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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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• FESS is a nasal endoscopic technique that
allows visualization of the paranasal sinuses
and nasal cavity without a skin incision
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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
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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.
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Complications- nose, orbit and brain
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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.
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Preoperative look out
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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.
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Preoperative preparation
• NSAIDs ?? • Bronchial asthma but beta blockers Local adrenaline • Long term steroids
• Planning deliberate hypotension • Ask h/o CVS CNS diseases
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• Helpful preoperative studies include
prothrombin time, activated thromboplastin
time, platelet count, and complete blood
count.
• ECG, ECHO, Xray, PFT
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• 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
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• 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 ??
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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
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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
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Intraoperative
• Dexa and propofol • Steroids – wheezing and PONV • Propofol - hypotension and PONV
• Glyco, fentanyl, isoflurane, vec –
• No halo , no atracs
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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.
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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 systolic blood pressure to 80-
90mmHg• Reduction of mean arterial pressure (MAP) to 50-65
mmHg• 30% reduction of baseline MAP
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Routine drugs
• Remifentanil- 1 µg.kg-1.min-1 and
0.05-2 µg.kg-1.min-1 infusionOne and one is OK
• Propofol 2.5 mg.kg-1 & 200 µg.kg-1.min-1
• Sevoflurane 2-2.5 %• Clonidine IV sos
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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
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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.
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• Reduce BP • better fields
• Reduce complications
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Other techniques
• Vasoactive medications are injected and infiltrated into the nasal sinuses to decrease mucosal congestion, reduce blood loss, and help achieve hemostasis
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Maintenance of Anesthesia
• Remifentanyl propofol 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.
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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
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What we use here – better field
• Propofol • Dexmed , clonidine • Fentanyl + iso • Local vasoconstrictors • Head up
• Preop beta blockers , captopril ??
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Emergence
• Smooth • No cough• Neostigmine and spasms • So LMA is better !!
• NO NSAIDs for pain relief• Remove pack
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Acta Anaesthesiologica ScandinavicaVolume 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
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The infraorbital nerve is located 1.5 cm lateral to the nasal bone and 1 cm below the orbital rim
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Infraorbital nerve block
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Maxillary nerve block
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Nasociliary nerve blockade
Posteroinferior 1.5 cm- 2.5 cm depth 1.5 ml
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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.
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Srilankan journal of anaesthesiology
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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 !!)
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Regional anaesthesia for FESS
• Maxillary nerve block + nasociliary nerve block
• Infraorbital nerve block + nasociliary nerve block
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summary
• Definition • Indications • Preop • Anaesthetic technique • Deliberate hypo • Post op pain + PONV
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Thank you all