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Maxillofacial surgery and anesthetic issues
Maxillofacial surgery involves the head, neck, face and jaws and can be done for congenital deformities, injuries, or tumors. Anesthesia for these procedures presents several challenges including a shared airway, potential for difficult intubation, blood loss requiring induced hypotension, and risks during emergence like airway obstruction. Careful pre-operative planning is important to choose the best airway management strategy and prevent complications. Induced hypotension can improve surgical conditions but risks need to be weighed. Emergence and extubation also require vigilance to address swelling and ensure hemostasis and a secure airway.
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Maxillofacial surgery and anesthetic issues
- 1. Maxillofacial surgery Anesthetic Issues DrBikash Subedi 2nd yr resident Moderator: Dr Sushila Tabdar Assoc. Professor Department of Anesthesia & IC,KMCTH
- 2. Maxillofacial surgery • diseases,injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and Cranio-maxillofacial region • Indications Correction of congenital deformities Acquired injuries Neoplasms Cosmetic (dental malocclusions)
- 4. Issues • Associated defects/injuries •Shared airway • Anticipated/Unanticipated Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • Post-operative complications & PONV PONV- postoperative nausea vomitting
- 5. Issues • Associated defects/injuries •Shared airway • Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • PONV
- 6. Associated Injuries/Complications • Airwaycompromise • Cervical spine injury • Head trauma/Pneumocephalus • Subcutaneous emphysema and pneumomediastinum • Trismus • Hemorrhage
- 7. Issues • Associated defects/injuries •Shared airway • Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • PONV
- 8. Airway sharing • Commonsite of Work • Pre-op discussion & planning helpful • Intraop assesssment of facial symmetry, mouth opening & teeth occlusion • Extra vigilance for tube dislodgement,kinking
- 9. Issues • Associated defects/injuries •Shared airway • Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • PONV
- 10. Anticipated problems • 1.Anticipateddifficult airway • 2.Restricted ability to open the mouth • 3.Possibility of cervical spine fracture • 4.Possibility of concurrent base skull fracture • 5. Full stomach (emergency cases)
- 11. Methods available • Awakevs Anesthetized patient • Orotracheal vs nasotracheal intubation • Fiberoptic laryngoscopy/intubation • Anterograde vs retrograde • Cricothyroidotomy, tracheostomy
- 12.
- 13. Intubation Retromolar intubation, TTbehind the most posterior molars, allows teeth to be brought into occlusion. • Submental intubation, TT is passed (without connector) through the floor of the mouth and out percutaneously.
- 14. The Internet Journalof Anesthesiology Volume 12. 2013 Faciomaxillary Surgery - Our Experience: Anaesthesiologist's Perspective M Sarkar, V Puri, D Kumar, Dewoolkar, C Shastri, M Shakeel • Abstract • Retrospective study • 241 patients who underwent elective surgeries for maxillofacial injuries (2002-2005) • Choice of airway management is directed by thorough preoperative evaluation including radiological study, surgical requirement of maxillomandibular fixation and experience of anaesthesiologist. • Wherever possible Submental intubation should be considered over tracheostomy to reduce morbidity.
- 15. Induction of anesthesia •Regular induction vs Rapid Sequence Induction • Opioids IV inducing agents +/- Muscle relaxants
- 16. Maintenance of anesthesia •Volatile agents or total i.v. anesthesia (TIVA). • analgesia may be provided with Morphine or shorter acting opioids such as Fentanyl or Alfentanil. • Remifentanil becoming popular, rapidly titratable, accelerated Wake up and recovery • Mandibular and maxillary nerve blocks performed by surgeons can aid intra/post-op analgesia
- 17. Issues • Associated defects/injuries •Shared airway • Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • PONV
- 18. Bleeding & Controlmeasures • Extensive blood supply to mid-face (maxillary artery/Pterygoid venous plexus) • Head-up positioning • Infiltration of large quantities of Epinephrine containing LA • Induced hypotension
- 19. Induced hypotension • Induced-hypotensioncan reduce blood loss, transfusion rate, and operating time. Not without risks !! • No more than 30% reduction with an absolute lower limit of 55 mm Hg (in ASA I patients)* • Caution in CAD,uncontrolled HTN,CVD,hepatic/renal impairment • Clonidine/Magnesium may contribute to postoperative analgesia. • Mg should be titrated and caution exercised, may prolong neuromuscular blockade • *Choi WS, Samman N • . Risks and benefits of deliberate hypotension in anaesthesia: a systematic review. Int J Oral Maxillofac Surg 2008;37:687- 703. doi:10.1016/j.ijom.2008.03.011.
