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Head neck onco- anesthesia
- 1. D R NA Y A N A K U L K A R N I C M C C N A S I K Anesthetic Considerations In Head Neck Oncosurgical Management
- 2. Objective 1/16/2016 dr nck cmccnasik 2 At the end of this session the delegate should have a fair idea of: The peri-operative management of patients undergoing surgery related to head and neck cancer
- 3. Head and neckcancer 1/16/2016 dr nck cmcc nasik 3 Worldwide 644k incidence and 350 k deaths • 50,000 Americans are diagnosed with a head or neck cancer (not including skin cancers that occur in the head or neck) ~ 5 percent of all cancers in the US – Majority are squamous cell carcinoma • Survival rates have improved – aggressive treatment – early detection – declining rates of tobacco and ETOH abuse • The role of HPV – The % of oropharyngeal cancers caused by human papillomavirus (HPV) has increased – 80% of oropharyngeal cancers are now caused by HPV (industrialized countries)
- 4. Epidemiology 1/16/2016 dr nck cmccnasik 4 Head and Neck Squamous cell carcinoma (HNSCC), which constitutes the most common upper aero digestive tract carcinomas. Accounts for 3% of all cancers in the developed countries like USA whereas in developing countries like India it accounts for 30% of all cancers.
- 5. EPIDEMIOLOGIC TRENDS OFHEAD AND NECK CANCERS 1/16/2016 dr nck cmcc nasik 5 Head and neck cancers are among the 10 most common cancers globally. In India, it accounts for one fourth of male cancers and one tenth of female cancers (Yeole 2001). Risk factors for head and neck cancers: Consumption of alcohol, Tobacco smoke, smokeless tobacco, alcohol, marijuana use, deficient diet, Human Papilloma virus infection
- 6. General considerations forHNF surgery 1/16/2016 dr nck cmcc nasik 6 • Airway Management – Anatomy (c-spine, +/- ROM, large tongue) – stridor or hoarseness – hx neck surgery, trauma, difficult intubation – infections (epiglottitis, abscess) – head/neck cancer radiation therapy low threshold for fiberoptic • backup plan • sharing of airway with surgeon • nasal intubation
- 7. Anesthetic considerations 1/16/2016 dr nckcmcc nasik 7 Problems related to age Problems related to cancer Securing airway Recovery
- 8. Age 1/16/2016 dr nck cmccnasik 8 Generally older patients Cardiac- Co dec by 1% per yr after 30 yrs so ability to in response to stress is diminished. Respiratory – PaO2 by 0.5% per yr after 20 yrs, so rapid hypoxemia esp if pt is smoker Hepatic – drug clearance is impaired. Renal- cr clearance also dec 1ml/min/yr after 20 yrs it means high sr creat may indicate underlying severe impairment in clearance.
- 9. Cancer 1/16/2016 dr nck cmccnasik 9 Chemo is given to cause tumor reduction. It can result in affection of multiple systems in body Due to cumulative dosages and drug toxicity: Renal Hepatic Hematological / bone marrow suppression Cardiac Pulmonary GI
- 10. Post radiotherapy 1/16/2016 dr nckcmcc nasik 10 Airway fibrosis Lung toxicity Restrictive cardiomyopathy Metabolic- Tumor cell destruction Tumor produced factors Electrolyte imbalances
- 11. Preoperative evaluation Wyss, A.et. Al Am. J. Epidemiol. (2013) 178 (5): 679-690. doi: 10.1093/aje/kwt029 1/16/2016 dr nck cmcc nasik 11 Determine degree of compromise and risk Focus preliminary exm on CVS , Airway and Pulmonary systems. – elderly comorbidities – hx of smoking, EtOH – Hx CAD, HTN, CRI, COPD – Prior anesthesia hx – preop testing imaging studies, PFTs, cardiac and hepatic function
- 12. Preoperative evaluation 1/16/2016 dr nck cmccnasik 12 Increasing risk factors- Obesity age> 60 h/o smoking PaCO2 > 45 mm Hg Max breathing capacity of < 50% of predicted in PFT’s Presence of pulmonary disease itself is predictor of high incidence of peri- operative pulmonary complications Proper preop preperation in pt with pulmonary disease can reduce periop morbidity and mortality Bronchodilators,mucolytics,incentive spirometry,abstinance from abusive agents, coughing and deep breathing. PFT- normalises by 8 wks. Reduction in COHb- 12 hrs. Stain M JAMA 211,787, 1970
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- 14. Images –difficult airway 1/16/2016 drnck cmcc nasik 14
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- 20. Dr. Binnions LemonLaw: An easy way to remember multiple tests… 1/16/2016 dr nck cmcc nasik 20 • Look externally. • Evaluate the 3-3-2 rule. • Mallampati. • Obstruction? • Neck mobility.
