Anesthetic issues associated with midline transfacial approaches

Abstract

The anesthetic management of patients undergoing procedures using midline transfacial approaches requires a clear understanding of lesion anatomy and surgical plan. A thorough preoperative anesthetic evaluation is necessary for all patients. Patients with extensive tumors of epithelial origin are frequently older with comorbid medical conditions. The examination should include evaluation of overall physical, metabolic, and nutritional status in addition to cardiovascular, pulmonary, and neurologic systems. Pulmonary function and anti-ischemic and antihypertension therapies should be optimized before surgery. Careful perioperative airway management is required. Awake fiberoptic intubation or elective, awake surgical securement of the airway may be required. Anesthetic technique should be tailored to the patient's physical status and specific intraoperative requirements, such as neurophysiological monitoring. Venous access must be sufficient to treat rapid and extensive blood loss. Invasive cardiovascular monitoring, such as central venous catheters, pulmonary artery catheters, or transesophageal echocardiography, may be necessary. Mild intraoperative hypothermia may be useful for brain protection, but its use should be weighed against possible deleterious effects on reconstructive soft tissue flaps. Postoperative care must include meticulous attention to airway, pulmonary, cardiovascular, and neurological status. These patients are at increased risk for delayed awakening, postoperative delirium, or both. Because of the potential for severe postoperative complications, most patients undergoing these procedures should remain in an intensive care setting for at least 24 hours postprocedure. Knowledge of the pathophysiology underlying these potential complications is necessary for formulating a rational anesthetic plan.