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Dr Poonam Bhadoria Professor Department of anaesthesia and intensive care Maulana Azad Medical College & Lok Nayak hospital New Delhi-110002. Anaesthetic management of a patient with carcinoma larynx for laryngectomy. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Identify

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anaesthetic management of a patient with carcinoma larynx for laryngectomy

Dr Poonam Bhadoria

Professor

Department of anaesthesia and intensive care

Maulana Azad Medical College &

Lok Nayak hospital

New Delhi-110002

Anaesthetic management of a patient with carcinoma larynx for laryngectomy

www.anaesthesia.co.inanaesthesia.co.in@gmail.com

slide2

Identify

  • Clinical presentation
  • investigation-IL
  • airway evaluation
  • essential monitoring
  • anaesthetic concerns
  • unexpected problems- after extubation in MLS

- during laryngectomy

spot

history
History
  • Age, Sex: 60 years male
  • Present history c/o

hoarseness, dyspnoea, stridor, cough, haemoptysis, dysphagia, referred pain to ear anorexia, mass in neck

  • Treatment history
    • Radiation - glottic oedema

trismus

fibrosis

stiff larynx + epiglottis

    • Chemotherapy
    • Surgery - scarring
slide4
Past history
    • Medical (COPD, CVS – aspirin)
    • Surgical (previous interventions)
  • Personal history – smoke, alcoholic
  • Dietary history
  • Occupational history; industrial and textile worker (air pollution and chronic inflammation of larynx)
examination
Examination
  • GPE
    • Built / nutritional status
    • Vitals
    • Oral cavity
    • Jugular venous pressure
  • Respiratory system –wheeze
  • Airway examination: distorted upper airway and obstructed, because of friable growth with or without tracheostomy.
investigations
Investigations
  • Routine
    • Haemogram , blood glucose, KFT, LFT, SE
    • Urine routine,
    • ECG
  • Specific: to assess extent, invasion, destruction
    • Chest X–ray PA
    • X–ray neck – AP / Lateral
    • Indirect laryngoscopy
    • PFT (COPD)
    • Laryngogram filling defect:
    • CT scan, barium swallow
    • MRI
slide7
Major← Plan →MLS or D/L

Short case long case

Short case

Long case

slide8
Preoperative preparation
  • Optimize lung functions:

antibiotics, bronchodilators, corticosteroids, chest physiotherapy including breathing exercises

  • Care of nutrition, hydration
  • Removal of bad teeth
  • Indirect laryngoscopy - review again
  • Treatment of associated medical disorders and age related problems
  • Counseling-post operative speaking
  • Care of tracheostomy
preoperative preparation
Preoperative preparation
  • Cessation of smoking

Time course beneficial effects

12-24 hours ↓CO and nicotine levels

48-72 hours ↓COHb levels normalizes and bronchociliary functions improve

1-2 weeks sputum production

4-6 weeks PFT improves

6-8 weeks immune function and drug metabolism normalize

8-12 weeks ↓overall PO morbidity

slide10
Preoperative preparation
  • Cessation of alcohol

effect on liver, gastric irritation, CVS, therefore pre-medication with antacids and metachlorpromide