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- 22. Golden pearls 1/16/2016 dr nckcmcc nasik 22 Fluid management in Cancer surgeries. Rehydration maintainance Replacement Other goals- Early ambulation Chest PT Recognise difficult airways and prepare for it.
- 23. General Considerations 1/16/2016 dr nckcmcc nasik 23 • Anesthetic Management – -Smooth emergence -Opioid based technique -antiemetic prophylaxis - OGT prior to emergence to empty stomach +/- – General with ETT vs. flexible ETT
- 24. General Considerations 1/16/2016 dr nckcmcc nasik 24 Adequate intra op/postop analgesia, highly reflexogenic areas – controlled hypotension – decrease SBP< 100mmHg, Keep MAP 60-70 Pt immobility muscle relaxation ?
- 25. Monitoring and access 1/16/2016 drnck cmcc nasik 25 – ECG – BP noninvasive vs. Arterial – pulse Ox – temp – end tidal CO2 – RLN nerve monitoring current practice – large bore IV, good access large bore IV, good access – positioning arms tucked, all access prior, sticky pulse ox, nerve stimulator (where?)
- 26. Intraoperative 1/16/2016 dr nck cmccnasik 26 - Protect eyes – Cardiac function monitored – Temp –Head of bed can be elevated aids venous drainage – +/- Reinforced ETT –Avoid drugs that stimulate sympathetic nervous system
- 27. Options 1/16/2016 dr nck cmccnasik 27 ETT with GA Awake FOI Awake DL and then assess intubation status Recent IDL to predict level of difficulty Trach with LA
- 28. Difficult mask ventilation 1/16/2016 drnck cmcc nasik 28 Age>55 Presence of beard BMI >26 Edentulous h/o snoring Massive jaw Poor neck extension Large tongue Mandibular space TMD MMP Neck Pharyngeal pathology Facial deformity Facial dressings Tumor growth on face h/o difficult airway Overbite shape of palate Inter incisor length Cervical vertebral ROM
- 29. Intraop airway management 1/16/2016 drnck cmcc nasik 29 Secure ETT prefer reinforced ETT Assess Surgical field requirement accordingly fix ETT Trach as an when indicated Prolonged reconstructions- keep head end elevated to minimise supraglottic edema Give dexamentasone Minimise ETT movement
- 30. Extubation 1/16/2016 dr nck cmccnasik 30 Keep tube exchanger at hand (bougie) Jet ventilation /both Preferably Keep lengthy and reconstructive surgical pts intubated overnight. Criterias for extubation- Severity of pulmonary disease Length and extent of surgery Ability to protect airway Ability to mobilize and remove secretions Amount of residual respiratory depression from residual anesthetic agents
- 31. Thyroidectomy 1/16/2016 dr nck cmccnasik 31 Maintain adequate depth of anesthesia – Remember DL is stimulant – B-blockers are your friend • Not particularly painful post-op. – Complete reversal intact reflexes – Recurrent Laryngeal Nerve Damage • unilateral = hoarseness • bilateral = aphonia and stridor
- 32. Thyroidectomy 1/16/2016 dr nck cmccnasik 32 –Hematoma formation –Hypoparathyroidism unintentional removal of parathyroid glands. (Chvostek’s and Trousseau’s) –Awake vs Deep extubation
