECHNIQUES FIBER OPTIC INTUBATION

GA TECHNIQUES
Rigid Fiberoptic laryngoscope

Retromolar Fiberscope

GA TECHNIQUES BULLARD LARYNGOSCOPE

GA TECHNIQUES SURGICAL AIRWAY

Classification According to Mouth Opening

Awake or Sedated
Normal mouth opening SLN block +Transtracheal LA

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

Techniques Under Vision

Awake Laryngoscopic

Fiberoptic

Intubation Under GA

Tracheostomy

Blind Techniques

Retrograde Wire Intubation

Lighted Stylet/ Light wand

Combi-Tube

Blind Nasal Intubation

Modified Techniques

Wu Scope

Bullard Laryngoscope

NEVER PARALYSE UNTILL POSSIBLE VENTILATION HAS BEEN ESTABLISHED RECENT SUCCESSFUL INTUBATION DOESNOT MEAN FUTURE POSSIBLE INTUBATION

FULL RANGE OF DIFICULT INTUBATION EQUIPMENT MUST BE AVAILABLE

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

Intraoperative Management Post operative Management

PRE-OPERATIVE PROBLEMS
Elderly, Chronically Debilitated Patients Malnourished

H/O Heavy Smoking with Resultant COPD

H/O Alcoholism Co-existing disease such as HTN,D.M, IHD, etc.

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

RECONSTRUCTIVE MAXILLOFACIAL SURGERY

Problems:
Major problem: Airway Management Extensive, long operation Significant blood loss Poor nutritional status Micro-vascular surgery
Caution with Vasoconstrictors Caution with Transfusion Caution with Diurresis Blood Rheology (Hct:25-27)

INTRA-OPERATIVE
Routine Monitoring NIBP ECG SPO2 ETCO2 TEMPERATURE Choice of Volatile Agent Choice of Anesthesia

INTRA-OPERATIVE MANAGEMENT
SPECIAL CONSIDERATIONS

Two large bore canulae

Invasive blood pressure monitoring Central venous pressure monitoring

Use of muscle relaxants

Induced hypotension Blood loss & transfusion Haemodynamic changes Venous air embolism

INTRA-OPERATIVE MANAGEMENT Two Large Bore Canulae

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 Invasive Blood Pressure Monitoring

is indicated due to following reasons : Blood loss may be rapid secondary to Neck dissection Pre operative radiotherapy Surgery close to big vessels of neck Frequent fluctuations in the blood pressure due to manipulation in the area of carotid body and sinus.

INTRA-OPERATIVE MANAGEMENT

Central Venous Pressure Monitoring

Risk of venous air embolism during neck dissection As a guide to the management of fluid therapy

The site of insertion is either: Antecubital vein Femoral vein

INTRAOPERATIVE MANAGEMENT Use of Muscle Relaxants

During surgery IPPV is carried out without muscle relaxant as surgeons need to identify the nerves during surgery

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 Blood Transfusion

Before the decision of blood transfusion the following points should be considered
Patients underlying medical condition Possibility of risks of transfusion hazards Increased risk of post-transfusion cancer recurrence as a result of immune suppression

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

Sinus arrest leading to asystole

Wide swings in blood pressure Prolonged QT Interval

INTRAOPERATIVE MANAGEMENT Haemodynamic Changes Treatment

Immediate cessation of the stimulus Blockage of the sinus with local anesthetic by the surgeon Vagolysis by atropine

INTRAOPERATIVE MANAGEMENT Venous Air Embolism

When the venous pressure in neck veins is low and these veins are open to atmosphere, air is sucked in causing air embolism. Diagnosis
Early Detection Hypoxia Hypotension Hypocarbia

INTRAOPERATIVE MANAGEMENT

Venous Air Embolism

Treatment
Compression of neck veins Positive pressure ventilation Place the patient in the left lateral position Aspiration of air through the central venous catheter Ionotropes

POST-OPERATIVE CARE

I.

ROUTINE CARE

II. SPECIAL CONSIDRATIONS ICU care & Possible mechanical Ventilation Hemodynamic Instability Analgesia Tracheostomy

POST-OPERATIVE CARE ICU Care & Possible Mechanical Ventilation

Patient should be kept in the intensive care unit for 24-48 hours
Prolonged Surgery Airway Oedema Co-existing diseases Risk of bleeding and/or neck hematoma

POST-OPERATIVE CARE Haemodynamic Instability

As bilateral neck dissection may result in post-operative hypertension and hypoxic drive because of the denervation of the carotid sinus and carotid body

POST-OPERATIVE CARE

Analgesia
Non Steroidal Anti-inflammatory Agents should be used as opioids cause respiratory depression in spontaneously breathing patients

When patient is on ventilator opioid analgesia can be given

POST-OPERATIVE CARE

Tracheostomy Care
Humidified Oxygen Intermittent Suction Sterile Precautions Adjustment of cuff pressure to15-20 mmHg Complications

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