General Anesthetic Technique

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A topical vasoconstrictor such as xylometazoline can be given on the ward 20 minutes prior to surgery. A vasoconstrictor on a swab/pledget or as liquid can be placed in the nose in the same way as under local anesthesia.

If a liquid is applied, the patient is positioned with their head extended and their shoulders being supported by a pillow. In this position with the head very extended, the solution inserted will bathe the spheno-

palatine artery; this appears to reduce the amount of peroperative bleeding. Whether cophenylcaine, or 2 ml of 6% cocaine with 8 ml of saline, or Moffatt's solution (2 ml of 6% cocaine, 1 ml of 1 : 1000 epinephrine, 1 ml of sodium bicarbonate 8%, made up with 6 ml of saline to 10 ml overall) is used depends on the surgeon's preference. It is best left in position for at least 5 minutes to have its maximum effect (Fig. 10.2).

We find that placing tampons on either side of the laryngeal mask is preferable to inserting wet gauze, which is far more abrasive on the soft palate, and the use of tampons is associated with less postoperative discomfort. Tampons are provided with their own inserters and a little sterile jelly placed on the end will ease their insertion.

If there are extensive polyps, it may not be possible to introduce the solution. In this case, the solution can be used to soak ribbon gauze or pattes and these can be inserted instead. They can be reinserted after a few minutes when the polyps have shrunk in order to get a better result. The longer the vasoconstrictor is left in position, the better the effect. If bleeding remains a problem, either through the amount lost or because of restricted visibility, it is best to place a pack with 1 : 10 000 epinephrine and wait, or move to operate on the other side. More concentrated epinephrine often has a sympathomimetic effect on the heart; occasionally it can affect the pupil through the sympathetic reflexes on the carotid in the sphenoid sinus. During the procedure, if there is a moderate amount of bleeding, you should use a larger sucker to remove the reservoir of blood in the nasopharynx before reinserting the other instruments as this minimizes the amount of time spent removing blood.

A key point regarding general anesthesia is for the anesthetist to reduce cardiac output primarily by ensuring that there is bradycardia. Oral metoprolol given the day before and on the morning of surgery can be used when there are no contraindications, for example, asthma. Smooth induction helps and a laryn-geal mask produces less stimulation and is now our main method of protecting the airway. It also produces less stimulation on extubation, with less coughing, and this reduces the bleeding on waking in recovery. Having the patient 20° body-up reduces the venous pressure. Vasodilators should not be used to reduce the blood pressure as these cause more bleeding.

We are not anesthetists, but we have observed several aspects of anesthetic technique that provide a better operative field:

Fig. 10.3 The surgeon is seated, with arm support to reduce fatigue and stabilize the arm holding the camera.

• A smooth induction, peroperative anesthesia, and reversal leads to less bleeding. Coughing on a cuffed tube will result in a great deal of bleeding. If this happens, it is best to wait until the patient has settled.

• Position the patient 20° body-up during surgery.

• The use of topical vasoconstrictors (and allowing sufficient time for them to work).

• Do not rely on vasodilatation to induce hypotension as this will result in more bleeding.

• If hypotensive techniques are used, it is best to keep the mean blood pressure between 65 and 75 mmHg.

• The use of a laryngeal mask reduces stimulation to the airway, particularly on extubation.

• Beta blockers need to be used with extreme care, and not in asthmatics.

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