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.
