Chapter 37. Anesthesia for Otorhinolaryngologic Surgery

• The anesthetic goals for laryngeal endoscopy include profound muscle paralysis to provide masseter muscle relaxation for introduction of the suspension laryngoscope and an immobile surgical field, adequate oxygenation and ventilation during surgical manipulation of the airway, and cardiovascular stability during periods of rapidly varying surgical stimulation.
• During jet ventilation, it is crucial to monitor chest wall motion and to allow sufficient time for exhalation in order to avoid air trapping and barotrauma.
• The greatest concern during laser airway surgery is an endotracheal tube fire. This risk can be minimized by using a technique of ventilation that does not involve a flammable tube or catheter (eg, intermittent apnea or jet ventilation through the laryngoscope side port), or by using a laser-resistant endotracheal tube and lowering the fraction of inspired oxygen (ideally, as close to 21% as possible, consistent with adequate tissue oxygenation, as monitored by pulse oximetry) and not using nitrous oxide.
• Techniques to minimize intraoperative blood loss include the use of cocaine or an epinephrine-containing local anesthetic for vasoconstriction, maintaining a slightly head-up position, and providing a mild degree of controlled hypotension.
• As always, if there is serious preoperative concern regarding potential airway problems, an intravenous induction may be avoided in favor of awake direct or fiberoptic laryngoscopy (cooperative patient) or an inhalational induction while maintaining spontaneous ventilation (uncooperative patient). In any case, the appropriate equipment and qualified personnel required for an emergency tracheostomy must be immediately available.
• The surgeon may request the omission of neuromuscular blockers during neck dissection or parotidectomy to identify nerves (eg, spinal accessory, facial nerves) by direct stimulation and to preserve them.
• Manipulation of the carotid sinus and stellate ganglion during radical neck dissection (the right side more than the left) has been associated with wide swings in blood pressure, bradycardia, dysrhythmias, sinus arrest, and prolonged QT intervals. Infiltration of the carotid sheath with local anesthetic will usually ameliorate these problems. Bilateral neck dissection may result in postoperative hypertension and loss of hypoxic drive because of denervation of the carotid sinuses and bodies.
• Patients undergoing maxillofacial reconstruction or orthognathic surgical procedures often pose the greatest airway challenges to the anesthesiologist. If there are any anticipated signs of problems with mask ventilation or tracheal intubation, the airway should be secured prior to induction of general anesthesia.
• If there is a chance of postoperative edema involving structures that could obstruct the airway (eg, tongue), the patient should be carefully observed and perhaps should be left intubated.
• Nitrous oxide is either entirely avoided during tympanoplasty or discontinued prior to graft placement.

Anesthesia for Otorhinolaryngologic Surgery: Introduction

In few other circumstances are cooperation and communication between surgeon and anesthesiologist more important than during airway surgery. Establishing, maintaining, and protecting an airway in the face of abnormal anatomy and simultaneous surgical intervention are demanding tasks. An understanding of airway anatomy (see Chapter 19) and an appreciation of common otorhinolaryngologic and maxillofacial procedures are invaluable in handling these anesthetic challenges.

Endoscopy

Endoscopy includes laryngoscopy (diagnostic and operative), microlaryngoscopy (laryngoscopy aided by an operating microscope), esophagoscopy, and bronchoscopy (discussed in Chapter 25). Endoscopic procedures may be accompanied by laser surgery.

Preoperative Considerations

Patients presenting for endoscopic surgery are often being evaluated for voice disorders (often presenting as hoarseness), stridor, or hemoptysis. Possible diagnoses include foreign body aspiration, trauma to the aerodigestive tract, papillomas, tracheal stenosis, tumors, or vocal cord dysfunction. Thus, a preoperative medical history and physical examination, with particular attention to potential airway problems, must precede any decisions regarding the anesthetic plan. In some patients, flow-volume loops (Chapter 6) or radiographic, computed tomography, or magnetic resonance imaging studies may be available for review. Many patients will have undergone preoperative indirect laryngoscopy or fiberoptic nasopharyngoscopy, and the information gained from these procedures may be of critical importance.

