What are the anesthetic considerations in laser surgery of the vocal cords?

From the Guidelines

Anesthetic management for laser vocal cord surgery should prioritize total intravenous anesthesia (TIVA) using propofol and remifentanil, along with specialized airway management techniques, to minimize the risk of airway fire and ensure optimal surgical conditions. The primary approach to airway management involves either a laser-safe endotracheal tube (ETT) or jet ventilation techniques, with smaller sizes (5.0-6.0 mm ID) preferred for laser-safe tubes, and cuff inflation using saline rather than air to prevent ignition 1.

Key Considerations

• The use of a dedicated silicone tracheal tube is strongly recommended to reduce the number of intubation attempts and minimize airway trauma 1.
• Techniques of tracheal intubation through a ‘dedicated airway’ should ensure that the vocal cords are open and non-reactive before attempting to advance the fibrescope or tracheal tube into the trachea 1.
• Airway injury may result from laryngoscopy, or insertion and presence of a tracheal tube or airway adjuncts, and can lead to significant morbidity and mortality 1.
• The operating room must be equipped with fire extinguishers, saline-soaked gauze, and disconnection protocols for the breathing circuit in case of airway fire, and the patient should be closely monitored for signs of airway compromise or fire 1.

Recommendations

• Total intravenous anesthesia (TIVA) using propofol and remifentanil should be used to avoid volatile anesthetics that support combustion.
• Laser-safe endotracheal tubes or jet ventilation techniques should be used to minimize the risk of airway fire.
• Smaller sizes (5.0-6.0 mm ID) of laser-safe tubes should be preferred, with cuff inflation using saline rather than air to prevent ignition.
• Dexamethasone (8-10 mg IV) should be administered to reduce laryngeal edema, and antiemetics like ondansetron (4 mg IV) should be used to prevent postoperative nausea and vomiting that could strain the surgical site 1.

Airway Management

• The sequence for ‘low-risk’, deep extubation should be followed, which includes ensuring that there is no further surgical stimulation, balancing adequate analgesia against inhibition of respiratory drive, and delivering 100% oxygen through the breathing system 1.
• The tracheal tube cuff should be deflated, and the patient should be positioned appropriately to minimize the risk of airway compromise.
• Airway patency should be reconfirmed after extubation, and the patient should be maintained on oxygen by mask until recovery is complete 1.

From the Research

Anaesthetic Considerations in Laser Vocal Cord Surgery

• The use of total intravenous anaesthesia (TIVA) has been studied in various surgical procedures, including those involving the airway 2, 3.
• In the context of laser vocal cord surgery, TIVA can provide a stable operative field and ensure patient safety throughout the procedure 2.
• The combination of propofol and remifentanil has been shown to be effective in achieving adequate hypnosis and analgesia during operative endoscopy tracheobronchial laser therapy 3.
• TIVA has also been used in ambulatory surgery, with benefits including rapid emergence and low incidence of postoperative nausea and vomiting 4.
• Guidelines for the safe practice of TIVA have been established, emphasizing the importance of competent and safe delivery of this technique by anaesthetists 5.

Key Considerations

• The choice of anaesthetic technique depends on various factors, including the patient's medical condition, the surgical procedure, and the anaesthetist's expertise 6, 5.
• TIVA can be a suitable option for patients undergoing laser vocal cord surgery, particularly when a stable operative field is required 2, 3.
• The use of TIVA requires careful monitoring and management of the patient's airway, as well as attention to the potential risks and complications associated with this technique 2, 5.

Anaesthetic Techniques

• TIVA with propofol and remifentanil has been shown to be effective in various surgical procedures, including laser vocal cord surgery 2, 3.
• The use of a laryngeal mask airway and controlled ventilation can provide a stable operative field and ensure patient safety during TIVA 2.
• The choice of anaesthetic technique should be individualized to the patient's needs and the surgical procedure, with consideration of the potential benefits and risks of TIVA 6, 5.