Difference between revisions of "Functional endoscopic sinus surgery"

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| anesthesia_type = General
| anesthesia_type = General
| airway = ETT
| airway = ETT
| lines_access = 1 x PIV
| lines_access = PIV
| monitors = Standard ASA<Br>5-lead EKG<Br>Core temp<Br>UOP<Br>EEG (optional)
| monitors = Standard
5-lead ECG
Temperature
± EEG
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative =  
| considerations_intraoperative = Maintain akinesis (roc vs remi)
Avoid bleeding with permissive hypotension and fluid restriction
| considerations_postoperative = PONV prophylaxis
| considerations_postoperative = PONV prophylaxis
}}
}}


Provide a brief summary of this surgical procedure and its indications here.
Functional endoscopic sinus surgery (also known as '''FESS''', includes subprocedures '''sinusotomy''', '''anstrostomy''', '''ethmoidectomy''', etc.) is performed via a minimally invasive technique to repair the sinuses. A scope through the nose is used to visualize the sinuses while instruments are passed through the nose.


== Preoperative management ==
== Preoperative management ==
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|Respiratory
|Pulmonary
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=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===


* Versed
* Premedicate with Versed as needed


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
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=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===


* 180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
* Head of bed rotated 90 or 180 away. Place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
* Supine
* Supine
* Arms tucked
* +/- arms tucked
** Additional IV access site options: saphenous veins
** Additional IV access site options: saphenous veins


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
There are two major considerations for this surgery:


* Prop gtt (if TIVA, start at 125 mcg/kg/min)  
* Patient akinesia is crucial given the danger of having small scopes with scalpel. This can be achieved either with muscle relaxant or opioid.
* Avoiding patient bleeding with relative permissive hypotension and fluid restriction. They are working in a very vascular space. Bleeding also limits scope visualization which impairs surgery.
 
 
Common anesthetic plan:
*Prop gtt (if TIVA, start at 125 mcg/kg/min)  
* Remi gtt (start at 0.1 mcg/kg/min)
* Remi gtt (start at 0.1 mcg/kg/min)
* +/- Volatile
* +/- Volatile
* As with many ENT cases in the nose, can be very stimulating, hence the suggested remi gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.  
* As with many ENT cases in the nose, can be very stimulating, hence the suggested remi gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
* Note down when throat pack is placed in and taken out during case.
* Limit fluids to less than 1L.
* Limit fluids to less than 1L.
* Foley: no
* Foley: no
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=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===


* Paralytic reversal  
* Surgeons may request to pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
* Paralytic reversal
* Spin back to neutral if working alone. Can extubate 180 if there are two anesthesia providers and the airway was not difficult.
* Spin back to neutral if working alone. Can extubate 180 if there are two anesthesia providers and the airway was not difficult.
* Awake extubation, but smooth, hence the remifentanil gtt (decrease to 0.03-0.05 mcg/kg/min for extubation).
* Awake extubation, but smooth, hence the remifentanil gtt (decrease to 0.03-0.05 mcg/kg/min for extubation).
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[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
[[Category:Otolaryngology]]

Latest revision as of 05:50, 13 June 2024

Functional endoscopic sinus surgery
Anesthesia type

General

Airway

ETT

Lines and access

PIV

Monitors

Standard 5-lead ECG Temperature ± EEG

Primary anesthetic considerations
Preoperative
Intraoperative

Maintain akinesis (roc vs remi) Avoid bleeding with permissive hypotension and fluid restriction

Postoperative

PONV prophylaxis

Article quality
Editor rating
In development
User likes
0

Functional endoscopic sinus surgery (also known as FESS, includes subprocedures sinusotomy, anstrostomy, ethmoidectomy, etc.) is performed via a minimally invasive technique to repair the sinuses. A scope through the nose is used to visualize the sinuses while instruments are passed through the nose.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication

  • Premedicate with Versed as needed

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

  • PIV x 1 (20g for drips, bolus)

Induction and airway management

  • Standard induction
    • Propofol
    • Short acting opioid vs beta blocker
      • Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
    • Rocuronium
      • Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
  • ETT with straight connector
    • Can you use standard ETT vs oral RAE, depending on surgeon preference. Taping a standard tube off to the left commissure is often acceptable as surgeons will typically be working on patient’s right.
    • Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.

Positioning

  • Head of bed rotated 90 or 180 away. Place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
  • Supine
  • +/- arms tucked
    • Additional IV access site options: saphenous veins

Maintenance and surgical considerations

There are two major considerations for this surgery:

  • Patient akinesia is crucial given the danger of having small scopes with scalpel. This can be achieved either with muscle relaxant or opioid.
  • Avoiding patient bleeding with relative permissive hypotension and fluid restriction. They are working in a very vascular space. Bleeding also limits scope visualization which impairs surgery.


Common anesthetic plan:

  • Prop gtt (if TIVA, start at 125 mcg/kg/min)
  • Remi gtt (start at 0.1 mcg/kg/min)
  • +/- Volatile
  • As with many ENT cases in the nose, can be very stimulating, hence the suggested remi gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
  • Note down when throat pack is placed in and taken out during case.
  • Limit fluids to less than 1L.
  • Foley: no

Emergence

  • Surgeons may request to pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
  • Paralytic reversal
  • Spin back to neutral if working alone. Can extubate 180 if there are two anesthesia providers and the airway was not difficult.
  • Awake extubation, but smooth, hence the remifentanil gtt (decrease to 0.03-0.05 mcg/kg/min for extubation).
  • Avoid positive pressure masking after extubation

Postoperative management

Disposition

  • PACU

Pain management

  • ENT will inject lidocaine with epinephrine, watch for IV injection → tachycardia, hypertension
  • Tylenol IV
  • Short-acting opioids, fentanyl (be judicious)

Potential complications

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Chetra Yean, Tony Wang and Chris Rishel

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