Anesthesia Student Survival Guide.pdf - Index of

296 ● AnesthesiA student survivAl Guide
Surgeons may desire to monitor the brachial plexus during fine dissection, yet
gross dissection around large neck muscles often benefits from muscle relaxation.
Therefore, coordination with regard to dosage and timing of neuromuscular
blockade should occur. Frequent manipulation of the head during the
procedure often leads to sudden circuit disconnect or tube malposition (mainstem
intubation with head flexion or cuff herniation with head extension).
These possibilities should be considered immediately if ventilator fault alarms
sound or hypoxemia develops.
Endoscopic Sinus Surgery
This is a common procedure performed for chronic sinusitis, severe epistaxis,
tumor resections of the anterior skull base, pituitary, and sinus cavities, and
repair of CSF leaks. Most patients who present for these procedures have limited
co-morbidities. One should be aware, however, of the physiologic consequence
of pituitary tumors and their removal (acromegaly, diabetes insipidus,
thyroid dysregulation). The anesthetic approach typically involves general
endotracheal anesthesia with non-invasive monitoring and single intravenous
access. Postoperative pain is usually limited and blood loss typically modest. In
complex cases of tumor resection or epistaxis treatment, large-bore IV access
and blood products should be available. A lumbar drain, to facilitate CSF drainage
and fluorescein dye injection, may be requested. Thorough suctioning of
the oropharynx prior to extubation is critical as large volumes of secretions
may accumulate. Some elect to pass an orogastric tube to evacuate blood and
secretions prior to extubation.
Inner Ear Surgery
Chronic mastoiditis, sensorinueral hearing loss, and otosclerosis are all common
indications for inner-ear surgery. Procedures include tympanoplasty, mastoidectomy,
stapedectomy, and cochlear implant. The procedures are routinely
performed under general anesthesia with LMA or endotracheal tube, although
stapedectomy can be safely performed with sedation in selected patients. There
is rarely significant blood loss and postoperative pain is usually not significant.
Intraoperative monitoring of the facial nerve is standard and requires avoidance
of muscle relaxation during the intraoperative period. A major problem
is postoperative nausea and vomiting which requires aggressive multi-modal
prophylaxis: a serotonin 5HT-3 antagonist, dexamethasone, scopolamine patch,
and promethazine are commonly employed.