ENT Eyes and Teeth

8/9/2019 ENT Eyes and Teeth

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Paediatric Anaesthesia:

Eyes, ENT and DentalMagen Schwarz


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Summary of Talk

!hthalmic Anaesthetics "ntra#ocular !ressure$E%A

Eye trauma

Stra&ismus surgery

'The (leeding Tonsil) Pre#o!

Peri#o! Post#o! issues

*A in Dental Procedures


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Paediatric !hthalmicProcedures

%sually under general anaethesia

%sually day !rocedures: E%A

+acimal duct !ro&ing

Stra&ismus correction

(eware the child with a cold


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Some -ongenital "ssues

Craniosynostosis syndromes .glaucoma, s/uint, cataracts,e0o!hthalmos1 ie -rouzons, A!erts, Pfei2er

Considerations3 mid#face hy!o!lasia

Craniofacial Syndromes .glaucoma, cataracts, s/uint1 ie *oldenhar, Treacher, -ollins, Smith#+emli#!itz

Considerations 3 4acial asymmetry, micrognathia

Downs Syndrome, Edwards Syndrome, Cri du ChatSyndrome.cataracts, stra&ismus1 Considerations 3 Di5cult intu&ation, -#s!ine insta&ility in Down6s

Marfans Syndrome .lens dislocation1 Considerations 3 Aortic root dilatation, aortic$mitral 7al7e regurgitation


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!hthalmic Medications

-blockers .Timolol1 3 glaucoma Systemic E2ect 3 (radycardia .refractory to Atro!ine18 &ronchos!asm in asthmatics

Carbonic anhydrase inhibitors .Acetazolamide1 3 *laucoma Systemic E2ect 3 Meta&olic acidosis, electrolyte a&normalities, allergies including

S9S

Antimuscarinics .Atro!ine$-yclo!entolate1 3 Pu!il dilatation Systemic E2ects 3 Dry mucous mem&ranes, nausea, tachycardia

-adreneric sym!athomimetic aents.Pheynle!hrine ;y!ertension, tachycardia

"ocal Anaesthetics .Tetracaine, 0y&u!rocaine, Pro0ymetacaine1 3Analgesic

Systemic E2ects 3 +A to0iscity, es!ecially in neonates


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Anaesthesia and "P

Normal "P ranges from ?@#@mm>g

Most induction agents will reduce "P


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culocardic eBe0

Seen in u! to C@= undergoing stra&ismus surgery

A2erent inner7ations

from the o!hthalmic

!ortion of the trigeminal

ner7e, relays 7ia the sensory

nucleus in the th7entricle,

with the e2erent im!ulse in

the agus ner7e

-ommonly due to traction on the medial rectus muscle Atro!ine .@mcg$kg1 or glyco!yrrolate .?@mcg$kg1

Se7o s >alothane

Atrac s oc

>igh - # consider controlled 7entilation


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Anaesthesia for Eye E%A

Most induction agents reduce "P Pathological increase in "P may &e masked

Fetamine: "M .


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Penetrating Eye Trauma

Patient will not &e fasted:

Su0amethonium will rise "P

Alternati7e: +arge dose NDM(,

entilate with cricoid !ressure

itreous e0trusion has not

&een associated with Su0amethonium

S" using ocuronium is now more !ossi&le with theuse of Suggamade0

Minimise e7ents that increase "P

-onsider !re#intu&ation +idocaine


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Nasolacrimal Ducts

(locked nasolacrimal ducts re/uire !ro&ing and irrigation %sually !resent early with tearing

(lood or dye can encroach the !osterior naso!haryn0

Short !rocedure

>y!otensi7e anaesthetic

may &e needed to reduce

&leeding;

+MA is su5cient

3 Ensure to suction


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Stra&ismus -orrection

Most common !aediatric eye surgery

Seen in H#a7e Atro!ine$*lyco!yrrolate handy

- reBe0

E0tu&ate dee!ly

A !eri&ul&ar &lock is good at reducing

PN and !ain

isk of glo&e !erforation

SuTenon &lock is 7ery e2ecti7e

PN is seen in


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(locks for Stra&isumusSurgery


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*A Dental Procedures

Pre#assessment: >istory and e0am; 4acial swellingJ

"s mouth o!ening limitedJ

"nduction: " or inhalational

Antisialogogue agents may hel!:

Atro!ine$*lyco!yrrolate

Maintenance: Nasal mask s ETT s Nasal ETT


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Paediatric ENT 3 (leedingTonsil

Seen in @;< 3 = !ost#tonsil surgery

>ot s -old techni/ues

A di5cult scenario; Potential hazardsto consider: >y!o7olaemic shock

Pulmonary as!iration

Di5cult intu&ation

isks of a second *A


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Pre#o! assessment: esuscitate &efore induction

@ml$kg stat &oluses in children

Note time since !re7ious surgery

4astedJ

Any clots in the mouth

Signs of airway di5culty -heck the !re7ious anaesthetic chart


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*eneral considerations: *et senior helpearly

suction de7ices

+aryngosco!es of correct size

ET tu&e 3 same size as last time and onesize smaller

Need two of each ET tu&e Kide &ore N* tu&ing

*et the surgeons scru&&ed and ready


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(leeding Tonsil 3 Anaesthetic

Techni/ue

() %nhalational induction, head down, lateral

Pros

# 4amiliar techni/ue,

o0ygenation well#maintained# *ra7ity hel!s drain &lood and clots

# Su0 can &e gi7en !rior to intu&ation

Cons

# Di5cult in an an0ious child# isk of dee! anaesthesia

# +ateral laryngosco!y is not a

common !ractice


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(leeding Tonsil 3 Anaesthetic

Techni/ue

*) %ntra+enous S%

Pros

# +ess stressful for the child

if cannula in situ

# "nduced su!ine with cricoid!ressure

# NM( create ideal en7ironment

for intu&ation

Cons

# mS" needed as im!ossi&le to !re#o0ygenate an an0ious childwho is &leeding

# *entle &ag#mask 7entilation re/uired

# isk of hy!o0ia if intu&ation is di5cult


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(leeding Tonsil

Perio!erati7e considerations Fee! the child warm, hy!othermia

!romotes coagulo!athy

N* tu&e after haemostasis

E0tu&ate awake in left lateral, headdown

'Tonsil !osition) A &olster !laced under the chest in the

lateral !osition

>ead is &elow the le7el of the chest


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(leeding Tonsil

Post#o!erati7e -are: -lose monitoring in a well#lit area

Fee! >& o7er g$dl !ro7ided no more

&leeding

Should remain

in hos!ital for

at least hours!ost &leed


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Thank#you

Any /uestionsJ

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