Anesthesia for Head and Neck Cancer

3/27/2015
Financial Disclosures
• None
Anesthesia for Head and Neck Cancer
Laura L. Ardizzone DNP, CRNA, DCC
Director Nurse Anesthesia Services, MSKCC
Adjunct Assistant Professor of Nursing
Fairfield University School of Nursing
ardizzol@mskcc.org/www.mskcc.org
Objectives
At the conclusion of this presentation, the participant should be able to :
1. Examine the etiology of major head and neck cancer
2. Describe the peri-operative management of patients undergoing
surgery related to head and neck cancer
2012
14.1 million new cases
8.2 million cancer deaths
 32.6 million survivors (within 5 years of diagnosis)
WHO/International Agency for Research on Cancer 2012
Worldwide incidence and mortality by cancer type
MALE
Incidence
Mortality
US Statistics – New cases in 2015 by state
FEMALE
1.
2.
3.
4.
5.
Lung
Breast
Colorectal
Prostate
Stomach
American Cancer Society, 2015
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2015 New Cancer Incidences by Gender
As of 1/2014 ~14.5 million Americans survivors
1620 Americans die each day
Mortality usually results from recurrence or metastases
Head and Neck Cancer
• Worldwide 644k incidence and 350 k deaths
• 50,000 Americans are diagnosed with a head or neck cancer (not including
skin cancers that occur in the head or neck)
– ~ 5 percent of all cancers in the US
– Majority are squamous cell carcinoma
• Survival rates have improved
– aggressive
gg
treatment
– early detection
– declining rates of tobacco and ETOH abuse
• The role of HPV
– The % of oropharyngeal cancers caused by human papillomavirus (HPV)
has increased
– 80% of oropharyngeal cancers are now caused by HPV (industrialized
countries)
HPV related H & N cancer – what the epidemiologic evidence shows us ?
HPV related H/N Cancer
HPV unrelated H/N cancer
Incidence trend
Increasing
Decreasing/stable
Anatomic Location
Tonsil and base of tongue
All H /N sites
Median age @ diagnosis
54
60
Socioeconomic status
Higher
Lower
Primary risk factors
Sexual Exposure to oral HPV
Tobacco & Etoh exposure
Survival
Better
Worse
82
57
3yr oropharyngeal %
Warning – graphics photos
ahead
• More likely to have an oropharyngeal primary tumor, diagnosed at a late
stage, and better survival than those with HPV-unrelated HNSC
• Race association incidence vs mortality
Considerations
General Considerations for Head and Neck surgery
• Airway Management
– Anatomy (c-spine, +/ROM, large tongue)
– stridor or hoarseness
– hx neck surgery, trauma,
difficult intubation
– infections (epiglottitis,
abscess)
– head/neck cancer 
radiation therapy
• low threshold for
fiberoptic
• backup plan
• sharing of airway with
surgeon
• nasal intubation
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3/27/2015
General Considerations
General considerations
• Preoperative evaluation
– elderly comorbidities
– hx of smoking, EtOH
• OR 3.49 = cigars
• OR 3.71 = Pipes
– Hx CAD, HTN, CRI, COPD
– Prior anesthesia hx
– preop testing  imaging studies, PFTs, cardiac and hepatic function
• Monitoring and access
–
–
–
–
–
–
–
–
ECG
BP noninvasive vs. arterial
pulse Ox
temp
end tidal CO2
RLN nerve monitoring  current practice
large bore IV, good access
positioning arms tucked, all access prior, sticky pulse ox, nerve
stimulator (where?)
Wyss, A. et. Al Am. J. Epidemiol. (2013) 178 (5): 679-690. doi: 10.1093/aje/kwt029
General Considerations
Anesthesia for Thyroidectomy
• Anesthetic Management
• Preoperative Assessment
–
–
–
–
–
–
–
–
Adequate intra op/postop analgesia, highly reflexogenic areas
controlled hypotension – dec SBP< 100mmHg, MAP 60-70
Pt immobility muscle relaxation ?