Effects Acute Chronic

inhalational agents, ↓ need ↑MAC

barbi+benzo+opioids more sensitive cross-tolerance

suxamethonium - ↑effect

relaxants: rely on hepatic clearance

drug of choice: atracurium

slide11
Preoperative advice
  • NPO, continue bronchodilators + morning dose of drugs, arrange blood, consent
  • Pre-medication – Glycopyrrolate 0.2 – 0.3 mg i/m, nasal drops ± FOB, ± IL, sedatives ±
  • If with tracheostomy: steam, nebulisation, encourage cough, suction,
surgical plan
Surgical plan
  • Direct laryngoscopy and biopsy (day care)
  • Major surgery
    • Partial / total laryngectomy
    • Laryngo-pharyngectomy
    • RND
    • Flap surgery
  • Besides normal routine check for Int.
    • Stylet , MLS tube
    • Tracheostomy set
    • Local: 2%, 4%, 10% for awake intubation
    • Availability of defibrillator
    • Other type and size of laryngoscope
    • check the equipment like FOB
    • Ready ENT surgeon
major surgery
Major surgery
  • Preoperatively arrange
    • Blood, Ryle’s tube CVP line, Foley’s catheter
  • If already tracheostomised
    • Care of tracheostomy tube
    • Montendo tube / Montgomery T – tube
  • I/V access
  • Premedication ±
  • Preoxygenation
  • Induction
    • Propofol / Thiopentone
    • Suxamethonium after mask ventilation
  • Maintenance on O2, N2O , Halothane or Isoflurane
monitoring
Monitoring
  • Routine
    • HR, ECG
    • SpO2, EtCO2
    • NIBP
    • Temperature (rectal + axillary probes)
  • In addition
    • CVP (towards higher side)
    • Urine output
    • Blood loss
    • Arterial line for serial estimation of blood gas and hematocrit
    • Airway pressures
  • Positioning – head up tilt (15 to 20 degree)
intra operative problems
Intra-operative problems
  • Bleeding (hematocrit 0.25 to .0.27)
    • ↓by positioning of patient (pillow under knees, reversed Trendelenburgh position), 2 mmHg fall in BP for each 2-5 cm rise in head position above the heart level.
    • Induced hypotension – inhalational, i/v (NTG, SNP etc).
    • Early, accurate assessment of blood loss: Timely replacement with blood / colloid.
  • Compromised cerebral circulation
    • carotid artery infiltration →↓cerebral arterial pressure
    • jugular vein infiltration →↑cerebral venous pressure
    • rotation of neck →↓carotid blood flow

Contd

slide16
Induced hypotension

Inhalational

Isoflurane

dose dependent hyotensive effect by vasodilatation

up to 40mmHg in 6 minutes, little change in CO

Halothane/enflurane

↓ BP, CO, Stroke volume →↑right heart filling pressure

IV agents

fentanyl 1-3mcg/kg

propofol 100mcg/kg/minute

NTG 0.5-3mcg/kg (BP 80-90mmHg)

SNP 3mcg/kg/minute, ↓es dias. by 30 to 40%

Contd

slide17
During opening of neck veins
  • Rapid fall in EtCO2, BP → Air embolism
  • ECG: inverted T, tall P, RBBB, RHS→VF
  • Treatment
    • Stoppage of surgery
    • Flood with saline/fluid
    • 100 % O2 , stop N2O- why?
    • Durhant’s position
    • Aspiration of air through CVP catheter
    • PPV

Contd

slide18
Carotid sinus stimulation → cardiac dysrhythmias, bradycardia, Hypotension
    • Denervation of carotid sinus body→ hypertension and loss of hypoxic derive.
    • Ablation of rt sympathetic ganglion-↑QT interval and malignant arrhythmias → cardiac arrest

Treatment – LA infiltration of carotid bulb / vagolytic agents

cessation of pressure

  • Hypotension
  • Hypothermia Contd
slide19
Intra-operative maintain adequate analgesia
  • When trachea is transected, tube is replaced by non kinkable tube (confirmed by capnography and auscultation)
  • ↑ airway pressure: malpositon of tube, bronchspasm, debris
  • Loss of airway at induction, midway, extubation, postoperative
slide20
In microvascular flap reconstruction
  • avoid vasoconstrictor
  • Avoid induced hypotension techniques
  • Maintain hematocrit 0.30
  • No diuresis
  • Avoid hypothermia
    • forced air warming blankets
    • IV warm fluids
    • Inspired anaesthetic gasses warm and humidified
slide21
Postoperative problems
    • Prolonged recovery – ICU care preferably
    • Ventilation care - pneumothorax, subcutaneous emphysema
    • Speaking
  • Postoperative care
    • Monitoring of vital signs
    • Care of tracheostomy
    • Chest physiotherapy, suctioning ,
    • head up 30° to help venous drainage
    • Chest X – ray, within 6 hours
    • No tight bandage– airway impingement
    • Bronchodilation, nebulisation
    • Oxygen and analgesia
rehabilitation
Rehabilitation

Vocal

  • Oesophageal speech
  • Artificial larynx (electro-larynx and trans-oral pneumatic device)
  • Tracheo–oesophageal speech (Blom-singer and Panje prosthesis)

