Special Considerations in Anesthesia for Laryngeal Cancer Surgery .. Supraglottic laryngectomy offers the advantage of cure with preservation of speech for. Therefore tracheotomy was standard part of laryngectomy (usually under local anesthesia) to establish airway with general anesthesia. The anaesthetic considerations for head and neck cancer surgery are . this is physically impossible (e.g. the post-laryngectomy patient) or because oral.
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This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The anaesthetic considerations for head and neck cancer surgery are especially challenging given the high burden of concurrent comorbidity in this patient group and the need to share the airway with the surgical team.
This paper provides recommendations on the anaesthetic considerations during surgery for head and neck cancer. Removal for tracheal tubes is the responsibility of the anaesthetist. This will vary with the surgery and the anaesthetist’s requirement to avoid airway compromise by way of gas exchange or soiling.
A guaranteed airway from pre-operative ward care through to safe discharge must be considered as an essential duty of care for any institution undertaking surgery of this nature. Comorbidity and pre-operative assessment are considered elsewhere in the guidelines. One must be aware that this group of patients are prone to sepsis and multi-organ failure needing intensive care support.
Such issues should be anticipated and discussed with the patient and relatives as part of the consent for surgery. Similarly, because many of the patients are elderly and with limited support at home, the implications of post-operative result and how the patient will be able to cope should be part of the decision to offer surgical treatment.
All theatre staff are recommended to participate lartngectomy this initiative to ensure that teams work effectively and that the right patients get the right surgical procedure they have consented to.
Anaesthesia for total laryngectomy.
In addition, reference should be made to anticipated airway problems and ensuring the necessary equipment is available. The basic requirements for monitoring maintenance of anaesthesia and recovery are outlined in the Association of Anaesthetists of Great Britain and Ireland recommendations 4th edition, and advanced monitoring is usually only considered for long procedures or when excessive blood loss is a reasonable possibility. While patients presenting for head and neck surgery may have co-existent problems that could make airway management difficult e.
Patients with pharyngolaryngeal tumours frequently have residual food debris at laryngoscopy which may interfere with the view obtained especially for instruments with a limited field of vision.
Anaesthesia for head and neck surgery: United Kingdom National Multidisciplinary Guidelines
Contractures resulting from the previous treatment are common in patients with head and neck cancer. They may have obvious external deformities and restricted movements e. Rigidity and distortion of the oropharyngeal tissues can interfere with facemask anaesthesla and conventional laryngoscopy. Maintenance of oxygenation is fundamental to airway management and techniques that extend the apnoeic window allow more controlled, less hurried and more careful, gentle instrumentation. Trans-nasal high-flow rapid insufflation ventilatory exchange or THRIVE delivered through a nasal high-flow oxygen delivery system has recently been shown to increase the apnoea time in head and neck patients including those with stridor to an average of 17 minutes.
Trans-nasal high-flow rapid insufflation ventilatory exchange combines apnoeic oxygenation, continuous positive airway pressure and flow-dependent deadspace flushing and has the potential to change the nature of difficult intubations from a hurried stop—start process to a more controlled event, with an extended apnoeic window and reduced iatrogenic trauma. If a patient is already at risk of airway obstruction due to tumour bulk, then it is probable that they will be at greater risk following induction of anaesthesia, whether intravenous or inhalational.
Even local anaesthesia is not anaesthesla risk because severe airway obstruction precipitated by laryngospasm has occurred. In some institutions, ventilation is established prior to induction of general anaesthesia via temporary crico-thyroid or lagyngectomy access. The latter is obviously preferable in patients with subglottic extension of a laryngeal tumour.
The use of muscle relaxant drugs to facilitate laryngoscopy in these cases is controversial because even if intubation conditions are improved this may be at the cost of greater risk of airway obstruction.
Current practice has also been influenced by the introduction of many new intubation devices, very few of which have been reported in large series of head and neck cancer patients. Many resections and free tissue transfers will not be associated with significant bleeding, though this is not necessarily true for tongue and mandibular resections where brisk bleeding may occur.
Hypotensive conditions may minimise blood loss and haemodilution is practiced in some institutions with a view to improved blood flow in free flaps. Intra-operative haemoglobin fkr central venous pressure measurements help in monitoring the need for blood transfusion. Cardiac monitoring was used regularly in only 9 per cent of UK units in an audit in For lengthy operative procedures increased attention needs to be paid to the inevitable consequences of prolonged immobility, impaired homeostasis associated with general anaesthesia and the saturation of fatty tissue with anaesthetic agents.
These equate to the need to protect from gravity-related pressure effects, thermal homeostasis, retention of urine and prolonged wake up time. Currently there is widely diverse practice in terms of post-operative airway management of head and neck cancer patients. For example, at one end of the spectrum almost all free-flap reconstructions are managed with temporary tracheostomy whereas elsewhere, overnight ventilation followed by extubation the following morning is laryngecttomy expected norm.
There are differences as to which patients warrant this level of airway protection and even as to suitability for delivery of such care by immediate return to the ward vs high dependency or intensive care. Laryngecctomy need for advanced airway protection is to avoid airway obstruction due to haemorrhage or other surgical complication affecting the airway. Tracheostomy is an intervention with its own risks including inadvertent decannulation and is also associated with increased hospital stay.
Overnight intubation may carry increased risk for patients with significant comorbidity. The relative decrease in senior and junior intensive care unit staff with no airway training may also condition local perceptions of relative risk. In the patient who presents with acute airway compromise the obvious option is to consider a tracheostomy under local anaesthesia. Even this may not be an easy option in the patient who is already desaturated, uncooperative and unable to lie flat.
