What is the recommended anesthesia plan for a patient undergoing surgery for ventral septal deviation?

Anesthesia for Septal Deviation Surgery

For septoplasty procedures, general anesthesia with short-acting agents is the standard approach, though local anesthesia with vasoconstrictor is feasible in carefully selected patients and offers advantages for fast-track surgery. 1, 2

Anesthetic Technique Selection

General Anesthesia (Standard Approach)

• General endotracheal anesthesia is preferred for most septoplasty cases to ensure complete immobility, controlled ventilation, and optimal hemodynamic stability throughout the procedure 3
• Use short-acting anesthetic agents with rapid onset and offset for easier recovery 4
• Maintenance can be achieved with either volatile inhalation agents or total intravenous anesthesia (TIVA); both are acceptable 4, 5
• Avoid nitrous oxide as it increases postoperative nausea and vomiting 4
• Volatile agents may provide cardioprotective benefits in patients with underlying cardiac disease 5

Local Anesthesia Option

• Pure local anesthesia is feasible in appropriately selected patients and demonstrates excellent potential for outpatient fast-track surgery 2
• Lignocaine 2% with adrenaline 1:200,000 is superior to prilocaine with felypressin for achieving a dry operative field, with mean blood loss of 7.5 ml versus 32.7 ml respectively (p<0.01) 6
• Maximum lidocaine dose should not exceed 7 mg/kg 1
• Local anesthesia requires highly cooperative patients who can tolerate the procedure while awake 2

Critical Hemodynamic Management

Blood Pressure Control

• Maintain blood pressure within the patient's normal baseline range throughout induction and maintenance 3
• Avoid both hypotension (which reduces coronary perfusion) and hypertension (which increases bleeding) 1, 3
• Target mean arterial pressure ≥60-65 mmHg minimum; hypotension below this threshold for >15 minutes causes postoperative organ injury 3

Vasoconstrictor Use

• Limit epinephrine concentration to 1:100,000 or less when infiltrating the surgical site 1
• In patients with concurrent cardiac disease or hypertension, consider avoiding epinephrine entirely as vasoconstrictors can create unfavorable hemodynamic changes 1
• Topical anesthesia can be applied first to reduce injection pain and anxiety 1

Airway and Ventilation Management

Positioning and Preparation

• Position the patient in a ramped position with the tragus of the ear level with the sternum for optimal airway access 4
• Allow extra time for positioning and performing anesthesia 4
• Monitor neuromuscular blockade depth and ensure complete reversal before extubation 4

Intraoperative Monitoring

• Continuous pulse oximetry and blood pressure monitoring are mandatory throughout the procedure 4, 1
• Drug delivery and monitoring should be performed by certified nursing personnel, nurse anesthetists, or anesthesiologists 4

Fluid Management

• Target euvolemia with 2-6 mL/kg/h of baseline intravenous fluid 4
• Review fluid balance regularly to avoid extremes that could cause organ dysfunction 4
• Consider esophageal Doppler-guided hemodynamic monitoring for more precise fluid titration in complex cases 4

Multimodal Analgesia Protocol

Postoperative Pain Management

• Implement a multimodal, opioid-sparing analgesic regimen combining non-opioid agents 4
• Use short courses of NSAIDs postoperatively unless contraindicated 4
• Minimize home-going opioid prescriptions 4
• Preemptive analgesia should be administered before surgical incision 4

PONV Prophylaxis

• Provide multimodal antiemetic prophylaxis targeting different chemoreceptor pathways, as nasal surgery patients are at high risk for postoperative nausea and vomiting 4, 3

Preoperative Optimization

Patient Assessment

• Evaluate the specific type of septal deviation (septal tilt 40%, C-shaped anteroposterior 32%, S-shaped anteroposterior 9%, or localized deviations 14%), as each requires different surgical management 7
• Document whether medical management has been attempted for at least 4 weeks before proceeding with surgery 8
• Assess for concurrent turbinate hypertrophy, which is present in up to 20% of patients and often requires simultaneous treatment 4

Anxiolysis

• Benzodiazepines are safe for anxious patients: diazepam 0.1-0.8 mg/kg or midazolam 0.5-1 mg/kg, as both are hepatically metabolized without cardiac-specific dose adjustments 1

Critical Pitfalls to Avoid

• Never use excessive epinephrine concentrations (>1:100,000) as this precipitates dangerous hypertension and tachycardia 1
• Do not proceed with elective surgery if the patient has uncontrolled medical conditions; optimize first 3
• Avoid prolonged hypotension (MAP <65 mmHg for >15 minutes) which causes irreversible organ injury 3
• Do not assume all septal deviations require the same surgical technique; failure to match the procedure to the deviation type leads to poor outcomes 7
• Never allow tachycardia to persist, as shortened diastolic filling time reduces cardiac output 1, 3

Special Considerations for Pediatric Patients

• Septoplasty is infrequently performed in children due to potential negative effects on nasal growth 8
• The threshold for surgical intervention is higher in adolescents, requiring exceptionally clear documentation of severe functional impairment and complete failure of conservative measures 8