Important initial questions that must be answered are whether the patient can be provided with positive-pressure ventilation with a face mask and rebreathing bag, and whether the patient can be intubated using conventional direct or video laryngoscopy. If the answer to either question is not “yes,” the patient’s airway should be secured prior to induction using an alternative technique (eg, use of a fiberoptic bronchoscope or a tracheostomy under local anesthesia; see Case Discussion, Chapter 19). However, even the initial securing of an airway with tracheostomy does not prevent intraoperative airway obstruction due to surgical manipulation and techniques.

Sedative premedication should be avoided in a patient with medically important upper airway obstruction. Glycopyrrolate (0.2-0.3 mg intramuscularly) 1 hr before surgery may prove helpful by minimizing secretions, thereby facilitating airway visualization.

Intraoperative Management

Muscle Relaxation

Intraoperative muscle relaxation can be achieved by intermittent boluses or infusion of intermediate-duration nondepolarizing neuromuscular blocking agents (NMBs) (eg, rocuronium, vecuronium, cisatracurium), or with a succinylcholine infusion. However, profound degrees of nondepolarizing block may prove difficult to reverse and may delay return of protective airway reflexes and extubation. Given that profound relaxation is often needed until the very end of the surgery, endoscopy remains one of the few remaining indications for succinylcholine infusions. Rapid recovery is important, as endoscopy is often an outpatient procedure.

Oxygenation & Ventilation

Several methods have successfully been used to provide oxygenation and ventilation during endoscopy, while simultaneously minimizing interference with the operative procedure. Most commonly, the patient is intubated with a small-diameter endotracheal tube through which conventional positive-pressure ventilation is administered. Standard tracheal tubes of smaller diameters, however, are designed for pediatric patients, and therefore are too short for the adult trachea and have a low-volume cuff that will exert high pressure against the tracheal mucosa. A 4.0-, 5.0-, or 6.0-mm specialized microlaryngeal tracheal tube (Mallinckrodt MLT®, Mallinckrodt Critical Care) is the same length as an adult tube, has a disproportionately large high-volume low-pressure cuff, and is stiffer and less prone to compression than is a conventional tracheal tube of the same diameter. The advantages of intubation in endoscopy include protection against aspiration and the ability to administer inhalational anesthetics and to continuously monitor end-tidal CO2.

In some cases (eg, those involving the posterior commissure or vocal cords), intubation with a tracheal tube may interfere with the surgeon’s visualization or performance of the procedure. A simple alternative is insufflation of high flows of oxygen through a small catheter placed in the trachea. Although oxygenation may be maintained in patients with good lung function, ventilation will be inadequate for longer procedures unless the patient is allowed to breathe spontaneously.

Another option is the intermittent apnea technique, in which ventilation with oxygen by face mask or endotracheal tube is alternated with periods of apnea, during which the surgical procedure is performed. The duration of apnea, usually 2-3 min, is determined by how well the patient maintains oxygen saturation, as measured by pulse oximetry. Risks of this technique include hypoventilation with hypercarbia, failure to reestablish the airway, and pulmonary aspiration.

Another attractive alternative approach involves connecting a manual jet ventilator to a side port of the laryngoscope. During inspiration (1-2 s), a high-pressure (30-50 psi) jet of oxygen is directed through the glottic opening and entrains a mixture of oxygen and room air into the lungs (Venturi effect). Expiration (4-6 s duration) is passive.

Cardiovascular Stability

Blood pressure and heart rate often fluctuate strikingly during endoscopic procedures for two reasons. First, some of these patients are elderly and have a long history of heavy tobacco and alcohol use that predisposes them to cardiovascular diseases. In addition, the procedure is, in essence, a series of physiologically stressful laryngoscopies and interventions, separated by varying periods of minimal surgical stimulation. Attempting to maintain a constant level of anesthesia invariably results in alternating intervals of hypertension and hypotension. Providing a modest baseline level of anesthesia allows supplementation with short-acting anesthetics (eg, propofol, remifentanil) or sympathetic antagonists (eg, esmolol), as needed, during periods of increased stimulation. Alternatively, some anesthesia providers use regional nerve block of the glossopharyngeal nerve and superior laryngeal nerve to help minimize intraoperative swings in blood pressure (see Case Discussion, Chapter 19).