- 33. Thyroid Storm 1/16/2016 dr nckcmcc nasik 33 Can occur intraop, most common 6-24 hour postop – Mimic MH intraop –Hyperpyrexia, tachycardia, altered consciousness hypotension consciousness, hypotension – Tx: hydration, cooling, esmolol infusion, propylthiouracil, sodium iodide, cortisol
- 34. For Tracheostomy 1/16/2016 dr nckcmcc nasik 34 • Pre-op Assessment – population usually includes: chronically ventilated pts, pts having other procedure where trach is required, pts with upper airway obstruction (emergency) – evaluate pt - ventilation settings – airway, coexisting dx – cardiac hx – neuro assessment may be sedated – In OR or Bedside +/- anesthesia
- 35. Intraop for Tracheostomy 1/16/2016 drnck cmcc nasik 35 - For intubated pts GETA –Airway compromised pts local anesthesia – mucosal swelling tissue fragility • risk of tracheal mucosal separation and false passage during trach – Communicate with surgeon when using cautery in the airway – 100% O2 required before insertion of trach
- 36. Intraoperative Trach 1/16/2016 dr nckcmcc nasik 36 Trachea opened above cuff, ETT retracted slowly with visualization of surgeon (communication), do not remove all the way until trach in place and +ETCO2 confirmation- • Pneumothorax • False passage – recognize, no CO2, PIP absent breath sounds, rigid bronchoscope and extra ETT available
- 37. Postoperative trach 1/16/2016 dr nckcmcc nasik 37 Transport to ICU with meds, equipment – Trach tube displacement, ETT and extra trach tube with stylet (obturator) available – Watch for bleeding
- 38. Anesthesia for ND 1/16/2016 drnck cmcc nasik 38 • Radical, modified, or functional • Usually performed with resection of primary lesion : thyroid, parathyroid, tongue, pharynx, larynx, etc.
- 39. Preop considerations forND 1/16/2016 dr nck cmcc nasik 39 – Airway decreased mobility 2°to radiation • backup plan • surgeon available surgeon available – Resp COPD, CO2 retention, PFTs – Cardiac: HTN, carotid artery stenosis
- 40. Intraoperative 1/16/2016 dr nck cmccnasik 40 – Moderate decrease in BP, - avoid adrenergic responses – Muscle relaxant +/- –Humidify gases reduce mucous plugging –VAE occurs rarely – Manipulation of carotid sinus bradycardia, -- ↓ BP
- 41. Esp right sideneck dissection 1/16/2016 dr nck cmcc nasik 41 • Right Radical Neck dissection - • may cause prolonged QT interval which may progress to ventricular arrhythmias and cardiac arrest (due to interruption of cervical sympathetic outflow to heart via right stellate ganglion)
- 42. Postoperative Considerations inND 1/16/2016 dr nck cmcc nasik 42 –HTN, ↑HR 2° to carotid sinus denervation – Facial nerve injury – RLN damage –Diaphragmatic paralysis – Pneumothorax –Agitation
- 43. Special considerations- minorprocedures but not so minor!! 1/16/2016 dr nck cmcc nasik 43 PEG insertion/ feeding gastrostomy in HN Ca pt on RT- neck movement negligible,anatomical landmarks not visible- Difficult airway so may need FOI GA PEG insertion. DL in partial stridor pt- Discuss possibility of Emergency trach with relatives in dire conditions as life saving measure. ECA ligation post CT/RT- difficult mask ventilation possibility must be kept in mind.
- 44. At the endTEAM EFFORT wins 1/16/2016 dr nck cmcc nasik 44