Smooth emergence
Opioid based technique
antiemetic prophylaxis
OGT prior to emergence to empty stomach +/General with ETT vs. flexible ETT
Preoperative Assessment: Thyroidectomy
– Airway
– Cardiac Hx
– Pre oxygenate inc BMRinc VO2desat quickly
– Higher incidence of myasthenia gravis and skeletal
muscle weakness inc sensitivity to muscle
relaxants
– Large IV
– Positionhead extended, arms tucked
– Hyperthyroidism: excess thyroid hormone(T3 + T4)
– s/sx: fatigue, sweating, heat intolerance, ↑HR, ↑BP, ↑Temp, weight
gain/loss, goiter, exophthalmos
– tx is medical therapy or subtotal thyroidectomy
– euthyroid prior to surgery
– pt should have normal thyroid function test prior to surgery and
HR < 85
– Antithyroid meds and B-blockers continued through morning of
surgery
Intraoperative : Thyroidectomy
– Protect eyes
– Cardiac function monitored
– Temp
– Head of bed can be elevatedaids venous
drainage
g
– +/- Reinforced ETT
– Avoid drugs that stimulate sympathetic
nervous system
– Hyperthyroid pts can be chronically
hypovolemic and vasodilated
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Intraoperative : Thyroidectomy
• Maintain adequate
depth of anesthesia
– Remember DL is
stimulant
– B-blockers are your
fi d
friend
• Not particularly painful
post-op
Thyroid Storm
– Can occur intraop, most common 6-24 hour
postop
– Mimic MH intraop
– Hyperpyrexia, tachycardia, altered
consciousness hypotension
consciousness,
– Tx: hydration, cooling, esmolol infusion,
propylthiouracil, sodium iodide, cortisol
Anesthesia for Parathyroidectomy – “pearls”
– Primary hyperparathyroidism may be
associated with MEN (multiple endocrine
neoplasia) syndrome pheo unrecognized
fatal
– Pts with osteoporosis may be predisposed to
vertebral compression during laryngoscopy
and bone fractures
Emergence/ Postoperative :Thyroidectomy
– Complete reversalintact reflexes
– Recurrent Laryngeal Nerve Damage
• unilateral=hoarseness
• bilateral=aphonia and stridor
– Hematoma formation
– Hypoparathyroidismunintentional removal
of parathyroid glands. (Chvostek’s and
Trousseau’s)
– Awake vs Deep
Anesthesia for Parathyroidectomy
Hyperparathyroidism: Pre -op
assessment
– primary causes: adenoma,
carcinoma, hyperplasia of gland
– secondary causes: adaptive
response to hypocalcemia
caused byy diseases
– most clinical manifestations are
secondary to hypercalcemia
• HTN, ventric dysrhythmias,
ECG changes, ileus, N/V,
muscle weakness, mental
status changes, renal stones,
impaired urine
concentrating, depression,
anorexia, abd and bone pain
Anesthesia for Parathyroidectomy
• Cardiac: HTN, ↓PR↓QT intervals, hypovolemia
(hypercalcemia)
– Normalize Ca++ level or at least dec
• volume and diuresis inc renal excretion of
Ca++
• Ca++ Channel blockers reduce afterload and
vasodilate coronary system=hypotension
• Response to NMB may be inc sec to increased
Ca++/ muscle weakness
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Intraoperative : Parathyroidectomy
–Avoid hypoventilation acidosis
increases ionized Ca++
–Similar to thyroidectomy
–Serial lab values
Anesthetic Considerations for Tracheostomy
Postoperative : Parathyroidectomy
• Similar to thyroid in regards to airway, RLN
damage, hematoma, stridor
• Hypoparathyroidism
– deficit of parathyroid hormone after
parathyroidectomy
– manifestations are result of hypocalcemia
(cardiovascular, musculoskeletal, neurologic)
Intraoperative Considerations :Tracheostomy
• Pre-op Assessment
– population usually includes: chronically ventilated
pts, pts having other procedure where trach is
required, pts with upper airway obstruction
(emergency)
– evaluate p
pt ventilation settings
g
– airway, coexisting dx
– cardiac hx
– neuro assessment may be sedated
– In OR or Bedside +/- anesthesia
– For intubated pts GETA
– Airway compromised pts local
– Inc mucosal swelling inc tissue fragility
• risk of tracheal mucosal separation
and false passage during trach
– Communicate with surgeon when using
cautery in the airway
– 100% O2 required before insertion of
trach
Intraoperative Considerations :Tracheostomy
Postoperative Considerations : Tracheostomy
• Trachea opened above cuff, ETT retracted slowly with
visualization of surgeon (communication), do not
remove all the way until trach in place and +ETCO2
confirmation
• Pneumothorax
• False
l passage
– Transport to ICU with meds, equipment
– Trach tube displacement, ETT and extra trach
tube with stylet (obturator) available
– Watch for bleeding
– recognize, no CO2, inc PIP, absent breath sounds, rigid bronchoscope
and extra ETT available
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Anesthesia for Neck Dissection
• Radical, modified, or
functional
• Usually performed with
resection of primary
lesion (thyroid,
parathyroid, tongue,
pharynx, larynx, etc.)