Laser Precautions

Laser light differs from ordinary light in three ways: it is monochromatic (possesses one wavelength), coherent (oscillates in the same phase), and collimated (exists as a narrow parallel beam). These characteristics offer the surgeon excellent precision and hemostasis with minimal postoperative edema or pain. Unfortunately, lasers introduce several major hazards into the operating room environment.

The uses and side effects of a laser vary with its wavelength, which is determined by the medium in which the laser beam is generated. For example, a CO2 laser produces a long wavelength (10,600 nm), whereas a yttrium-aluminum-garnet (YAG) laser produces a shorter wavelength (1064- or 1320-nm). As the wavelength increases, absorption by water increases, and tissue penetration decreases. Thus, the effects of the CO2 laser are much more localized and superficial than are those of the YAG laser.

General laser precautions include the evacuation of toxic fumes (laser plume) from tissue vaporization; these have the potential to transmit microbiological diseases. When significant laser plume is generated, fitted respiratory filter masks compliant with Occupation Safety and Health Administration standards should be worn by all operating room personnel. In addition, during laser procedures, all operating room personnel should wear laser eye protection, and the patient’s eyes should be taped shut.

Although specialized, laser-resistant endotracheal tubes may be used, it must be emphasized that no endotracheal tube or currently available endotracheal tube protection device is reliably laser-proof. Therefore, whenever laser airway surgery is being performed with an endotracheal tube in place, the following precautions should be observed:

• Inspired oxygen concentration should be as low as possible by utilizing air in the inspired gas mixture (many patients tolerate an FIO2 of 21%).
• Nitrous oxide supports combustion and should be avoided.
• The endotracheal tube cuffs should be filled with saline. Some practitioners add methylene blue to signal cuff rupture. A well-sealed cuffed tube will minimize oxygen concentration in the pharynx.
• Laser intensity and duration should be limited as much as possible.
• Saline-soaked pledgets (completely saturated) should be placed in the airway to limit risk of endotracheal tube ignition and damage to adjacent tissue.
• A source of water (eg, 60-mL syringe) should be immediately available in case of fire.

These precautions limit, but do not eliminate, the risk of an airway fire; anesthesia providers must proactively address the hazard of fire whenever laser or electrocautery is utilized near the airway (Table 37-3).

If an airway fire should occur, all air/oxygen should immediately be turned off at the anesthesia gas machine, and burning combustible material (eg, an endotracheal tube) should be removed from the airway. The fire can be extinguished with saline, and the patient’s airway should be examined to be certain that all combustible fragments have been removed.

Nasal & Sinus Surgery

Common nasal and sinus surgeries include polypectomy, endoscopic sinus surgery, maxillary sinusotomy (Caldwell-Luc procedure), rhinoplasty, and septoplasty.

Preoperative Considerations

Patients undergoing nasal or sinus surgery may have a considerable degree of preoperative nasal obstruction caused by polyps, a deviated septum, or mucosal congestion from infection. This may make face mask ventilation difficult, particularly if combined with other causes of difficult ventilation (eg, obesity, maxillofacial deformities).

Nasal polyps are often associated with allergic disorders, such as asthma. Patients who also have a history of allergic reactions to aspirin should not be given any nonsteroidal antiinflammatory drugs (including ketorolac) for postoperative analgesia. Nasal polyps are a common feature of cystic fibrosis.

Because of the rich vascular supply of the nasal mucosa, the preoperative interview should concentrate on questions concerning medication use (eg, aspirin, clopidogrel) and any history of bleeding problems.

