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Oralandmaxillofacial

surgeryanesthesia

Oralandmaxillofacial

sur1一、Characteristicsofthepatientsandtheoperation.Anesthesiamanagement.(一)Anatomyandphysiolosy(1)CongenitallipandpalatecleftInfants—anestheticendurance—compensationfunction—respirationsystemisspecialCoexistentdiseases—VSDASDetcOral-noseconnected—difficultyingettingfoodrespirationsysteminfection.

一、Characteristicsofthepatie2(2)BilateraltemporomandibularjointsrigidityDifficultyinopeningthemouth—Chronichypoxaemia—Poororalsanitation—Malnutrition—fluidandelectrolytesunbalance

(2)Bilateraltemporomandibular3(3)OraltumorDifficultyinopeningthemouth,pharyngealobstruction—TrachealintubationisdifficultOldagepatients—coexistentdiseases(hypertension,chronicbronchialinflammation.coronaryheartdisease,diabetic

(3)Oraltumor4(4)TraumaIfthesoftpalate、peripharynx、baseofthetongueareinvolved,tissueswelling,pharyngealcavityisnarrowed.Fracturedislocationstifle(suffocate)Bleeding,secretionsaspiration.(5)Mandible-thorax,mandible-neckadherence,scarformationandcontractionsaroundthemouth.—Head-neckisfixed,headisextremelybent—Tracheaisshiftedtooneside—Trachealintubationandtracheostomyaredifficult(4)Trauma5(6)CongenitalmaxillofacialdeformityPierre-Robinsyndrome,Treacher-Collinssyndrome—TrachealIntubationisdifficultAnesthesiaenduranceisdecreased.

(6)Congenitalmaxillofacialde6（二）Characteristicsofthesurgery(1)Premedication（Atropine.Sod-luminalMorphine.Midazolumetc.）Theobjectivesofpremedicationareto：—Allayanxietyandfear—Reducesecretions—Enhancethehypnoticeffectofgeneralanestheticagents—Reducepostoperativenauseaandvomiting—ReducethevolumeandincreasethePHofgastriccontents—Attenuatevagalreflexes—AttenuatesympathoadrenalresponsesIfthepreoperationairwayobstrutionisexisted,don’tuseanypremedicationsthatwillsuppresstherespiration(e.gmorphine)

（二）Characteristicsofthesurg7(2)Anestheticinductionandtrachealintubationmaybedifficult.—temporomandibularjointsrigidity—Hugetumor—Severetrauma(3)Sharedairway—Observationandmanagementarelimited.—Blood、secretionsanddebrismaycontaminatethelartynx.—Gagandoperationapparatusmaycompressthetrachealtube,causepartialairwayobstruction

(2)Anestheticinductionandtr8(4)Heamorrhage—Thesurgeoncann’toperateclearly—Largequantitybloodlossesmayresultinshock.(5)Prolongedplasticoperation—moreanestheticcomplications.(6)Resuscitation—Wehopethepostoperativerecoveryisquickandsmooth.(7)Differentageranges—Forinfantsandoldagepatients,theanesthesiamanagementisdifficult.

(4)Heamorrhage9(三)Howtodealwiththementionedproblems(1)Forthepatientswithairwayobstruction,donn’tuserespirationsuppressivedrugsaspremedications.(2)Toensuretheairway,weshouldadministertrachealintubationortracheostomy.

(三)Howtodealwiththementio10(3)Tofixthetrachealtubeandconnectingtubeinposition;protecttheanaesthetictubingfromdislodgement.(4)Chooseanappropriateintubationroute—nasalintubution—Oralintubution

(3)Tofixthetrachealtubean11(5)HypotensiontechniqueUsethistechniqueinimportantprocedure.Thehypotensivedurationshouldbeshort.SBP>90mmHg,MBP>60mmHg.(6)Tofulfilrespirationself-regulation,thepostoperativeresuscitationshouldbequick.(7)Preventpostoperativenauseaandvomiting—relatedtopharyngealstimulation,postoperativepain,anestheticdrugsetc.