Intraoperative considerations: neck dissection
– Moderate decrease in BP, avoid adrenergic
responses
– Muscle relaxant +/– Humidify gases reduce mucous plugging
– VAE occurs rarely
l
– Manipulation of carotid sinusbradycardia,
↓BP
Postoperative Considerations: neck dissection
– HTN, ↑HR  2° to carotid sinus denervation
– Facial nerve injury
– RLN damage
– Diaphragmatic paralysis
– Pneumothorax
– Agitation
Preoperative considerations: neck dissection
– Airway  decreased mobility 2° to
radiation
• backup plan
• surgeon available
– Resp  COPD, CO2 retention, PFTs
– Cardiac: HTN, carotid artery stenosis
Special focus : Right side neck dissection
• Right Radical
Neck dissection
• may cause
prolonged QT
interval which
may progress to
ventricular
arrhythmias
h th i and
d
cardiac arrest
(due to
interruption of
cervical
sympathetic
outflow to heart
via right stellate
ganglion
Anesthesia for Laryngectomy
• Total Laryngectomy
– removal of vallecula to first or second tracheal rings
– trachea brought out to skin as end tracheostomy
– Stoma - no ETT or trach tube required
• Supraglottic
– resection of larnyx from ventricle to base of tongue, leave true
cords
– temp trach required
• Hemilaryngectomy
– removal of a unilateral true and false cord, keep epiglottis and
opposite vocal cord
– trach required
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3/27/2015
Back to basics : Laryngectomy
Preoperative Assessment : Laryngectomy
– Diagnosis: cancer, intractable aspiration
– Airway assessment/ evaluation…awake
trach?
– Anticipate DIFFICULT INTUBATION!
– Smoke,
S k ETOH,
ETOH COPD
COPD, C
Cardiac,
di etc.
t
– Large IV
– May turn OR table
– Anode tube
Intraop/ Emergence: Laryngectomy
– Smooth emergence
– Mod dec BP
– May be combined with neck dissection and PEG
placement
Maxillofacial Reconstruction
–Correct effects of trauma i.e. Leforte
Fractures
–Congenital malformations
–Radical Cancer
Surgerymandibulectomy
Preoperative Considerations: Maxillofacial Reconstruction
Intraoperative: Maxillofacial Reconstruction
• Airway evaluation – mouth
opening, neck mobility, nasal
patency
• Blood loss? IVs
• Oropharyngeal pack decrease blood going into
larynx/trachea
• Sharing of space with surgical team
– Can you mask ventilate
– Awake fiberoptic? Nasal, oral?
– Nasal RAE tube, regular tube with
connector
– Tracheostomy
• No nasal intubation with
Lefort II and III may have
coexisting basilar skull
fracture
– vigilance with monitoring of tube, ETCO2, esophageal probe?, increased
PIP, disconnect of circuit
• Extubate @ end
– Is there edema, will airway be obstructed? Pt fully awake?
