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Anesthesia For Peroral Endoscopy

Sources: 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

rocedures. 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.

[67] 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.