Position: Supine, arms tucked, head turned away from field, Bed turned 90 degrees, Bed turned 180 degrees
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes
Lead: Yes

Preparation – Have the glidescope available and ready. Ask the surgeon if he/she will prefer to have the bed rotated 90 or 180 degrees. It’s also a good idea to have the airway cart (fiber-optic, cricoid kit) close by, along with the ENT surgeon at bedside on induction.

Airway assessment – The patient will have a severely limited range of motion, so airway assessment may be difficult. For this reason, it is good practice to have items ready in the event of a difficult airway (eg. video laryngoscope, etc.)

Induction – Have the patient pre-oxygenated as much as possible before induction. You may not be able to easily mask ventilate due to potential facial deformities. Many ENT surgeons will require or ask for a nasal intubation to be able to better visualize the surgical field.

Airway Access – Access to the airway/head during the surgery will be severely limited. Make sure the airway is very well secured. Train of four (TOF) will need to be done on the extremities.

Site Prep – The surgeon will be in the mouth, so keeping it dry will be important/helpful. Robinul (~0.2 mg) is a good drug to give on induction or pre-operatively (where not contraindicated). After induction and securing the airway, thoroughly suction the mouth.

PONV and Anesthetic Approach – Post operative nausea and vomiting could be especially bad for these patients. Avoiding intraop opioids can be beneficial to avoid this. IV Tylenol, Toradol, precedex, and ketamine could be considered in place of fentanyl, etc. TIVA may also be considered to avoid nausea and vomiting induced by volatile anesthetics. Intraoperative antiemetics (zofran, decadron, pepcid, etc) should be prophylactically given. After the surgery is complete, thoroughly empty the stomach with an NG tube (this is sometimes done by the surgeon).

Extubation – Awake extubation is best – the patient must be able to protect their own airway.

Wire Cutters – The jaw will likely be wired shut. Have wire cutters available if needed for quick access post-op.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

180 degree turns (general considerations): Arrange lines and monitor cords in anticipation to turn. If turning right, keep cords and lines draped to the left. If turning left, keep cords and lines draped to the right. Have a circuit extension connected. Disconnect the circuit when turning and immediately reconnect.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.