• If jaw wired shut be sure to have cutting tools at
bedside
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Nasal Surgery Procedures
• Rhinoplasty
• Septoplasty
• External or
Endoscopic Sinus
Surgery
General Considerations: Nasal Surgery
• Anesthetic Considerations
– Local vs. General septoplasty and
septorhinoplasty may be performed under local
with sedation
– IV access
– Positioning head elevated 30°
30 ↓ bleeding,
bleeding table
turned, eye protection
– Vasoconstrictors shrink nasal mucosa
– Epinephrine 3-5 mcg/kg
– Local Anesthetic blocks anterior ethmoidal and
sphenopalatine nerves
– Cocaine 3mg/kg 30 min max effect
Anesthetic Considerations : Nasal Surgery
–Throat pack
–blood loss/epistaxis (hypotensive
technique)
–antiemetic
antiemetic prophylaxis
–emergence/extubation
Preoperative Considerations for Nasal Surgery
– Nasal Obstruction? (polyps, deviated septum,
mucosal congestion)
– Hx of bleeding problems
Cocaine Cardiovascular effects
– Local anesthetic
– Reactions not like other local anesthetics
– Inhibits reuptake of norepi at adrenergic nerve
terminals so potentiates adrenergic
responsevasoconstriction of arteries
h
hypertension
and
d ventricular
l
dysrhythmiasmyocardial ischemia
– Dysrhythmias treated with Ca+ channel blocker,
myocardial ischemia tx with NTG
Laser (Light Amplification by Stimulated Emission of Radiation) Surgery
– Precision, hemostasis
– Minimal edema, pain
– Uses and side effects vary with
wavelength
– CO2 gas long wavelength longer
wavelength greater absorption by
water, less tissue penetrated
(superficial)
– YAG shorter wavelength
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Perioperative Considerations : Laser
–Evacuation of fumes
–Protective eye gear for all personnel
–Pt. eyes protected
–ETT
ETT fi
fire
–Trained Laser operator
Prevention of Airway Fire
– Metal tube, reinforced tube, metallic tape
wrapped around ETT
– Keep inspired FiO2 low
– No Nitrous Oxide supports combustion
– May
M fill cuff
ff with
ith saline
li or methylene
th l
blue
bl
– Limit laser duration and intensity
– Saline soaked pledgets in airway
– Source of water immediately available
Robotic H&N procedures
Treatment of Fires in the OR
– **Halt procedure
– **Call for help
– Airway fire
•
•
•
•
•
IMMEDIATELY, without waiting
Remove tracheal tube
Stop the flow of all airway gases
Remove sponges and flammable material from airway
Pour saline
l into airway
– Non-airway fire
•
•
•
•
IMMEDIATELY, without waiting
Stop the flow of all airway gases
Remove drapes and all burning and flammable materials
Extinguish burning materials by pouring saline
– Reestablish or continue ventilation
– Examine airway for damage
• Robotic
Tonsillectomy
• Laser for airway
tumors…and cryo,
and stenting…plus a
little jjet ventilation
• Redo surgery after
previous
thyroidectomy, or
radiation, or
laryngectomy
If Fire is Not
Extinguished Use
a CO2 fire
extinguisher
If FIRE PERSISTS:
•activate fire alarm
•evacuate patient
•close OR door
•turn off gas supply
to room
ASA 2013 – Practice Advisory
References
• Barash et. al. (2013) Clinical Anesthesia (7th ed) Lippincott, Williams & Wilkins
• Butterworth, J, Mackey, D & Wasnick, J. (2013) Morgan & Mikhail’s Clinical
Anesthesiology ( 5th ed) McGraw Hill
• Fleisher, L & Roizen, M (2011) Essence of Anesthesia Practice (3rd ed)
Philadelphia: Elsevier
• Joseph, A & D’Souza, G. (2012) Epidemiology of Human PapillomavirusRelated Head and Neck Cancer . Otolaryngologic Clinics of North America 45
( ) 739–764
(4)
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• Miller, R & Pardo , M. ( 2011) Basics of Anesthesia (6th ed) . Philadelphia:
Elsevier
• Nagelhout, J. & Plaus, K. (2009) Nurse Anesthesia , (5th ed)St Louis, Missouri:
Elsevier
• Wyss, A. (2013) Cigarette, Cigar, and Pipe Smoking and the Risk of Head and
Neck Cancers: Pooled Analysis in the International Head and Neck Cancer
Epidemiology Consortium . American Journal of Epidemiology 178 (5) 679-690
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3/27/2015
Anesthesia for Head and Neck Cancer
Laura L. Ardizzone DNP, CRNA, DCC
Director Nurse Anesthesia Services, MSKCC
Adjunct Assistant Professor of Nursing
Fairfield University School of Nursing
ardizzol@mskcc.org/www.mskcc.org
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