Anesthetic Considerations for Orthognathic Surgery: OTHER ASSESSMENTS

In: Anesthesia

24 Feb 2010

As for any other operation, significant past medical history, drug history, allergies, and past anesthetic history are recorded. Respiratory and cardiovascular systems and any other related systems are examined. Hb, blood picture, and biochemistry, ie, electrolytes and urea, assessments and an ECG, as a baseline, are carried out as routine investigations.

PREPARATION

Preparation includes the preparation of the patient, the technique, and the postoperative care. This includes explaining the procedure, getting the patient’s written consent, and improving any condition that requires improvement. Thus, an upper respiratory infection is treated prior to anesthesia. Blood is cross-matched if severe bleeding is expected during the operation. An anxiolytic such as oral midazolam or diazepam is prescribed as premedication. Apcalis Oral Jelly

Preparation of the technique includes preparation of the anesthetic, monitoring and resuscitation equipment, and the drugs required to induce and maintain anesthesia. One must be prepared for a difficult intubation, especially if the airway assessment has predicted so. If intubation is to be carried out in the induction room, a tilting trolley and high-volume suction are essential. Laryngoscopes that are available and familiar to the anesthetist are assembled. Various types of laryngoscopes, such as ones with a curved blade, a straight blade, a polio blade, a spatulate blade (bellhouse), and/or a shallow spatulate blade (bizzari-guffrida) and laryngoscopes with prisms or fiberoptics are available to assist in difficult intubation. –

A range of endotracheal tubes is essential. The endotracheal tubes preferred for orthognathic surgery are nonkinking types. Rush silicone flexometallic tubes with low-pressure, high-volume cuffs are ideal since they are long and can be bent at the tip of the nose, needing no additional curved connectors. Further, the high volume of the cuff spreads the pressure on the tracheal mucosa over a larger surface, and the cuff pressure can be monitored throughout the operation and maintained within safe limits, preventing damage to tracheal mucosa. Nasal RAE® tubes can also be used. However, they may be occluded during manipulations by the surgeons. Guides may be used to direct the endotracheal tube into the trachea. A malleable stillete is useful at the initial stage to insert the tube through the nasal passage. A light wand may be inserted into the trachea and the endotracheal tube guided through it. In any major center where maxillofacial surgery is being carried out, a range of fiberoptic bronchoscopes should be available to the anesthetist. The availability of this equipment has made the life of the anesthetist much easier since predicted difficult intubations are easily intubated with the fiberoptic bronchoscope. canadian antibiotics

Pharyngeal airways, both nasal and oral, are important since they help keep an airway open in a patient whose tongue falls back and obstructs the airway. A facial mask of the appropriate size for the patient is made ready. When preparing for difficult intubations, Brain laryngeal masks should not be forgotten. They make the difficult manual ventilation much easier on many occasions. Magill’s forceps may be necessary to place the endotracheal tube in the trachea during intubation with the laryngoscope and to insert a nasogastric tube and the throat pack. A cricothyrotomy set, a tracheotomy set, and a jet ventilator may become useful in difficult intubations, if these are available. If a very difficult intubation is to be expected, one must make sure that the surgeon is in the theater ready to perform an emergency tracheostomy if airway management becomes impossible with the above techniques. Emergency tracheostomy is very rare in elective orthognathic surgery due to the availability of numerous types of equipment used to mitigate difficult intubation.

Postoperative care could be planned preoperatively in elective orthognathic surgery. If the jaws are to be wired together, it may be planned to send the patient to a high-dependency ward or an intensive care unit for the postoperative management on the first day. In orthognathic surgery, patient-controlled analgesia appears to be extremely useful. Thus, if one decides to give patient-controlled analgesia for pain relief, this should be explained to the patient preoperatively and the patient should be taught how to obtain a dose of the drug.


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