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Anesthesia For Peroral Endoscopy
Category: ANESTHESIA FOR PERORAL ENDOSCOPY
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
A dyspneic patient should never be given a general anesthetic. Cocaine
should not be used on children under ten years of age because of its
extreme toxicity. To these two postulates always in mind, a third one,
applicable to both general and local anesthesia, is to be added--total
abolition of the cough-reflex should be for short periods only.
General anesthesia is never used in the Bronchoscopic Clinic for
endoscopic procedures. The choice for each operator must, however, be
a matter for individual decision, and will depend upon the personal
equation, and degree of skill of the operator, and his ability to
quiet the apprehensions of the patient. In other words, the operator
must decide what is best for his particular patient under the
conditions then existing.
Children in the Bronchoscopic Clinic receive neither local nor
general anesthesia, nor sedative, for laryngoscopic operations or
esophagoscopy. Bronchoscopy in the older children when no dyspnea is
present has in recent years, at the suggestion of Prof. Hare, been
preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a
child of six years) or a full physiologic dose of sodium bromide. The
apprehension is thus somewhat allayed and the excessive cough-reflex
quieted. The morphine should be given not less than an hour and a half
before bronchoscopy to allow time for the onset of the soporific and
antispasmodic effects which are the desiderata, not the analgesic
effects. Dosage is more dependent on temperament than on age or body
weight. Atropine is advantageously added to morphine in bronchoscopy
for foreign bodies, not only for the usual reasons but for its effect
as an antispasmodic, and especially for its diminution of
endobronchial secretions. True, it does not diminish pus, but by
diminishing the outpouring of normal secretions that dilute the pus
the total quantity of fluid encountered is less than it otherwise
would be. In cases of large quantities of pus, as in pulmonary abscess
and bronchiectasis, however, no diminution is noticeable. No food or
water is allowed for 5 hours prior to any endoscopic procedure,
whether sedatives or anesthetics are to be given or not. If the
stomach is not empty vomiting from contact of the tube in the pharynx
will interfere with work.
With adults no anesthesia, general or local, is given for
esophagoscopy. For laryngeal operation and bronchoscopy the following
technic is used:
One hour before operation the patient is given hypodermatically a full
physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded
with atropin sulphate (gr. 1/150). Care must be taken that the
injection be not given into a vein. On the operating table the
epiglottis and pharynx are painted with 10 per cent solution of
cocain. Two applications are usually sufficient completely to
anesthetize the exterior and interior of the larynx by blocking of the
superior laryngeal nerve without any endolaryngeal applications. The
laryngoscope is now introduced and if found necessary a 20 per cent
cocain solution is applied to the interior of the larynx and
subglottic region, by means of gauze swabs fastened to the sponge
carriers. Here also two applications are quite sufficient to produce
complete anesthesia in the larynx. If bronchoscopy is to be done the
gauze swab is carried down through the exposed glottis to the carina,
thus anesthetizing the tracheal mucosa. If further anesthetization of
the bronchial mucosa is required, cocain may be applied in the same
manner through the bronchoscope. In all these local applications
prolonged contact of the swab is much more efficient than simply
painting the surface.
 In cases in which cocain is deemed contraindicated morphin alone
is used. If given in sufficient dosage cocain can be altogether
dispensed with in any case.
It is perhaps safer for the beginner in his early cases of
esophagoscopy to have the patient relaxed by an ether anesthesia,
provided the patient is not dyspneic to begin with, or made so by
faulty position or by pressure of the esophagoscopic tube mouth on the
tracheoesophageal party wall. As proficiency develops, however, he
will find anesthesia unnecessary. Local anesthesia is needless for
esophagoscopy, and if used at all should be limited to the
laryngopharynx and never applied to the esophagus, for the esophagus
is without sensation, as anyone may observe in drinking hot liquids.
Direct laryngoscopy in children requires neither local nor general
anesthesia, either for diagnosis or for removal of foreign bodies or
growths from the larynx. General anesthesia is contraindicated because
of the dyspnea apt to be present, and because the struggles of the
patient might cause a dislodgment of the laryngeal intruder and
aspiration to a lower level. The latter accident is also prone to
follow attempts to cocainize the larynx.
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