- 20. Hypotensive Anesthesia versusNormotensive Anesthesia during Major Maxillofacial Surgery: A Review of the Literature The Scientific World Journal August: 2014 Michal Barak MD 1 Leiser Yoav DMD, PhD2, Imad Abu el-Naaj DDS 3 1Department of Anesthesiology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel • Conclusions • Patients who undergo major maxillofacial surgery are at risk of considerable intra- operative bleeding, and the outcome of the surgical procedure depends on the quality of the surgical field conditions. Since hypotensive anesthesia can reduce the extent of intraoperative bleeding and can potentially improve the quality of the surgical field conditions, hypotensive anesthesia is considered to be beneficial during these procedures. However, hypotension carries the risk of hypoperfusion in vital organs and is unsafe in certain patients. Thus, the magnitude of the blood pressure reduction should be adjusted to the patient's general condition, age, and existing diseases. Normotensive or modified hypotensive anesthesia should be used for patients with ischemic heart disease, carotid artery stenosis, a disseminated vascular disease, kidney dysfunction, or severe hypertension who are scheduled to undergo a major maxillofacial operation. • Appropriate patient selection, careful monitoring, and adequate intraoperative volume replacement are mandatory in hypotensive anesthesia for its safe implementation in patients who are scheduled to undergo a major
- 21. Issues • Associated defects/injuries •Shared airway • Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • PONV
- 22. Emergence and Extubation •Discontinue Induced hypotension • Removal of the throat pack • ?Airway cleared with suction • Ensure hemostasis before jaw wiring is carried out (esp if intermaxillary fixation) • Deep smooth Vs Safer Awake extubation
- 23. Issues • Associated defects/injuries •Shared airway • Difficult intubation • Bleeding & Induced hypotension • Emergence/Extubation • Post-operative complications
- 24. Postoperative complications • Vigilancefor soft tissue swelling/hematoma which can result in airway obstruction • Management of pain and PONV are paramount. Vomiting in patients in IMF is dangerous • With IMF, wire cutters must always be kept next pt. for emergency (vomiting, airway obstruction, bleeding) IMF= intermaxillary fixation
- 25. PONV • Orthognathic surgeryassociated with a high incidence of PONV 7-40% • Intra-operative steroids (usu dexamethasone) administered also efficacious anti-emetics and contribute to analgesia. • The use of additional anti-emetics should be considered
- 26. Post op Analgesia •Postoperative pain after orthognathic surgery often not severe, probable contribution by intra-op use of LA • Usu managed by Opioids with PCM and NSAIDs
- 27. Conclusion • Close communication& detailed understanding of the surgical plan to be followed • Specific considerations airway management techniques to assist surgical hemostasis and reduce blood loss effective anti-emesis and vigilance for postoperative airway complications
Editor's Notes
- #3 Orthognathic surgery, (Greek: orthos ‘straight’, gnathos ‘jaw’) involving osteotomy and repositioning of the mandible, maxilla, or both is performed to treat skeletal disproportion of the lower face
- #6 Associated cardiovascular effects with cleft palate/lip
- #9 Not only is the airway shared, as with any oral surgery, but orthognathic surgery also requires that the patient's mouth is free for the occlusion of the teeth to be checked intra-operatively with and without the wafers As the correction of facial symmetry and profile is a fundamental goal of the surgery it is also necessary for the surgeons to periodically undrape the face to assess the relationship between lips and central facial structures, and so anesthetic equipment should not unnecessarily distort these tissues
- #12 nasotracheal intubation is contraindicated in the presence of fracture of nasal skeleton, skull base fracture and CSF rhinorrhoea
- #14 Retromolar intubation, an attempt is made to pass a reinforced oral TT (inserted conventionally) behind the most posterior molars, thus still allowing the teeth to be brought into occlusion. Submental intubation, the end of the conventionally inserted oral TT is passed (minus its connector) through the floor of the mouth and out percutaneously. Neither of these is ideal from the surgical perspective and the risk of accidental TT dislodgement is high. Tracheostomy
- #15 The Internet Journal of Anesthesiology Volume 12 Number 1 Original Article
- #17 analgesia may be provided with morphine or with shorter acting opioids such as fentanyl or alfentanil. With either volatile agents or TIVA, the use of remifentanil is becoming popular, its rapidly titratable nature allowing for smooth anesthesia during intermittently highly stimulating surgery. Wake up and recovery may also be accelerated
- #19 Minimizing blood loss intra-operatively can be difficult, especially during maxillary surgery. The bony mid-face receives an extensive blood supply and the posterior maxilla is also in close proximity to a rich venous plexus. Bleeding can therefore be heavy from both soft tissue and bone. Bleeding can occur from branches of the third part of the maxillary artery and on occasions from the pterygoid venous plexus which can lead to major blood loss. T
- #20 number of contraindications to induced hypotension including ischemic heart disease, uncontrolled hypertension, diabetes, severe anaemia, haemoglobinopathies (such as Sickle cell anaemia), cerebrovascular disease, and hepatic and renal impairment. Some of these are relative and induced hypotension may still be used, but with caution and closer monitoring.
- #25 Management of pain and PONV are paramount. Vomiting in patients in IMF is dangerous and if jaws are wired there must be wire cutters immediately available which accompany the patient from theatre, to the PACU, and also to the ward
- #26 Intra-operative steroids, usually dexamethasone, are administered primarily to minimize postoperative swelling but are also efficacious anti-emetics and contribute to analgesia. Orthognathic surgery is nevertheless associated with a high incidence of postoperative nausea and vomiting (PONV) of 7–40% even with peri-operative steroids the occurrence of which is undesirable in these patients, particularly if jaw fixation is to be used after operation in some form (see below). The use of additional anti-emetics should be considered
- #27 As with many types of head and neck surgery, postoperative pain after orthognathic surgery is often not severe, and this is contributed to by the generous intra-operative use of local anesthesia
- #28 Good anaesthesia for orthognathic and TMJ surgery requires close communication with the surgical team and a detailed understanding of the surgical plan to be followed both intra-operatively and after operation. Specific considerations include airway management, techniques to assist surgical haemostasis and reduce blood loss, effective anti-emesis and vigilance for postoperative airway complications. Induced-hypotension is of benefit to patient outcome and safe when undertaken in an appropriate manner.