Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content +++ Preoperative Considerations ++ Seek history of obstructive sleep apnea (OSA), bleeding disorders, loose teeth, sickle cellOSA and tonsillar hypertrophy = airway obstructionInspect oropharynx: percentage of area occupied by hypertrophied tonsils correlates with ease of mask ventilationCheck hematocrit, use of ASA or other anticoagulantsHigh incidence of PONVConsider vigorous IV hydration to counteract dehydration due to poor oral intake +++ Anesthetic Plan ++ Aim: rapid emergence to alertness prior to leaving OR. Ability to clear secretions and protect airway is keyAvoid sedative premedication in patients with OSA or large tonsilsIV induction for adults. Mask induction with N2O, O2, and volatile agent for childrenConsider oral RAEPONV prophylaxis with ondansetron, dexamethasoneDecompress stomach with orogastric tube prior to emergence (swallowed blood is a potent emetic) +++ Perioperative Pearls ++ Up to 8% experience postoperative hemorrhage. Usually occurs within 24 hours of surgery, may occur 5–10 days postoperativelyChronic hypoxemia, hypercarbia = increased airway resistance leads to cor pulmonaleNote EKG for findings of RVH, dysrhythmias; CXR with cardiomegalyCXR or TTE may be indicated in patients with suspicion of cor pulmonale +++ Preoperative Considerations ++ Hemorrhage rate higher in adults, male gender, and presence of peritonsillar abscessCheck Hgb, Hct (might not drop if acute bleeding; estimate bleeding clinically based on hemodynamic response), and coagulationType and cross-match readyHypotension a late symptom +++ Anesthetic Plan ++ Oxygenate and resuscitate firstDependable large-bore IV accessAnticipate difficult laryngoscopy: clots, bleeding, swelling, and edemaUse smaller ETTRapid sequence induction (RSI): preferred but patient may inhale blood, CV depression on top of hypovolemia2 wall suctions availableHead-down position for intubationDecompress stomach with orogastric tube to clear blood after securing airwayExtubate when fully conscious and able to protect airway +++ Perioperative Pearls ++ Rebleeds usually occur within 6 hours of surgeryBleeding may be occultProblems usually due to aspiration, hypovolemia, difficult laryngoscopy ++ Pediatric patients with recurrent otitis media frequently have URIs as wellOkay to do surgery on most patients with URI; just give postoperative O2Short, same-day surgeriesAvoid premedication due to short duration of surgeryConsider mask ventilation with volatile anesthetic, N2O, and oxygen for surgeryThe only case that can be performed without inserting an IV +++ Preoperative Considerations ++ High incidence of PONVMastoid surgery: facial nerve usually monitored +++ Anesthetic Plan ++ Mask for IV induction for children; IV induction for adultsNeck turned laterally. Be careful of positioningFacial nerve monitoring = no NMB during caseAvoid N2O: middle ear is air-filled, nondistensible spacesNo NMB and no N2O means high-dose volatile agent or ... GET ACCESS TO THIS RESOURCE Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. Access My Subscription GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessAnesthesiology 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessAnesthesiology Full Site: One-Year Individual Subscription $995 USD Buy Now View All Subscription Options