Intraoperative Management

Many nasal procedures can be satisfactorily performed under local anesthesia with sedation. The anterior ethmoidal nerve and sphenopalatine nerves (Figure 19-3) provide sensory innervation to the nasal septum and lateral walls. Both can be blocked by packing the nose with gauze or cotton-tipped applicators soaked with local anesthetic. The topical anesthetic should be allowed to remain in place at least 10 min before instrumentation is attempted. Supplementation with submucosal injections of local anesthetic is often required. Use of an epinephrine-containing solution or cocaine (usually a 4% or 10% solution) will shrink the nasal mucosa and potentially decrease intraoperative blood loss. Intranasal cocaine (maximum dose, 3 mg/kg) is rapidly absorbed (reaching peak levels in 30 min) and may be associated with cardiovascular side effects (see Chapter 16).

General anesthesia is often preferred for nasal surgery because of the discomfort and incomplete block that may accompany topical anesthesia. Special considerations during and shortly following induction include using an oral airway during face mask ventilation to mitigate the effects of nasal obstruction; intubating with a reinforced or preformed Mallinckrodt oral RAE® (Ring-Adair-Elwyn) endotracheal tube (Figure 36-1); and tucking the patient’s padded arms, with protection of the fingers, to the side. Because of the proximity of the surgical field, it is important to tape the patient’s eyes closed to avoid a corneal abrasion. One exception to this occurs during dissection in endoscopic sinus surgery, when the surgeon may wish to periodically check for eye movement because of the close proximity of the sinuses and orbit (Figure 37-1); nonetheless, the eyes should remain protected until the surgeon is ready to observe them. NMBs are often utilized because of the potential neurological or ophthalmic complications that might arise if the patient moves during sinus instrumentation.

Coughing or straining during emergence from anesthesia and extubation should be avoided, as these events will increase venous pressure and increase postoperative bleeding. Unfortunately, relatively deep extubation strategies that are commonly and appropriately utilized to accomplish this goal also may increase the risk of aspiration.

Head & Neck Cancer Surgery

Surgery for cancer of the head and neck includes laryngectomy, glossectomy, pharyngectomy, parotidectomy, hemimandibulectomy, and radical neck dissection. An endoscopic examination following induction of anesthesia often precedes these surgical procedures. Timing of a tracheostomy, if planned, depends upon the patient’s preoperative airway compromise. Some procedures may include extensive reconstructive surgery, such as the transplantation of a free microvascular muscle flap.

Preoperative Considerations

The typical patient presenting for head and neck cancer surgery is older and often has had many years of heavy tobacco and alcohol use. Common coexisting medical conditions include chronic obstructive pulmonary disease, coronary artery disease, hypertension, diabetes, alcoholism, and malnutrition.

Airway management may be complicated by abnormal airway anatomy, an obstructing lesion, or by preoperative radiation therapy that has fibrosed, immobilized, and distorted the patient’s airway structures.

Intraoperative Management

Monitoring

Because many of these procedures are lengthy and associated with substantial blood loss, and because of the prevalence of coexisting cardiopulmonary disease, arterial cannulation is often utilized for blood pressure monitoring and frequent laboratory analyses. If central venous access is deemed necessary, the surgeon should be consulted to ascertain that planned internal jugular or subclavian venous access will not interfere with the intended surgical procedures; in such cases, if both internal jugular and both subclavian veins are unavailable, antecubital or femoral veins are reasonable alternatives. Arterial lines and intravenous cannulas should not be placed in the operative arm if a radial forearm flap is planned. A minimum of two large-bore intravenous lines and a urinary catheter (preferably with temperature-monitoring capability) should be placed. A forced-air warming blanket should be positioned over the lower extremities to help maintain normal body temperature. Intraoperative hypothermia and consequent vasoconstriction can be detrimental to perfusion of a microvascular free flap.

Intraoperative nerve monitoring is increasingly utilized by surgeons in anterior neck operations to help preserve the superior laryngeal, recurrent laryngeal, and vagus nerves (Figure 37-2), and the anesthesia provider may be asked to place a specialized nerve integrity monitor endotracheal tube (Medtronic Xomed NIM® endotracheal tube) to facilitate this process (Figure 37-3).