(5)Hypotensiontechnique12二、TheanestheticchoicesandcommonanestheticmethodsAccordingtothepatient’scondition,surgery’srequirements,surgeon’sexperienceandtheanesthetist’spreference,theanestheticmethodisdifferent

二、Theanestheticchoicesandc13(一)Localanesthesia—Administrationissimple,disturbancetothebodyenviromentissmall,postoperativerecoveryisquick.—Forinfantsandmentalorphysicaldisability,localanesthesiacombinedwithbaseanesthesiaisnecessary.—Duringtheoperation,ifthelocalanesthesianeedtobechangedtogeneralanesthesia,trachealintubationisnecessary.

(一)Localanesthesia14（二）BaseanesthesiaKetamine,pethidine-droperidol,midazolum.KTM:5-10mg/kgim,3min-5mingotosleep,maintaintime25min-36min,Midazolum0.1-0.2mg/kgivorim.

（二）Baseanesthesia15（三）Generalanesthesia（1）Inductionandintubation—Rapidinduction—Slowinduction:lightanesthesia+localanestheticspray—Laryngoscopicintubation,awakeintubcotion,awakefibreopticintubation.,Tracheostomy.

（三）Generalanesthesia16(2)Anestheticmaintenance—Inhalation(enflurane,isoflurane,sevoflurane,desoflurane,N2O)—Combinedintravenous(valume,midazolum,fentanyl,norcuron,etc)—Intravenous-inhalationcombinedGeneralenesthesiacombinedwithlocalanesthesiaisimportant.

(3)Postoperativeresuscitation

(2)Anestheticmaintenance17三、Managementduringandafteranesthesia(一)Duringanesthesia(1)Ensuretheairway—Causesofairwayobstructionsare:Tonguefallingdown,laryngospasm,bronchiospasm,secretions、blood、debrisdrainintolarynx,trachealtubekinking(2)MaintainstatisfiedventilationInadequateventilationmayresultinhypoxaemia,hypercapnia.

三、Managementduringandafter18HypoxicinspiredgasmixtureEquipmentOxygensupply(cylinder/pipelinefailure,misconnection)Flowmeters(inaccuratesettings,leak)Breathingsystem(obstruction,leak)HypoventilationEquipmentVentilatorfailureBreathingsysten(obstruction,leak,disconnection)Trachealtube(obstruction,oesophagealintubation)PatientRespiratorydepressioninspontaneouslybreathingpatientsObstructionV/QmismatchPatientInadequateventilationEndobronchialintubationSecretionsPneumothoraxBronchospasmPulmonaryaspirationPulmonaryedemaInadequateperfusionEmbolus(gas,thrombus)LowcardiacoutputOtherMethaemoglobinaemia,MalignanthyperthermiaCausesofhypoxaemiaduringanesthesia

HypoxicinspiredgasmixtureOx19Intraoperativehypercapniaiscausedbyinadequatecarbondioxideremovalorexcessivecarbondioxideproduction,Inadequabecarbondioxideremovalismostcommonlycausedbyhypoventilation.

Intraoperativehypercapniais20Thecriteriaofsatisfiedventilation:Spo298-100%PEtCO230-45mmHgBlood-gasanalysis.TV8-10ml/kg(Neonate6-7ml/kg)Rf12/min(NeonateRf)

Thecriteriaofsatisfiedvent21(3)Circulationmanagement—InsertionofanI.Vcannula—FluidtherapyNormalmaintenancerequirementsRestoreTBWafteraperiodoffastingReplacesmallbloodlosses,lossofECFintothe“thirdspace”andlossesofwaterfromtheskin,gutandlungs.Bloodlossesinexcessof15%ofbloodvolumeintheadultarereplacedusuallybyinfusionofstoredblood.Smallerbloodlossesmaybereplacedbyacrystalloidelectrolytesolutionandacolloidsolution.—MaintainsteadyBP.HR

(3)Circulationmanagement22(二)Managementafteranesthesia(1)Airwaymanagement—Extubationconditions:①Completelyawake.②normalventilation,③SPO2>96%(airinha