INTRODUCTION
With respect to patient safety, the preparation of emergency equipment, the dosing of critical medications, and the implementation of emergency scenario planning all play a vital role in office-based nasal and sinus procedures. , Additionally, the integration and activation of a procedural team, including the surgeon, advanced practice provider, nurse medical assistant, and/or anesthesia provider, during emergency scenarios is helpful, so in the case of a critical event, all members of the procedural team understand their potential role. Second, the equipment required during office-based procedures or surgeries can differ from that which is used during routine clinical activities or interventions, and thus it is vital to ensure all procedural staff are properly trained in the care and usage of any unfamiliar equipment. Specific supplies are discussed in detail later; however, for any major in-office procedure, it is important that the room be equipped with a standard vitals machine, including blood pressure monitoring and continuous oxygen saturation monitoring. Additionally, an automated external defibrillator, an oxygen tank, and a “crash cart” with appropriate medication to run a code event should be readily accessible if needed.
Notably, most complications are managed similarly to how they would be handled in an operating room (OR) setting; therefore, it is essential to attempt to mimic an OR setup when performing office-based procedures. Instead of exhaustively covering every complication, this chapter aims to provide an overview of the most common medical emergencies that can occur during office-based nasal and sinus procedures, along with strategies for their management. These include emergencies such as anaphylaxis and airway management, anesthesia complications, management of hypotensive episodes or hypertensive urgency, nasal hemorrhage, and severe pain management.
EMERGENCY SCENARIOS
Epistaxis/Nasal Hemorrhage
Similar to nasal and sinus procedures performed in the OR, the most common complication and potential medical emergency of in-office rhinologic procedures is epistaxis. , As such, one must be fully prepared to manage sinonasal hemorrhage with full consideration of all potential equipment needs ( Fig. 5.1 ). A vasoconstrictor, such as oxymetazoline or 1:1000 epinephrine-soaked cottonoids, should be present for all procedures and will be commonly employed as a “preprocedure” agent for any nasal/sinus procedure to limit mucosal bleeding from the nasal and sinus cavity. In our experience, we have a distinct setup for the management of severe epistaxis, which includes a variety of topical agents and instruments, including a bovie, suction cautery, thrombin-based hemostatic agents, inflatable balloon catheters, and absorbable packing materials ( Fig. 5.1B ).
(A) Procedural cabinet with layout of endoscopic endonasal instrumentation. Importantly, this procedural cabinet is connected to a suction cannister to provide suction capabilities during rhinologic procedures. (B) Hemostasis station with readily available medication, absorbable agents, nonabsorbable agents, and balloon catheters to handle moderate to severe bleeding. Additionally, we have surgical equipment including bovie electrocautery and suction-bovie equipment in place as needed, in addition to prepared thrombin matrix that can be applied topically.
Bleeding should be categorized as venous or arterial, which is a critical distinction as the source of bleeding affects the type of management strategy. In cases of minor bleeding, the surgeon may apply gentle pressure to the bleeding site and elevate the patient’s head to help stop the bleeding. For persistent bleeding from the nasal cavity, the surgeon should consider the use of topical vasoconstrictor agents such as oxymetazoline or 1:1000 epinephrine-soaked cottonoids. In more severe cases of bleeding, bovie, bipolar, or suction cautery can be used to coagulate any large vessels. If suction cautery is not available, the surgeon can attempt to control bleeding either by packing the sinus with gauze or applying a balloon catheter ( Fig. 5.1B ). If the bleed cannot be adequately controlled with the above measures, consider emergency protocols such as activating a patient “code” procedure to facilitate proceeding to the operating room or interventional radiology suite for definitive bleeding control. After initial bleeding is controlled, any number of topical procoagulants (i.e., tranexamic acid or anti-fibrinolytic agents) can be placed either directly onto the area of concern or throughout the sinonasal cavity to limit recurrence and control bleeding during the remainder of the procedure.
As with all nasal and sinus procedures, regardless of where they are performed, it is essential for the surgeon to closely monitor the patient’s vital signs and bleeding status during and after the procedure. Patients should be educated on basic postoperative care such as nasal saline irrigation and avoiding blowing the nose, as well as advised on when they need to seek medical attention.
Anesthetic Complications
Anesthesia complications can occur during in-office ENT procedures, and it is important to be prepared to manage them effectively to ensure the patient’s safety and well-being. This should include guidelines for monitoring the patient’s vital signs, administering medications and fluids, and responding to emergencies. The health care provider should also have access to emergency equipment and medications in case they are needed. One of the benefits of office-based procedures is the shorter recovery time that results from avoiding general anesthesia. Additionally, hemostasis is improved during in-office procedures, both by the avoidance of general anesthetics, which cause vasodilation, and the elevated position of the head with seated positioning. ,
Although general anesthesia is seldom used, complications can still arise from the use of local anesthetic agents. Local anesthetics are classified into esters and amides, with a variety of options available. Surgeons must be familiar with each agent and have a thorough understanding of its toxicity profile. Some common causes of anesthesia-related emergencies during in-office procedures include allergic reactions, respiratory depression leading to hypoxia, and cardiovascular instability. , , Allergic reactions are uncommon; however, they occur slightly more frequently with ester-class agents. Management of allergic reactions is discussed in detail in the anaphylaxis section.
Most emergencies that arise with local anesthesia occur due to local anesthetic systemic toxicity (LAST), which is related to high plasma volumes, often due to intravascular injection. The occurrence is relatively rare and can largely be prevented by withdrawing before injecting to ensure the anesthetic is not injected intravascularly. Should intravascular injection occur, initially, high plasma concentrations will produce central nervous system (CNS) stimulation (including seizures), followed by CNS depression (including respiratory arrest). The initial CNS stimulatory effect is absent in some patients and is more common when using amides (epinephrine in particular). Therefore, following all injections, the surgeon should monitor the patient’s vital signs. If CNS instability arises and LAST is suspected, the management includes adequate oxygenation and ventilation, seizure termination, maintenance of circulation, and intravenous lipid emulsion therapy. In some cases, the patient may need to be transferred to an inpatient setting for further treatment and clinical monitoring.
Last, in the case of a cardiac arrest, the appropriate protocol for cardiopulmonary resuscitation (CPR) should be followed as outlined in the standard Advanced Cardiac Life Support (ACLS) guidelines. , , , Knowledge of the location and proper instruction on the utilization of an emergency defibrillator is critical for any emergency protocol during in-office procedures ( Fig. 5.2B ). Chest compressions should begin immediately and continue until the individual regains a spontaneous heartbeat. The use of local anesthetics does not harm the heart muscles as long as they do not cause tissue oxygen deprivation. With proper circulation, full recovery can occur even after prolonged CPR. Maintaining proper blood flow will also speed up the recovery by aiding in the elimination of the local anesthetic from the heart tissue.