Because of the need to attend to the problem, there fir be limited time for radiological imaging. Heliox mixtures may provide symptomatic relief, while further information is obtained, e. Many of these cases will prove to have a laryngeal tumour, in which case surgeons generally prefer that tracheostomy is avoided. It may be possible to de-bulk the tumour once intubation is lqryngectomy, but experienced practitioners need to be involved if this is to be attempted. Whether or not the patient presents as an emergency, there are two objectives.
Firstly a biopsy will be taken for tissue diagnosis and secondly the tumour bulk will be reduced so as to minimise any likelihood of obstruction. Immediately after the procedure, the anaesthetist needs to confirm that the airway will be unobstructed e.
This is the more usual situation where the risk of airway obstruction is considered less likely. The anaesthetist will usually have information about the lesion e.
Ideally, any surgeon would wish to have an unrestricted view of the lesion to be operated on. In the case of laryngeal tumours, the most common compromise is to use a small diameter micro-laryngoscopy tube 6.
Other gor which allow a much less restricted field are: These alternatives tend to become more of a problem if the operative procedure is prolonged. The risk of airway fires due to laser is low provided careful precautions including laser safe tubes are used. Post-operative haemorrhage and oedema risks mean that tracheostomy remains an important consideration in extensive resections.
Attempts have been made to increase the success of free-flap anastomoses by medical means but there is no general consensus as to what if anything is efficacious. Doppler probes are available to monitor anastomotic vessel patency but are expensive and tend to be restricted in use to inaccessible sites, composite flaps where skin colour may not reflect the deeper layer viabilitycontinued arterial spasm risk and patients who have had previous radiation.
Early return to theatre, however, in the event of compromise, may allow the flap to be snaesthesia if the blood flow can be restored. Neck haematoma, flap failures, fistulas and airway management issues lafyngectomy. When patients are admitted to a post-anaesthesia care unit with tracheal tubes in place, continuous capnography monitoring is appropriate and their removal remains the anaesthetist’s responsibility.
Severe bleeding is possible if major neck vessels are eroded. This sort of haemorrhage can arise suddenly and with little warning. Everyone involved needs to be acutely aware of what is needed by way of immediate measures e. Proximity to the emergency theatres and kit available on the ward should be important considerations. Analgesic requirements tend to be less than for body cavity surgery, but this will not necessarily be the case in patients on moderate doses of opiates for pre-operative pain problems.
Flap donor sites may have their own analgesic requirements. The need for a covering tracheostomy may have been underestimated.
Airway oedema can develop rapidly and is often precipitated by venous obstruction, posture change e. Neck haematomas can be particularly deceptive because any associated airway oedema bears little resemblance to the apparent severity of neck swelling.
If there is time it may be helpful to perform nasendoscopy larymgectomy to deciding how to anaesthetise for corrective surgical measures. Many head and neck surgery patients will be looked snaesthesia in enhanced care by virtue of their comorbidity, the length of surgical laryngectlmy or the need to closely monitor the free flap.
It is unusual for any patient to be ventilated post-operatively. Ffor handover forms are commonly used to summarise surgery and anaesthesia intra-operative events with a description of the resulting airway anatomical configuration and advisory options in the event of potential airway problems.
Larynngectomy Intensive Care Society has produced guidelines for the management of tracheostomy and temporary tracheostomy in particular.
Anticipated complications include bleeding, tube obstruction and accidental decannulation. Dealing with any of these issues commonly requires senior and experienced staff and they will frequently resort to conventional oral intubation to secure the airway prior to re-establishing the compromised tracheostomy, but oral intubation may not be feasible either because this is physically impossible e.
These situations can be very serious both because of the technical challenges posed and the limited time available for re-establishing the compromised airway. It is essential that anyone dealing with these situations must know what surgery has been performed and whether oral intubation is a feasible alternative. An ERP can be formulated around the head and neck cancer patient’s overall journey.
These programmes have been shown to improve outcomes in patients larngectomy major colorectal and gynaecological procedures, by reducing length of stay and day morbidity. Extrapolation of these concepts to patients with head and neck laryngecctomy undergoing major resections and free-flap surgery may help in improving outcomes.
Relevant pre-operative measures might include carbohydrate loading with carbohydrate drinks 1—2 days before surgery. In the post-operative phase, early enteral feeding is advocated. National Center for Biotechnology InformationU.
The Journal of Laryngology and Otology. Author information Copyright and License information Disclaimer. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence http: This article has been cited by other articles in PMC. Abstract This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK.
Pre-operative assessment Comorbidity and pre-operative assessment are considered elsewhere in the guidelines. General anaesthetic considerations World Health Organization WHO checklist All fof staff are recommended to participate in this initiative to ensure that teams work effectively and that the right patients get the right surgical procedure gor have consented to.
Management of elective laryngectomy | BJA Education | Oxford Academic
Monitoring requirements The basic requirements for monitoring maintenance of anaesthesia and laryngecomy are outlined in the Association of Anaesthetists of Great Anaesthdsia and Ireland recommendations 4th edition, and advanced monitoring is usually only considered for long procedures or when excessive blood loss is a reasonable possibility. Prophylaxis for thromboembolism is discussed elsewhere in these guidelines 1. Airway considerations While patients presenting for head and neck surgery may have co-existent problems that could make airway management difficult e.
Oxygenation Maintenance of oxygenation is fundamental to airway management and techniques that extend the apnoeic window allow more controlled, less hurried and more careful, gentle instrumentation.
Induction of anaesthesia If a patient is already at risk of airway obstruction due to tumour bulk, then it is probable that they will be at greater risk following induction of anaesthesia, whether intravenous or inhalational. Fluid management and blood loss Many resections and free tissue transfers will not be associated with significant anqesthesia, though this is not necessarily true for tongue and mandibular resections where brisk bleeding may occur.