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Preoperative Considerations

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  • Seek history of obstructive sleep apnea (OSA), bleeding disorders, loose teeth, sickle cell
  • OSA and tonsillar hypertrophy = airway obstruction
  • Inspect oropharynx: percentage of area occupied by hypertrophied tonsils correlates with ease of mask ventilation
  • Check hematocrit, use of ASA or other anticoagulants
  • High incidence of PONV
  • Consider vigorous IV hydration to counteract dehydration due to poor oral intake

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Anesthetic Plan

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  • Aim: rapid emergence to alertness prior to leaving OR. Ability to clear secretions and protect airway is key
  • Avoid sedative premedication in patients with OSA or large tonsils
  • IV induction for adults. Mask induction with N2O, O2, and volatile agent for children
  • Consider oral RAE
  • PONV prophylaxis with ondansetron, dexamethasone
  • Decompress stomach with orogastric tube prior to emergence (swallowed blood is a potent emetic)

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Perioperative Pearls

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  • Up to 8% experience postoperative hemorrhage. Usually occurs within 24 hours of surgery, may occur 5–10 days postoperatively
  • Chronic hypoxemia, hypercarbia = increased airway resistance leads to cor pulmonale
  • Note EKG for findings of RVH, dysrhythmias; CXR with cardiomegaly
  • CXR or TTE may be indicated in patients with suspicion of cor pulmonale

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Preoperative Considerations

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  • Hemorrhage rate higher in adults, male gender, and presence of peritonsillar abscess
  • Check Hgb, Hct (might not drop if acute bleeding; estimate bleeding clinically based on hemodynamic response), and coagulation
  • Type and cross-match ready
  • Hypotension a late symptom

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Anesthetic Plan

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  • Oxygenate and resuscitate first
  • Dependable large-bore IV access
  • Anticipate difficult laryngoscopy: clots, bleeding, swelling, and edema
  • Use smaller ETT
  • Rapid sequence induction (RSI): preferred but patient may inhale blood, CV depression on top of hypovolemia
  • 2 wall suctions available
  • Head-down position for intubation
  • Decompress stomach with orogastric tube to clear blood after securing airway
  • Extubate when fully conscious and able to protect airway

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Perioperative Pearls

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  • Rebleeds usually occur within 6 hours of surgery
  • Bleeding may be occult
  • Problems usually due to aspiration, hypovolemia, difficult laryngoscopy

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  • Pediatric patients with recurrent otitis media frequently have URIs as well
  • Okay to do surgery on most patients with URI; just give postoperative O2
  • Short, same-day surgeries
  • Avoid premedication due to short duration of surgery
  • Consider mask ventilation with volatile anesthetic, N2O, and oxygen for surgery
  • The only case that can be performed without inserting an IV

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Preoperative Considerations

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  • High incidence of PONV
  • Mastoid surgery: facial nerve usually monitored

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Anesthetic Plan

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  • Mask for IV induction for children; IV induction for adults
  • Neck turned laterally. Be careful of positioning
  • Facial nerve monitoring = no NMB during case
  • Avoid N2O: middle ear is air-filled, nondistensible spaces
  • No NMB and no N2O means high-dose volatile agent or propofol infusion
  • Consider relative hypotension MAP 20% below ...

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