return to: Otology - Neurotology

ANESTHESIA CONSIDERATIONS

1. Positioning/monitoring
   1. BP cuff on contralateral side to surgery
   2. Advise anesthesia that we will be turning 180 degrees
      1. Have circuit extensions available
      2. They can work on extra IV lines or arterial lines after rotating bed
         1. Allows both teams to work on patient simultaneously
         2. Eliminates tangling of lines if placed after rotating bed
2. Anesthetic agents
   1. Advise the need for "no paralysis" during the case for facial nerve monitoring
      1. Short-acting or no paralysis for induction/intubation
   2. We recommend against the use of nitrous oxide when we plan on tympanic membrane grafting
3. ETT taped off of contralateral side to surgery
   1. No tape past nasal ala
4. Maintain blood pressure with a systolic around 100 mm Hg

PATIENT PREPARATION AND POSITIONING

1. Bed
   1. "X-ray" riser removed from bed
   2. Base of bed reversed (may depend on type of bed)
   3. 3 sets of straps
2. Patient will be laid supine with head of patient 180 degrees from anesthesia
   1. Rotate head so that surgical side is up
   2. Reston ® or thin foam or gel pad under head
   3. Towel roll under contralateral cheek to prevent hyperrotation and subluxation in pediatric/geriatric patients
3. Tucking/Padding
   1. BOTH Arms are tucked into draw sheet with ulnar nerves well-padded
   2. Low-profile elbow guards placed and padded
   3. Three sets of straps:
      1. Strap over chest + elbow guard
      2. Strap over hip/upper thigh
      3. Strap over lower leg
      4. Avoid strap over knees or ankles
   4. Double check arms and legs padding to ensure safety.
4. A "test roll" is performed after patient secured to bed.
5. Lower body Bair Hugger (Arizant Inc., Eden Prairie, Minnesota) only, if Bair Hugger desired by anesthesia personnel.
   1. Full body Bair Hugger gets in the surgeon’s way
   2. Possible need for abdominal fat harvest

NIMS FACIAL NERVE MONITOR  

1. Half-pieces of Tegaderm ®
2. Red = mouth
3. Blue = eye
4. Ground electrodes
   1. Green above white
   2. Set at least 1 cm apart
   3. Only need one set of grounds if bilateral surgery
5. When securing NIMS to bed, ensure that the Prass probe insert is not covered and is accessible by nursing.
   1. Do not allow cord to drag, as it is likely to get dislodged during surgery.
   2. Tuck onto bed rails
6. Set up and tested according to manufacturer’s instructions

INTRAOPERATIVE AUDITORY BRAINSTEM MONITORING (SEE FIGURE)

1. 4 electrodes, two ear inserts
   1. Red = right
      1. Mastoid electrode
      2. Ear insert
   2. Blue = left
      1. Mastoid electrode
      2. Ear insert
   3. White = crown of head
   4. Green = forehead
2. Electrodes come off on the side of surgery
3. Ear inserts come off on the contralateral side of surgery

MEDICATIONS: SEE OTOLOGY ANTIBIOTIC ADMINISTRATION GUIDELINES

1. Local anesthetic
   1. Adult strength: 1% lidocaine in 1:100,000 epinephrine
   2. Pediatric strength: 0.5% lidocaine with 1:200,000 epinephrine
   3. Canal injection under general anesthesia: 1:20,000 plain epinephrine
   4. Canal injection under local anesthesia: 1:20,000 plain epinephrine + 1% lidocaine