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Overview

Superlative surgical outcomes rarely occur by chance but are the product of a complex process that starts long before the day of surgery and lasts for at least 30 days after. This process is based on two factors: (1) active perioperative optimization of the patient’s medical comorbidities and (2) consistent surgical and anesthetic approaches to procedures. To achieve this goal, active collaboration and communication with anesthesiologists, internists, and other consultants is necessary throughout the perioperative period. Anesthesiologists are uniquely situated in the health care system to implement the “perioperative surgical home” model of care. Therefore, anesthesia for head and neck surgery includes an understanding of pharmacology, fluid, airway, and medial comorbidity management to act as a framework for these collaborations.

Anesthetic agents are classified by their primary actions; sedative hypnotics, amnestic, analgesics, and muscle relaxants. Most agents provide a combination of these effects and can be utilized solely or in combination with one another to provide surgical conditions and minimize patient risk.

Continuum of Depth of Sedation

  • Minimal sedation anxiolysis

    1. Normal response to verbal stimuli

  • Moderate sedation/analgesia (“conscious sedation”)

    1. Active response to verbal or tactile stimuli

  • Deep sedation/analgesia

    1. Active response to painful stimuli only

  • General anesthesia

    1. Unarousable to any stimuli

It is critical to understand that only the patient’s response to stimuli defines the level of sedation. Therefore, the level of sedation is never defined by a particular anesthetic agent, its dose, or the airway management technique or device utilized. For example, it is possible, in a very rare patient, to achieve the level of general anesthesia with propofol and a nasal cannula or conversely an intubated patient with minimal sedation anxiolysis. Additionally, any level of sedation may be combined with local anesthetics, nerve blocks, or nonsedating systemic analgesics to improve surgical conditions and decrease patient risk. Monitored anesthesia care is not synonymous with moderate sedation or any particular pharmacological agents. MAC is defined by the anesthesiologist’s ability to assess the patient, anticipate physiological derangements, and medical sequelae of the procedure as well as the anesthesiologist’s ability to intervene to rescue a patient’s airway and convert to general anesthesia if required.

A majority of patients have some degree of apprehension concerning an upcoming surgical procedure, and more often than not, the “anesthesia” figures prominently in this anxiety. It is therefore crucial that the anesthesiologist devotes the necessary time to explain the sequence of events comprising the anesthetic and to thoroughly answer any questions that patients or their family may have.

Anesthetic Agents

Sedative Hypnotics and Amnestics

In general, it is thought that anesthetics act by reversibly inhibiting neurosynaptic function of various regions or components of the cell membrane, either through action on membrane proteins or lipids or through modulation of the inhibitory neurotransmitter gamma-amino butyric acid (GABA). Because these compounds are involved in a number ...

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