Tracheostomy

Head and neck cancer surgery often includes tracheostomy. Immediately prior to surgical entry into the trachea, the endotracheal tube and hypopharynx should be thoroughly suctioned to limit the risk of aspiration of blood and secretions. If electrocautery is used during the surgical dissection, the FIO2 should be lowered to 30% or less, if possible, in order to minimize the risk of fire as the trachea is surgically entered. In any case, the easiest way to avoid an airway fire in this circumstance is for the surgeon NOT to use the cautery to enter the trachea. After dissection down to the trachea, the tracheal tube cuff is deflated to avoid perforation by the scalpel. When the tracheal wall is transected, the endotracheal tube is withdrawn so that its tip is immediately cephalad to the incision. Ventilation during this period is difficult because of the large leak through the tracheal incision. A sterile wire-reinforced endotracheal tube or L-shaped cuffed laryngectomy tube is placed in the trachea, the cuff is inflated, and the tube is connected to a sterile breathing circuit. As soon as correct position is confirmed by capnography and bilateral chest auscultation, the original endotracheal tube is removed. An increase in peak inspiratory pressure immediately after tracheostomy usually indicates a malpositioned endotracheal tube, bronchospasm, debris or secretions in the trachea, or, rarely, pneumothorax.

Maintenance of Anesthesia

Following reanastomosis of a microvascular free flap, blood pressure should be maintained at the patient’s baseline level. The use of vasoconstrictive agents (eg, phenylephrine) to maintain systemic blood pressure should be minimized because of potential decrease in flap perfusion due to vasoconstriction. Similarly, the use of vasodilators (eg, sodium nitroprusside or hydralazine) should be avoided in order to minimize any decrease in graft perfusion pressure.

Transfusion

Transfusion decisions must balance the patient’s immediate surgical risks with the possibility of an increased cancer recurrence rate resulting from transfusion-induced immune suppression. Rheological factors make a relatively low hematocrit (eg, 27% to 30%) desirable when microvascular free flaps are performed. Excessive diuresis should be avoided during microvascular-free flap surgery in order to allow adequate graft perfusion in the postoperative period.

Cardiovascular Instability

Maxillofacial Reconstruction & Orthognathic Surgery

Maxillofacial reconstruction is often required to correct the effects of trauma (eg, LeFort fractures) or developmental malformations, for radical cancer surgeries (eg, maxillectomy or mandibulectomy), or for obstructive sleep apnea. Orthognathic procedures (eg, LeFort osteotomies, mandibular osteotomies) for skeletal malocclusion share many of the same surgical and anesthetic techniques.

Preoperative Considerations

Intraoperative Management

Maxillofacial reconstructive and orthognathic surgeries can be lengthy and associated with substantial blood loss. An oropharyngeal (“throat”) pack is often placed to minimize the amount of blood and other debris reaching the larynx and trachea. Strategies to minimize bleeding include a slight head-up position, controlled hypotension, and local infiltration with epinephrine solutions. Because the patient’s arms are typically tucked at the side, two intravenous lines may be established prior to surgery. An arterial line may be placed. If head-up tilt is utilized, it is important that the arterial blood pressure transducer be zeroed at the level of the brain (external auditory meatus) in order to most accurately determine cerebral perfusion pressure. In addition, the anesthesia provider must be alert to the increased risk of venous air embolism in the setting of head-up tilt.

Because of the proximity of the airway to the surgical field, the anesthesiologist’s location is more remote than usual. This increases the likelihood of serious intraoperative airway problems, such as endotracheal tube kinking, disconnection, or perforation by a surgical instrument. Monitoring of end-tidal CO2, peak inspiratory pressures, and breath sounds via an esophageal stethoscope assume greater importance in such cases. If the operative procedure is near the airway, the use of electocautery or laser increases the risk of fire. At the end of surgery, the oropharyngeal pack must be removed and the pharynx suctioned. Bloody debris is typically found during initial suctioning, but should diminish with repeat efforts.

Ear Surgery

Frequently performed ear surgeries include stapedectomy or stapedotomy, tympanoplasty, and mastoidectomy. Myringotomy with insertion of tympanostomy tubes is the most common pediatric surgical procedure and is discussed in Chapter 42.