Other rehabilitation procedure

  • Social
  • Psychological
  • Vocational
patient s limitations
Patient’s limitations
  • Swimming
  • Cannot call aloud
  • Climbing up the stairs,
  • Strenuous work
  • High altitude
slide25
D/L BIOPSY or MLS

Day care surgery

Goals COMPLAINTS

Clear view Hoarseness,

Immobile field stridor

Sufficient space to work haemoptysis

CVS stability

Etiology

  • Benign growth
  • Vocal cord dysfunction
  • Foreign body aspiration
  • Obstructed tumour
  • Papillomatosis
slide26
How to proceed ?
  • Airway concerns
  • Anaesthetic concern
slide27
Airway concerns

Mask ventilation?

Intubation with laryngoscopy ?

Any doubt - secure airway before induction by FOB or by tracheostomy ↓ LA

-airway evaluation for type of lesion

(95% ant. & 5% post.)

-i/l & d/l (laryngeal inlet), CT, MRI

-discuss with surgeon for size of tumor

slide28
LA
    • Topical, oral lignocaine lozenges
    • Oral 4 % lignocaine gargles, spray
    • Nerve block (SLN and glossopharyngeal)
    • Nebulization with 4% xylocaine
nebulisation
Nebulisation
  • 4-6 ml 4 % lignocaine
  • Particle size >100 microns-oral

60-100 microns-trachea

30-60 microns-larger bronchi

10-30 microns-small bronchi

<5 microns-alveoli

  • >50 % loss during spont resp
slide31
Anaesthetic concerns (MLS)

What are they ?

  • Rapid awakening & return of protective airway reflexes
  • Minimize secretions and reflexes
  • Protection to trachea
  • Ensure good ventilation & oxygenation

-Review on table

-Pre-oxygenation

-Glycopyrrolate 0.2-0.3mg IM

-no premed. If any s/o UAO

slide32
Intubation depending on spread of growth
  • Small – routine paralysis, tracheal intubation
  • Mod. Large – awake intubation / tracheostomy ↓ LA as airway obstruction may worsen after anaesthesia. -If ventilation- yes – intubation ↓ VA and S/R -If ventilation- no - intubation awake + block + IV sedation

-limited pre-medication

  • Large, impinging on upper airway – stridor at rest preoperative tracheostomy, no pre-medication
  • No BNI if friable lesion
slide33
Methods for ventilation

(Manual and automated)

  • Ventilation with ETT
  • Venturi jet ventilation (supraglotic)
  • Intermittent apnea technique
  • HFPPV
ventilation oxygenation
Ventilation & oxygenation

A). ETT – 5mm ID, long with standard cuff (Micro laryngeal tube) low pressure high volume tube

  • Control ventilation-:

advantages

- prevent aspiration

- maintain inhalation anaesthesia

- monitor ETCo2

disadvantages

- limited access to surgeons

- possible distortion of tissue during intubation

slide35
Alternatives techniques (post. commi. lesion)

(balanced technique-injector below vocal folds/lx)

B). Jet ventilation

  • ETT not required
  • Unobstructed view (profound messeter relax)
  • Alignment of laryngoscope & tracheal axis. (pneumatic knife)
  • Full relaxation of V.C.
  • Free egress of gas
  • Monitor chest wall motion

contd

slide36
Ventilatory rate – 6-7 bpm at 30-50 PSI I/E 1.5:6 sec (Saunder’s jet injector)
  • Cuffed Carden tube.
  • Contraindicated in children, obese & bullous emphysema.
  • Risks -barotrauma, stomach dilatation, forcing of blood & tumour in lungs, pneumothorax, hypotension.

C). Intermittent intubation and apneic period.

