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Anaesthesia for FESS

Anaesthesia for FESS. Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab.DCA , Dip. Software statistics- Phd Mahatma Gandhi Medical college and research institute , puducherry , India.

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Anaesthesia for FESS

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  1. Anaesthesia for FESS Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics- Phd Mahatma Gandhi Medical college and research institute , puducherry , India

  2. FESS is a nasal endoscopic technique that allows visualization of the paranasal sinuses and nasal cavity without a skin incision

  3. History • Described in the late 1970s by Messerklinger and Stamberger, FESS has become increasingly popular in the last 30 years and is now one of the most commonly performed ambulatory surgical procedures in otolaryngology • Almost 350 cases / year in MGMC

  4. Indications • surgical treatment of sinusitis; nasal polyps; epistaxis; • bacterial, fungal, recurrent, acute, and chronic sinus problems. • Extended • skull base surgery, trans sphenoidal pituitary tumor resection, and treatment of vascular malformations.

  5. Complications- nose, orbit and brain

  6. Intraoperative bleeding • Intra operative bleeding and poor surgical conditions not only increase complications but also can prolong total surgical time and lead to incomplete resection of tissue or tumors, which may require reoperations.

  7. Preoperative look out

  8. Samter’s triad • Samter’s triad, or aspirin-exacerbated respiratory disease, is the combination of reactive airways disease, chronic rhinitis and nasal polyps, and sensitivity to aspirin. • The disease is produced by an abnormality in the arachidonic acid cascade resulting in overproduction of leukotrienes.

  9. Preoperative preparation • NSAIDs ?? • Bronchial asthma but beta blockers Local adrenaline • Long term steroids • Planning deliberate hypotension • Ask h/o CVS CNS diseases

  10. Helpful preoperative studies include prothrombin time, activated thromboplastin time, platelet count, and complete blood count. • ECG, ECHO, Xray, PFT

  11. In highly motivated patients with minimal or limited sinonasal disease, simple sinus surgery can be performed with infiltration of local anesthetic, nerve blocks, and vasoconstrictors alone or with monitored anesthesia care

  12. Combined with local anesthetics, vasoconstrictors are frequently employed. • Topical agents are also used in combination with infiltration techniques. • Oxymetazoline, phenylephrine, cocaine, and epinephrine are the vasoactive agents most commonly used in FESS. • ENT surgeons pack ??

  13. GA • children, • developmentally disabled adults, • potentially difficult airways • have a risk of aspiration • require longer operative times • Concepts ?? • Motionless, bloodless field and a secure airway

  14. Anaesthetic technique • Controlled GA – ETT routine tube or RAE • LMA - throat pack !! • In patients with a history of significant gastro esophageal reflux disease, obesity, hiatal hernia, or prior gastric surgery, use of LMAs should be discouraged. • LMAs do not protect against aspiration as well as cuffed ETTs -- but ?? Studies

  15. Intraoperative • Dexa and propofol • Steroids – wheezing and PONV • Propofol - hypotension and PONV • Glyco, fentanyl, isoflurane, vec – • No halo , no atracs

  16. Deliberate hypotension • “Controlled” hypotension is an anesthetic technique aimed at “deliberately” significantly decreasing the MAP • Advocated to aid in the reduction of blood loss and improve visualization in sinus surgery.

  17. Deliberate hypotension • one can safely achieve a 30% decrease from baseline MAP or an absolute value of 50 mm Hg in healthy patients with ASA class I status • But the definition is • Reduction of the systolicblood pressure to 80-90mmHg • Reduction of meanarterial pressure (MAP) to 50-65 mmHg • 30% reduction of baseline MAP

  18. Routine drugs • Remifentanil- 1 µg.kg-1.min-1 and 0.05-2 µg.kg-1.min-1 infusion One and one is OK • Propofol 2.5 mg.kg-1 & 200 µg.kg-1.min-1 • Sevoflurane 2-2.5 % • Clonidine IV sos

  19. How to give controlled hypotension • the answer is -- VIAGRA • V – Vasodilators (SNP, NTG, Adenosine) • I - Inh. Agents , IV anaesthetics • A - Adrenergic blockers(labetolol,esmolol) • G – Ganglion blockers • R – Regional • A – Anaesthesia

  20. Saudi Journal of Anaesthesia Vol. 7, Issue 2, April-June 2013 • Both dexmedetomidine or esmolol with sevoflurane are safe agents for controlled hypotension and are effective in providing ideal surgical field during FESS. Compared with esmolol, dexmedetomidine offers the advantage of inherent analgesic, sedative and anesthetic sparing effect.

  21. Reduce BP • better fields • Reduce complications

  22. Other techniques • Vasoactive medications are injected and infiltrated into the nasal sinuses to decrease mucosal congestion, reduce blood loss, and help achieve hemostasis

  23. Maintenance of Anesthesia • Remifentanylpropofol TIVA • Remi + isoflurane • Fentanyl + isoflurane • nitrous oxide (50%–75%) with remifentanil (0.1–0.5 mg/kg/min)/propofol (25–50 mg/kg/min) infusions can be used.

  24. Maintenance of Anesthesia • mild degree of hypocapnia or hyperventilation has long been advocated to induce vasoconstriction in the nasal sinuses and minimize bleeding • Hypercapnia and oozing is well known • Controlled ventilation – must • PEEP increased incidence of bleeds

  25. What we use here – better field • Propofol • Dexmed , clonidine • Fentanyl + iso • Local vasoconstrictors • Head up • Preop beta blockers , captopril ??

  26. Emergence • Smooth • No cough • Neostigmine and spasms • So LMA is better !! • NO NSAIDs for pain relief • Remove pack

  27. ActaAnaesthesiologicaScandinavicaVolume 49, Issue 10, pages 1471–1476, November 2005 • Local anesthesia for functional endoscopic sinus surgery employing small volumes of epinephrine-containing solutions of lidocaine produces profound hypotension • Nasociliary nerve block + infra orbital nerve block --- OK

  28. The infraorbital nerve is located 1.5 cm lateral to the nasal bone and 1 cm below the orbital rim

  29. Infraorbital nerve block

  30. Maxillary nerve block

  31. Nasociliary nerve blockade Posteroinferior1.5 cm- 2.5 cm depth 1.5 ml

  32. Technique • To perform blockade of the nasociliary nerve, the medial canthus is identified and a line is drawn superiorly to a point just below the eyebrow. • The skin overlying this area is prepared with antiseptic solution, with care being taken to avoid spillage into the eye. • A 22-gauge, 1½-inch needle is inserted at this point, and, with close contact kept with the bony surface of the orbit, the needle is carefully advanced posteroinferiorly approximately 35 degrees off the perpendicular to a depth of approximately 1¼ inches.

  33. Srilankan journal of anaesthesiology

  34. Coroner's Clot • Any clot left behind can be inhaled after removal of a tracheal tube and lead to total airway obstruction and death—hence the term “coroner's clot.” • Be more careful in OSA patients • IV cannula – be there till pack removal (nasal) • Post op pain relief - RA, narcotics , para ( oral !!)

  35. Regional anaesthesia for FESS • Maxillary nerve block + nasociliary nerve block • Infraorbital nerve block + nasociliary nerve block

  36. summary • Definition • Indications • Preop • Anaesthetic technique • Deliberate hypo • Post op pain + PONV

  37. Thank you all

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