Intraoperative Management

Nitrous Oxide

Nitrous oxide is not often used in anesthesia for ear surgery. Because nitrous oxide is more soluble than nitrogen in blood, it diffuses into air-containing cavities more rapidly than nitrogen (the major component of air) can be absorbed by the bloodstream (see Chapter 8). Normally, changes in middle ear pressures caused by nitrous oxide are well tolerated as a result of passive venting through the eustachian tube. However, patients with a history of chronic ear problems (eg, otitis media, sinusitis) often suffer from obstructed eustachian tubes and may, on rare occasion, experience hearing loss or tympanic membrane rupture from administration of nitrous oxide anesthesia.

During tympanoplasty, the middle ear is open to the atmosphere, and there is no pressure build-up. Once the surgeon has placed a tympanic membrane graft, the middle ear becomes a closed space. If nitrous oxide is allowed to diffuse into this space, middle ear pressure will rise, and the graft may be displaced. Conversely, discontinuing nitrous oxide after graft placement will create a negative middle ear pressure that could also cause graft dislodgment.

Hemostasis

As with any form of microsurgery, even small amounts of blood can obscure the operating field. Techniques to minimize blood loss during ear surgery include mild (15°) head elevation, infiltration or topical application of epinephrine (1:50,000-1:200,000), and moderate controlled hypotension. Because coughing on the endotracheal tube during emergence (particularly during head bandaging) will increase venous pressure and may cause bleeding (as well as increased middle ear pressure), deep extubation is often utilized.

Facial Nerve Identification

Preservation of the facial nerve is an important consideration during some types of ear surgery (eg, resection of a glomus tumor or acoustic neuroma). During these cases, intraoperative paralysis with NMBs may confuse the interpretation of facial nerve stimulation and should not be used unless requested by the surgeon.

Postoperative Vertigo, Nausea and Vomiting

Because the inner ear is intimately involved with the sense of balance, ear surgery may cause postoperative dizziness (vertigo) and postoperative nausea and vomiting (PONV). Induction and maintenance with propofol have been shown to decrease PONV in patients undergoing middle ear surgery. Prophylaxis with decadron prior to induction, and a 5-HT3 blocker prior to emergence, should be considered. Patients undergoing ear surgery should be carefully assessed for vertigo postoperatively in order to minimize the risk of falling during ambulation secondary to an unsteady gait.

Oral Surgical Procedures

Most minor oral surgical procedures are performed in a clinic or office setting utilizing local anesthesia, augmented with varying degrees of oral or intravenous sedation. If intravenous sedation is employed, or if the procedure is complex, a qualified anesthesia provider should be present. Typically, a bite block and an oropharyngeal throat pack protect the airway. For light to moderate levels of sedation, the oropharyngeal pack prevents irrigating fluids and dental fragments from entering the airway. Deep sedation and general anesthesia require an increased level of airway control by the anesthesia provider. Regardless of whether deep sedation or general anesthesia is inadvertent or intended, appropriate equipment, supplies, and medications must be immediately available to help insure that any anticipated or unexpected anesthesia-related problem occurring in an office or clinic setting can be safely addressed with the same standard of care that is required in the hospital or ambulatory surgery center.

Minor oral surgical procedures, such as exodontias, typically last no more than 1 hr. The surgical field is amenable to a nerve block or infiltration by a local anesthetic. In adults, most oral surgeons use 2% lidocaine with 1/100,000 epinephrine or 0.5% bupivacaine with 1/200,000 epinephrine in quantities no greater than 12 mL and 8 mL, respectively. The anesthesia provider must be informed by the surgeon of the local anesthetic used and its concentration and volume injected so that the allowed dosage based on weight is not exceeded. Pediatric patients, in particular, are at risk of local anesthesia toxicity due to an actual overdose or an accidental intravascular injection.

