Anaesthesia for laser surgery of the upper airway

Anaesthesia for surgery of the upper airway presents the anaesthetist with the dual problems of sharing the airway and the concomitant diseases of the patient. The laser adds the problem of a potent source of ignition of any flammable substance in an atmosphere which encourages combustion.No single technique provides the answer for all situations, there being a number of different methods depending on the age and health of the patient and the site of the lesion. In general, children are best managed breathing spontaneously. Conversely adults are usually best managed with paralysis and IPPV, which is provided either by a protected endotracheal tube or by some form of jet ventilation.     

Anaesthesia for carbon dioxide laser laryngeal surgery in infants

Problems associated with the presence of a tracheal tube during anaesthesia for infant laryngeal surgery using the carbon dioxide laser are described. This paper discusses alternatives and describes an effective anaesthetic technique and a new tracheal tube.     

Anaesthesia for obesity surgery

The aim of this article is to give a brief but comprehensive overview of the current management of the patient undergoing bariatric (weight loss) surgery. This article will discuss the different types of obesity surgery commonly performed, and the practical aspects of how to manage these patients both perioperatively and postoperatively. The principles described can be utilised in the management of obese patients attending for other types of surgery.     

Anaesthesia for urological surgery

A wide variety of patients present for urological surgery, from young fit patients to the elderly with multiple co-morbidities. Urological surgery ranges from minor, minimally invasive procedures to major surgery with significant physiological disturbance. It presents several specific challenges to anaesthetists. In day-case urology, a rapid turnover of patients, many of whom are elderly with significant co-morbidity, is required. General anaesthesia, with the patient breathing spontaneously through a laryngeal mask, is often used. Transurethral resection of prostate (TURP) has a specific complication, TURP syndrome, which occurs when excess irrigation fluid is absorbed, causing hypervolaemia and hyponatraemia. Spinal anaesthesia is often chosen because it allows early identification of the neurological deterioration seen in this condition. For major urological procedures careful preoperative assessment is essential as the incidence of cardiorespiratory co-morbidity is high. This assessment, in conjunction with the nature of the surgery, will guide preoperative investigations. Cardiopulmonary exercise testing has been shown to identify high-risk patients and may be helpful. General anaesthesia, with intermittent positive pressure ventilation, and an epidural is the technique of choice. There is a risk of major blood loss, so blood must be cross-matched and available. Large-bore access and invasive monitoring are needed. A careful assessment and appropriate management of fluid balance, using a goal-directed system, is important. Temperature should be monitored and normothermia maintained. Meticulous patient positioning and protection of pressure areas is essential to prevent nerve damage and compartment syndrome in prolonged procedures. Postoperative high-dependency care is beneficial.     

Anaesthesia for gastrointestinal surgery

Patients with gastrointestinal disease will present with a range of nutritional, fluid and electrolyte disturbances. This article will discuss how to recognize these problems and try to minimize their impact on recovery. A growing body of evidence shows that adoption of a package of care known collectively as enhanced recovery significantly reduces postoperative morbidity and reduces length of hospital stay. For anaesthetists the changes involve analgesic regimens and perioperative fluid and nutrition management. This evidence has been brought together in the national Enhanced Recovery After Surgery Programme and has been introduced to many hospitals for elective bowel surgery patients. The principles of the programme will be discussed. Aspects of it can be applied to many other surgical groups.     

Anaesthesia for obesity surgery

Surgery to aid weight loss is termed bariatric surgery and is becoming increasingly common as the prevalence of obesity rises. Bariatric surgery has been shown to have a sustained long-term therapeutic effect on obesity and is recommended by the National Institute for Health and Clinical Excellence as part of a complete weight loss programme. It is usually performed by a minimally invasive laparoscopic technique. Anaesthesia for bariatric surgery provides challenges for the anaesthetist in perioperative management owing to the surgical techniques and the comorbidities associated with obesity. Caution also needs to be taken with patients who have had bariatric surgery when they present for subsequent surgery.     

Anaesthesia for orthognathic surgery

Anaesthesia for orthognathic surgery requires thorough preoperative planning and multidisciplinary involvement. Patients are generally young and healthy, though there is an increasing trend in treatment of patients with obstructive sleep apnoea syndrome, associated with increased premorbid disease burden. Principles of perioperative management include close cooperation between surgeon and anaesthetist, a multifaceted approach to minimizing blood loss, multimodal analgesia, anti-emesis prophylaxis, and a carefully planned, communicated and executed airway management strategy. Nasotracheal intubation is routinely performed to maximize surgical access and permit intraoperative dental occlusion, though retromolar or submental intubation may occasionally be indicated. Patients with temporomandibular joint pathology or some congenital syndromes may necessitate awake airway management techniques. A clear strategy for tracheal extubation should be established in advance, including a well-defined re-intubation plan, especially for patients with intermaxillary fixation devices. Patients should be managed in an appropriately equipped and staffed postoperative care facility.     

Anaesthesia for spinal surgery

Patients with and without spinal disease are at risk of neurological damage during anaesthesia, even when the surgery is not directed at the spine. Certain types of spinal surgery carry a substantial risk. Reports of spinal cord damage due to direct laryngoscopy are unconvincing. Evoked potential spinal cord monitoring is used increasingly during anaesthesia, and successful recording of potentials requires the co-operation of the anaesthetist. Airway problems are common in cervical spine disease, particularly if the disease affects the upper three vertebrae. Anterior surgical approaches to the craniocervical junction involve extensive surgery, with implications for airway management and nutrition.