In-Patient Dental Anesthesia Major oral and fasciomaxillary surgery Classifications: Major Orthognathic Surgery (late teenage& adults) Tumor surgery.

In-Patient Dental Anesthesia Major oral and fasciomaxillary surgery

Classifications:

Major Orthognathic Surgery (late teenage& adults)

Tumor surgery (elderly) Palate Surgery (infants&children)

In-Patient Dental Anesthesia

Problems:

Major problem: Airway Management Extensive, long operations Significant blood loss Poor nutritional status Micro-vascular surgery

In-Patient Dental Anesthesia Airway Management

IMPORTANT POINTS

NEVER PARALYSE UNTILL POSSIBLE VENTILATION HAS BEEN ESTABLISHED

RECENT SUCCESSFUL INTUBATION DOESNOT MEAN FUTURE POSSIBLE INTUBATION

FULL RANGE EF DIFICULT INTUBATION EQUIPMENT MUST BE AVAILABLE

In-Patient Dental Anesthesia Airway Management

Choice of the technique depends on several factors:

Patient safety Experience of the anesthetist Known difficult airway Requirements: nasal or oral Post operative jaw wiring

N orm al A irw ay

A w a k e o r S e d a te d U n d e r G A

D iff icu lt A irw ay

A ir w a y M a n a g em e n t

A w a k e o r S e d a te d

S L N b lo ck +T r a nstr ac h ea l L A

N o r m a l m ou th o pe n ing

R e tro g ra d e In tu b at ion

L im ited

A w a ke In tu b at io n w ith F .O .

E x tre m ely lim ited

C h idr e n / U nc o a pe r a tiv e A d u lts / Se p s is A sse ss / A n t ic ho lin er g ic / A n xio ly tic ( if a n y)

U n d e r G e n e r a l A n e sth e s ia

1 ) In h a la t io n a l / a sse s : V e n t ila t io n / V e iw

(= /- short acting M R)

2 ) S tille te / D if f er e n t L a ry n ge o sco p es

F a c e M a sk + F .O . + M o d if ie d O r a l A W

3) L M A / L M A + F .O .

4 ) F .O u s in g S e d a t ion O r lig h t G A

5 ) T r a c he o sy om y u n d er ligh t G A

6 ) B lin d N a sa l T e c hn iq ue

Emergency Maxillofacial Surgery

Maxillofacial Trauma

Types of Injury

Fasciomaxillary Injury

Accompanied injury

Neck Injury Cervical Spine Injury Head Injury Closed Head Injury & Cervical Spine Injury

Fasciomaxillary Injury

One third of causalities Maxilla is the most common(24%) Followed by the mandible (18%) Most maxillary fractures are compound comminuted

Types Le Forte I: Transverse Fracture

Le Forte II Pyramidal Fracture

Le Forte III: Craniofacial Fracture

Neck Injury

10% are accompanied by carotid artery injuries

Presented with either severe hematoma or expanding neck hematoma

SymptomsDysphagiaConstant coughHemoptysisInspiratory stridorHoarseness of voiceSubcutaneous Emphysema

TypesOpen TraumaClosed Trauma

Cervical Spine, Spinal Cord Injury

Should always be considered

Involvement of C7

(or oedema of near by cervical spines)

Significant Hemodynamic Instability

Significant Respiratory Distress

Head Injury

17.5% with facial fractures (10% severe)

Early recognition

Loss of consciousness

Glascow Coma Scale

Secondary brain insult

Pre- Anesthetic AssessmentProblems

Airway Obstruction (early tracheostomy is not universal)

Difficult Intubations

Unstable Cervical Spine

AcuteAirway Problems:Aspired teethOral bleedingTrismusEpistaxisNasal CSF

leakage

Pre- Anesthetic AssessmentProblems

Blood loss in excess of patient blood volume

Full Stomach ( blood, debris, delayed emptying)

Large Air leaks, Risk of subcutaneous emphysema, pneumothorax

Pre- Anesthetic AssessmentProblems

CSF leaks with constant risk of meningitis

Increased ICP with secondary brain insult

Presence of co-existing disease (ASA)

Existing drug or alcohol intoxication

Anesthetic management

I) Specific Management

Facial Trauma Facial Trauma with Closed Head Injury Facial Trauma with Spinal Cord Injury Facial Trauma and Neck Injury

II) General

III) Airway

Anesthetic managementSpecific Management: Facial

Trauma

All facial traumas must be Suspected for IC and Spinal injuries

Airway

Hold tongue, head down, turned one side Nasopharyngeal airway (I&CI) Throat pack Scissors or wire cutter

Anesthetic managementSpecific Management:

Facial Trauma with closed head injury

Reduction of ICP is the Main Goal

Not a situation for blind nasal Head elevation 20o –30o

Control body temperature Prophylactic phenytoin Avoid hypervolemia and hypotonic fluids Avoid hypoglycemia and hyperglycemia

Anesthetic managementSpecific Management:

Facial Trauma with spinal cord injury

Not a situation for blind nasal ET intubation (technique) Respiratory dysfunction (up to 3 weeks) Spinal shock

Anesthetic managementSpecific Management:

Facial Trauma with neck Injury Airway Secure then control hemorrhageAirway

ETT through the wound Awake orotracheal intubation Avoid MR in uncertain airway

Respiration ( Risk of pneumothorax)

Avoid IPPV Avoid nitrous oxide Avoid sedation

Hypovolemia

Anesthetic managementGeneral Management

IV lines, Urinary catheters, stomach tubes Monitors Measure to reduce ICP Fluid therapy and replacement therapy FIO2 should be at maximum

Premedication Anticholinergics Avoid premedication Heavy premedication

Anesthetic managementGeneral Management

Important Points

Airway must be a priority (secondary brain insult)

Excitement is a sign of hypoxia rather than pain

Accidental extubation is a well recognized hazards

Anesthetic managementGeneral Management

Important Points

Decreasing level of consciousness is a reliable sign of head injury

Major surgery may be delayed until the patient’s neurological conditions has established

Important to differentiate between blood and CSF

Consider all patient full stomach

Anesthetic managementAirway

CHRACTERISTICS

TECHNIQUE (algorism)

Awake vs. anesthetized Nasotracheal vs. Orotracheal Blind vs. Visual Direct vs. Fiberoptic Antegrade vs. Retrograde Tracheostomy, Cricothyrotomy

Transtracheal Jet Ventilation

Anesthetic managementAirway :

CHRACTERISTICS

Dynamic not static All hypoxic All full stomach Unique optimum position for the airway

(semi prone, sitting up, leaning forward)

Anesthetic managementAirway :

Technique

Is there a possibility of concurrent basal skull fracture?

Nasotracheal intubation is absolute contraindication

Anesthetic managementAirway :

Technique

Is there a possibility of injury of cervical spine?

Manual in line axial traction Bullard laryngoscope(It matches anatomy not to align the airway to match the blade)

Open the AirwayEndotracheal Intubation “Aligning Axes of the Airway”

Open the AirwayEndotracheal Intubation “ Laryngoscopes ”

Anesthetic managementAirway :

TechniqueIs the patient is unable to open his mouth?Why?

Reflex spasm (I.e.Trismus) (Anesthesia may relief the spasm)

Mechanical dysfunction (i.e.TMJ) (Blind nasal intubation or Fiberoptic intubation)

Bimandibular fracture at the level of second or first molar

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