Maxillofacial surgeryAnesthetic Issues

Dr Bikash Subedi

2nd yr resident

Moderator: Dr Sushila TabdarAssoc. Professor

Department of Anesthesia & IC,KMCTH

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

• IndicationsCorrection of congenital deformitiesAcquired injuriesNeoplasmsCosmetic (dental malocclusions)

Issues

• Associated defects/injuries

• Shared airway

• Anticipated/Unanticipated Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• Post-operative complications & PONV

PONV- postoperative nausea vomitting

Issues

• Associated defects/injuries

• Shared airway

• Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• PONV

Associated Injuries/Complications

• Airway compromise

• Cervical spine injury

• Head trauma/Pneumocephalus

• Subcutaneous emphysema and pneumomediastinum

• Trismus

• Hemorrhage

Issues

• Associated defects/injuries

• Shared airway

• Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• PONV

Airway sharing

• Common site of Work

• Pre-op discussion & planning helpful

• Intraop assesssment of facial symmetry, mouth opening & teeth occlusion

• Extra vigilance for tube dislodgement,kinking

Issues

• Associated defects/injuries

• Shared airway

• Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• PONV

Anticipated problems

• 1.Anticipated difficult 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)

Methods available

• Awake vs Anesthetized patient

• Orotracheal vs nasotracheal intubation

• Fiberoptic laryngoscopy/intubation

• Anterograde vs retrograde

• Cricothyroidotomy, tracheostomy

DIFFICULT AIRWAYALGORITHM

Intubation

Retromolar intubation, TT behind 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.

The Internet Journal of Anesthesiology Volume 12. 2013Faciomaxillary Surgery - Our Experience: Anaesthesiologist's PerspectiveM 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.

Induction of anesthesia

• Regular induction vs Rapid Sequence Induction

• OpioidsIV inducing agents+/- Muscle relaxants

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

Issues

• Associated defects/injuries

• Shared airway

• Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• PONV

Bleeding & Control measures

• Extensive blood supply to mid-face(maxillary artery/Pterygoid venous plexus)

• Head-up positioning

• Infiltration of large quantities of Epinephrinecontaining LA

• Induced hypotension

Induced hypotension

• Induced-hypotension can 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.

Hypotensive Anesthesia versus Normotensive Anesthesia during Major Maxillofacial Surgery: A Review of the Literature The Scientific World Journal August: 2014Michal 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

Issues

• Associated defects/injuries

• Shared airway

• Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• PONV

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

Issues

• Associated defects/injuries

• Shared airway

• Difficult intubation

• Bleeding & Induced hypotension

• Emergence/Extubation

• Post-operative complications

Postoperative complications

• Vigilance for soft tissue swelling/hematoma which canresult 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

PONV

• Orthognathic surgery associated 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

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

Conclusion

• Close communication & detailed understanding of the surgical plan to be followed

• Specific considerations airway managementtechniques to assist surgical hemostasis and reduce blood loss effective anti-emesis andvigilance for postoperative airway complications