Intravenous sedation during oral surgical procedures greatly increases the patient’s comfort and facilitates surgery. A combination of fentanyl (1-3 mcg/kg) and midazolam (20-50 mcg/kg) is usually adequate prior to injection of the local anesthetic. The sedation can be further augmented by additional small dosages of fentanyl, midazolam, or propofol. Propofol (20-30 mg is a typical incremental dose for an adult) is a good standby drug, if the surgeon requires a brief episode of unconsciousness.

These techniques require a high level of cooperation and participation by both the surgeon and anesthesiologist. If there is the possibility of increased risk due to preexisting medical conditions, less than ideal airway, or extent of contemplated surgical procedure, it is safer to perform the procedure in a hospital or ambulatory surgery center setting with general endotracheal anesthesia.

Case 37

Bleeding Following Sinus Surgery

A 50-year-old man has a paroxysm of coughing in the recovery room while awakening following uneventful endoscopic sinus surgery. Immediately afterward, his respirations seem labored with a loud inspiratory stridor.

What is the differential diagnosis of inspiratory stridor?

The acute onset of inspiratory stridor in a postoperative patient may be due to laryngospasm, laryngeal edema, foreign body aspiration, or vocal cord dysfunction. Laryngospasm, an involuntary spasm of the laryngeal musculature, may be triggered by blood or secretions stimulating the superior laryngeal nerve (see Chapter 19). Laryngeal edema may be caused by an allergic drug reaction, hereditary or iatrogenic angioedema, or a traumatic intubation. Vocal cord dysfunction could be due to residual muscle relaxant effect, hypocalcemic alkalotic tetany, intubation trauma, or paradoxical vocal cord motion (ie, hysterical stridor).

Another paroxysm of coughing is accompanied by hemoptysis. What is your immediate management?

Bleeding after nose or throat surgery can be very serious. Patients who are not fully awake may continue to gag and cough on the secretions, increasing venous pressure and worsening the bleeding. Furthermore, they may aspirate blood and other secretions. Fortunately, because of its physiological pH, aspiration of blood is not as serious as aspiration of acidic gastric contents. Nonetheless, the airway should be immediately secured in the obtunded patient. This may be accomplished with an awake intubation or a rapid-sequence induction.

If the patient is awake and alert enough to cough and swallow and does not seem to be aspirating blood, the first priority should be to decrease the bleeding as quickly as possible. Immediate measures that should be considered include raising the head of the bed to decrease venous and arterial pressures at the site of bleeding and aggressively treating any degree of systolic hypertension with intravenous antihypertensive agents. Sedation should be avoided so that airway reflexes are not compromised.

Despite these measures, the bleeding continues, and surgical intervention seems to be necessary. Describe your strategy for induction of anesthesia in this patient.

Before induction of general anesthesia in a bleeding patient, hypovolemia should be corrected with isotonic crystalloid, or colloid if the patient does not respond to crystalloid. The degree of hypovolemia is difficult to assess because much of the blood may be swallowed, but it may be estimated by changes in vital signs, postural hypotension, and hematocrit. Cross-matched blood should be readily available, and a second large-bore intravenous line secured. It must be appreciated that from an anesthetic standpoint, this is an entirely different patient than the one who presented for surgery initially: the patient now has a full stomach, is hypovolemic, and may prove to be a more difficult intubation.

The preferred technique in this patient is a rapid-sequence induction with cricoid pressure. Drug choice (eg, ketamine, etomidate) and dosage should anticipate the possibility of hypotension from persistent hypovolemia. Qualified personnel and appropriate equipment for an emergency tracheostomy should be immediately available. An orogastric tube should be passed to decompress the stomach.

Which arteries supply blood to the nose?

The arterial supply of the nose is provided by the internal maxillary artery and the anterior ethmoid artery. These may have to be ligated in uncontrollable epistaxis.

Describe extubation.

Because this patient is still at risk of aspiration, extubation should not be attempted until the patient has fully awakened and regained airway reflexes. Although it is desirable to limit coughing and “bucking” on the endotracheal tube during emergence, this may be difficult to achieve in the awakening patient. Intravenous lidocaine (1.5 mg/kg) may be helpful in this situation.

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