Anesthesia type: GETA

Surgery Time: 2-4 hours (long)

Position: Supine

Preoperative Implications: OSA is a very common condition. Consider STOP-BANG assessment. Make sure to have a type and cross done. Possibilities for high blood loss. Consider securing a second IV, especially if the case is anticipated to last more than 3 hours. The arms will be tucked and wrapped, so options to start another IV could be limited. Also consider securing the BP cuff to the lower extremity as it is common to get erroneous readings from medical personnel working around the upper body.

Induction Implications: Robinul given with your preoperative midazolam is a handy trick to get secretions to a minimum. Nasal intubation (Magill forceps, Afrin or other vasoconstriction nasal spray). Muscle relaxation. 1:200,000 Epinephrine Injections prior to incision so anticipate rise in heart rate and blood pressure. Eyes should receive ointment and taped/tagadermed. Throat pack is indicated. Ensure the in/out times are recognized/documented. Dexamethasone will likely be given early (typically 8 mg IV).

Maintenance Implications: Bed turned 90-180 degrees. Head of bed up 15-30 degrees. Avoid high blood pressures. High possibilities of blood loss due to vasculature of the face so try to keep blood pressures lower (usually systolic somewhere close to 90 or 100) always remembering to keep pressures within 20% of baseline.

Emergence Implications: Awake extubation. Smooth as possible. Antiemetics are especially important to avoid any kind of PONV. Consider the full run of antiemetics. Remember, the patients mouth will likely be closed so PONV could be disastrous. Empty the stomach at the end of the case with an NG tube. The surgeon may request to do this, so have one ready. Jaw will be wired or banded shut, so have wire cutters or scissors on hand in the event of an emergency. Pain is a big issue with these patients, so use a multimodal approach (NSAIDs, Acetaminophen, etc)