What the Anesthesiologist Should Know before the Operative Procedure

Critical issues include

– Is this a routine elective procedure or urgent due to an impending intracranial complication?
– What are the implications of urgency of procedure for NPO violations and URIs?
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– What is the advantage of premedication for induction versus delay of postoperative discharge?
– Will the provider be able to mask-ventilate in multiple positions as surgeon maneuvers the patient’s head?
– Will an IV line be necessary for induction, maintanence, or postoperative management, due to a comorbidity or length of procedure?
– How will postoperative pain and emergence agitation be managed in the PACU?

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Most often, BMT is a routine elective procedure for recurrent acute otitis media or hearing loss concerns. Less commonly, BMT may be an urgent or emergent procedure due to acute mastoiditis, labyrinthitis, facial paralysis, or intracranial suppurative complications such as meningitis.

Emergent/urgent:Concern for irreversible intracranial complications mandate provider to go ahead with procedure, with possible impact on airway management and medical management.

Elective:May warrant delay or cancellation for NPO violations, concerning URI, and optimization of medical or surgical disease.

2. Preoperative evaluation

Asthma, congenital heart disease, GERD, OSA, obesity, diabetes mellitus (DM) type 1, Down’s syndrome, mucopolysaccharidoses, MH susceptible

Medically unstable conditions warranting further evaluation include asthma, congenital heart disease, uncontrolled GERD, and DM 1.

Delaying surgery may be indicated if it is an elective procedure in a patient with uncontrolled asthma, acute URI, unrepaired CHD, or Down’s syndrome with uncleared cervical spine

For those patients in whom anxiolytic premedication with midazolam is warranted, one should not avoid administration due to concerns of delaying postoperative discharge.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

Congenital heart disease

Patient should have recent echocardiogram to ascertain optimization of medical treatment.

In disease processes with importance of optimizing preload, it is important to maximixe fluid intake with clears until 2 hours prior to procedure. However, it is still generally unnecessary to place IV line due to the shortness of the procedure.

Hypoplastic left ventricle patients should ideally be scheduled between their Glenn and Fontan procedures if possible.

c. Pulmonary

Reactive airway disease (Asthma)

Recent illness may exacerbate asthma symptoms up to 4-6 weeks after illness. However, with frequency of viral illnesses in this patient population, if (1) there is no fever, (2) there is no lower respiratory symptoms, and (3) child has a normal pattern of activity at home, proceeding with this short procedure may be reasonable. Active wheezing is certainly a reason for postponement of an elective procedure, and follow-up with a pulmonologist for optimization of medical disease (i.e., maintenance inhaled steroid) may be appropriate.

d. Renal-GI:

GERD

Inhalation induction with mask ventilation may still be reasonable depending on the extent of the GERD.

e. Neurologic:

Neurologically impaired patients with gastrostomy tubes should be vented prior to induction. Seizure patients with vagal nerve stimulators usually do not need the stimulators turned off prior to the procedure.

f. Endocrine:

Obesity:

May involve difficulty with mask ventilation. Careful vigilance for likely need for oral airway (or an LMA) is critical. If procedure is combined with tonsillectomy or adenoidectomy, it may be reasonable to intubate prior to myringotomy.

DM 1:

Patient should generally be the first case of the day, with maximization of clear fluids until 2 hours prior to surgery.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Mucopolysaccharidoses:

May involve issues with mask ventilation and airway management. These patients should not be cared for in a surgicenter if at all possible.

Malignant hyperthermia (MH):

Patients susceptible to MH should have IV started (possibly utilizing nitrous oxide to facilitate if needed) to proceed with TIVA and nontriggering anesthetic. These patients should not be cared for at a surgicenter if at all possible.

Down's syndrome:

The combination of extreme bradycardia upon sevoflorane inductions and prolonged length of procedure due to difficult ear canal anatomy, may warrant placing an IV for these patients.

Hematology:

Patients with bleeding disorders may warrant a choice other than Toradol for postoperative pain management.

4. What are the patient's medications and how should they be managed in the perioperative period?

Generally, all medications should be continued perioperatively. DM type 1 patients should confer with their endocrinologist for appropriate management on the evening prior to the procedure. Seizure medications, cardiac medications, and transplant medications should generally be continued.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

N/A

i. What should be recommended with regard to continuation of medications taken chronically?