D). HFPPV, less risk of barotrauma. (80-300/min)

- 2-3 ml/kg  T.V

slide38
Reflex responses: -HT, tachycardia, arrhythmia

-Use : topical lignocaine,

or I/V (1-1.5mg/kg)

-I/V fentanyl, esmolol (200- 400mcg/minute)

Anaesthesia :-Propofol (2mg/kg), fentanyl (1-2mcg/kg)

-topical anaesthesia of larynx

-appropriate muscle relaxation

-suxamethonium, intermediate acting

-Ensure adequate depth

-remifentanyl -potent rapid recovery profile

-thorough suction before extubation

Remember if difficult intu then difficult extubation

slide39
Monitoring: ECG-essential as sym stimulation ++,

BP, Oximetry, ETCo2

  • Post op risk: -MI or Ischemia 1.5-4%

-laryngospasm,

-laryngeal edema

-strider

-restlessness (hypoxia, pain)

  • barotrauma and pneumothorax
  • Aspiration / seeding of polyp into trachea

Laryngospasm

laryngospasm
Laryngospasm
  • Reflex closure of upper airway from spasm of glottic

musculature

  • Mechanism
    • False cords and epiglottic body come together
    • Extrinsic muscles of larynx create ball valve mechanism
    • Reflex apnea d/t stimulation of SLN
  • Etiology
    • Stimulation by blood, vomitus , secretions
    • Light planes of anaesthesia
    • Chemical irritation of laryngeal , pharyngeal mucosa
    • Can persist even after irritation ceases
    • Visceral pain reflex
    • Negative pressure pulmonary edema (as a result)
slide41
Treatment
    • Removal of stimulus
    • 100 % oxygen
    • Lifting the mandible up and maintain sniffing position
    • Sustained positive pressure → bulge in pyriform fossa
    • Low dose Suxa (10 – 20 mg i/v)
    • If fails , 100 mg Suxa and intubate
    • i/v lidocane
    • Propofol and ketamine → inhibit the N-methyl-D aspartate receptor
our role
Our role

“Pro active approach to prevent or terminate the laryngospasm and thus preventing hypoxemia is the mark of a seasoned anaesthesiologist ”

stridor
Stridor

Immediate attention, establish cause, intubation ±, assess severity situation and clinical details

Treatment

  • Heliox helium 70% + 30% O2
  • Full monitoring + head end of bed up by 45 to 90 degree
  • Nebulize epinephrine
  • Dexamethasone 4-8mg/8-12 hourly if oedema is the casue
laser surgery
Laser surgery
  • Light amplification by stimulated emission of radiation: useful tool in modern surgery
  • CO2 laser :-
    • Invisible infra red light
    • Absorbed by tissue water
    • is used for treatment of early carcinoma of larynx
    • Beam focused to small spot-precise controlled coagulation.
    • Incision or vaporization of tissue, suitable for vocal cord & laryngeal surgery (10 W power with 0.1 sec pulses & a small spot)
slide45
LASER
  • Advantages Disadvantages

No bleeding Lack of pathology specimen

No oedema, scarring Damage to surrounding tissue

Rapid healing Risk to eyes

ETT damage and Intratracheal fire

Hazards

    • To staff, patient and theatre
    • Eyes are vulnerable
    • Fire & explosion (thermal effect)
    • Noxious fumes
    • Ignition of inflammable materials
slide46
Safety considerations
  • OT warning signs for laser use.
  • Restrict entry into OT
  • Wear protective eye glasses (wave length specific).
  • Avoid flammable materials (drapes, plastic tubes etc.).
  • Patient's eyes – taped closed & cover with wet pads
  • Wet towels to drape.
  • Competent personnel for equipment use
  • Avoid misdirection of beam
  • Avoid ETT in short procedures use venturi
  • Ready bucket of clean water for dipping the tube
  • Smoke evacuators at surgical site
slide47
Metal endotracheal tube
  • Norton’s stainless steel spiral coil without cuff

(Walls not air tight)

  • Laser flextube air tight stainless steel spiral with two distal cuffs
  • Bivona foam cuff aluminum spiral tube with outer silicone Coat and self inflating foam sponge filled cuff
slide48
Airway fire (0.1%) protocol
  • Fatal due to

Thermal injury, Chemical burn – brochospam & edema, melting & burning ETT lead to obstruction

  • Management

-use of special tubes

-stop O2, remove ETT, flood with saline

-bag & mask/venturi ventilation

-if difficult airway, remove ETT on guide wire

-check bronchoscopy

-post operative: sitting position, X-ray chest , antibiotics, humidified O2, steroids

slide50
GOOD LUCK

www.anaesthesia.co.inanaesthesia.co.in@gmail.com