Functional endoscopic sinus surgery

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
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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

Patient preparation and premedication

• Premedicate with Versed as needed

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)

Procedure variants

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