All medications should be continued preoperatively.

j. How To modify care for patients with known allergies –

Pain medication should be altered based on preexisting allergies. Other drug allergies are not usually an issue with regard to this procedure.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

Patients do not routinely receive antibiotics for this procedure.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents:

Proposed general anesthetic plan: IV placement after inhaled nitrous oxide, followed by propofol infusion with IV Toradol/fentanyl/PR Tylenol for postoperative pain control
Ensure MH cart available: [MH protocol]

Family history or risk factors for MH:

IV placement after inhaled nitrous oxide, followed by propofol infusion with IV Toradol/fentanyl/PR Tylenol for postoperative pain control.

Local anesthetics/muscle relaxants

These drugs are not usually administered for this procedure.

5. What laboratory tests should be obtained and has everything been reviewed?

Lab work is not usually necessary for this procedure.

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Procedure is generally performed with inhaled sevoflurane induction via mask. Appropriate head positioning is critical to maintain an open airway. Oral and nasal airways should be available. IV placement is not generally necessary due to the short length of the procedure. If needed due to comorbidity, length of procedure, or management of postoperative agitation, this can usually be placed after induction. Pain management can be achieved via injection of IV/IM ketoralac, intranasal fentanyl, and/or PR Tylenol. Postoperative agitation can be managed with an injection of IV Precedex if additional adjunct is deemed necessary.

a. Regional anesthesia

There is no need for regional anesthesia with this procedure.

b. General Anesthesia

Benefits: Include a quiet surgical field minimizing the possibility of damage to the eardrum by the surgeon.

Drawbacks: Possibility of losing the airway upon inhalation induction in a patient with difficult mask ventilation.

Airway concerns: Importance of maintaining an appropriate mask seal with fluctuating head and hand positions to facilitate surgical placement of the myringotomy tubes cannot be overemphasized. It is extremely important to recognize airway obstruction quickly, especially in the infant age group, due to their lack of airway reserve and hence, the real possibility of severe desaturation upon obstruction.

c. Monitored Anesthesia Care

In older adolescents, this a possibility with topical anesthesia. However, if the patients have been scheduled by the surgeon to come to the operating room, this technique may not be successful .

6. What is the author's preferred method of anesthesia technique and why?

What prophylactic antibiotics should be administered?

There is generally no need for perioperative antibiotics for this procedure.

What can I do intraoperatively to assist the surgeon and optimize patient care?

It is important to communicate with surgeon regarding head positioning and sharing the airway; optimizing both the surgical view, as well as maintaining the patency of the airway.

What are the most common intraoperative complications and how can they be avoided/treated?

Foremost is airway obstruction, both during induction, requiring prompt response by the anesthesiologist, as well as during maintenance, especially with movement of the head position. It is important to communicate with the surgeon in the event of airway obstruction. Oral airways, nasal airways, and LMAs should be available in case of need. Apnea upon inhalation induction, especially in an infant, is always a possibility, with the possible need for manual ventilation. Bradycardia and even cardiac arrest are rare, but nevertheless a possible, complications of inhaled induction.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

N/A

c. Postoperative management

What analgesic modalities can I implement?

IV/IM Toradol, intranasal fentanyl, PR Tylenol, or oral Tylenol administered 45 minutes prior to surgery.

What level bed acuity is appropriate?

This is generally an outpatient procedure

What are common postoperative complications, and ways to prevent and treat them?

Emergence agitation is a distinct possibility in those procedures lasting more than a few minutes. Most often, this is effectively managed with IV or IM ketorolac, intranasal fentanyl, PR Tylenol, or a combination of these drugs. If there is a particular concern, one might consider placing an IV line or injecting IV Precedex prior to emergence. Intranasal Versed can be used if emergence delirium has already occurred in the PACU without an IV line. Intranasal dexmedetomidine has a prolonged onset and will probably not be beneficial.

What's the Evidence?

Galinkin, JL. “Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia”. Anesthesiology . vol. 93. 2000. pp. 1378-83. (This paper highlights the benefits of intranasal fentanyl.)

Davis, PJ. “Recovery characteristics of sevoflurane and halothane on preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion”. Anesth Analg . vol. 88. 1999. pp. 34-8. (This paper highlights the benefits of IV ketorolac.)

Pappas. “Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery”. Anesth Analg . vol. 96. 2003. pp. 1621-4. (This paper highlights the benefits of IM ketorolac.)

Haupert, MS. “Parental satisfaction with anesthesia without IV access for myringotomy”. Arch Otolaryn Head Neck Surg . vol. 130. 2004. pp. 1025-8. (This paper highlights the lack of a need for IV access.)

Borland, LM. “Frequency of anesthesia-related complications in children with Down's syndrome under general anesthesia for non-cardiac procedures”. Peds Anesth. vol. 14. 2004. pp. 33-38. (This paper highlights the possible complications associated with Down's syndrome.)

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