CO-EXISTING DISEASES

1. ▪ Many pts have comorbidities (eg, cancer, developmental delay, mental retardation & seizures).

PREOPERATIVE ASSESSMENT

1. ▪ Studies: none

2. ▪ Premed: PO midazolam 0.5 mg; max 10 mg

3. ▪ NPO: std

PROCEDURAL CONSIDERATIONS

1. ▪ Supine

2. ▪ OR table may be turned to side.

3. ▪ Limited access to airway during procedure

4. ▪ IV fluids: LR; 3rd space loss minimal

5. ▪ Monitors: std

6. ▪ Risks: nasal bleeding from intubation, undetected disconnect or obstruction of breathing circuit under drapes; obstructed ETCO2 tubing under drapes; hyperthermia if warming measures used

7. ▪ Soften nasal tube by storing in warm water, or use lubricated red rubber catheter as introducer.

8. ▪ Adjuvant tx: 0.05% oxymetazoline spray to each nasal passage to lessen bleeding with nasal intubation; avoid phenylephrine spray

ANESTHETIC PLAN

1. ▪ Inhalation/IV induction of choice

2. ▪ NMB helps facilitate nasal intubation.

3. ▪ Nasal intubation OK in all ages

4. ▪ Use nasal RAE & secure to forehead with taped head wrap.

5. ▪ Use same size nasal ETT as oral.

6. ▪ Magill forceps usually necessary to pass nasal ETT through glottis

7. ▪ Maintenance: balanced technique: N2O & inhalational agent

8. ▪ Awaken & extubate in OR.

PAIN MANAGEMENT

1. ▪ Intraop: fentanyl 1–2 mcg/kg or morphine 0.05 mg/kg

2. ▪ PR acetaminophen 40 mg/kg

3. ▪ Local anesthesia by dentist

PACU/POSTOPERATIVE CONSIDERATIONS

1. ▪ Nasal bleeding

2. ▪ Analgesia for gum soreness: acetaminophen PO 10–15 mg/kg and/or PO ibuprofen 10 mg/kg