Anesthesia and management of intraoperative bleeding

Anesthesia for resection of juvenile angiofibroma (JA) imposes numerous challenges for the anesthesiologist. These include but are not limited to detection of preoperative complications associated with embolization of the vessels feeding the tumor and radiotherapy and avoiding aspiration of blood and secretions during induction of anesthesia and recovery from anesthesia and extubation of the patient’s trachea. Intracranial extension of JA necessitates special anesthetic considerations. A special consideration is accorded to intraoperative bleeding which occasionally may be massive and life threatening, to the blood and blood product replacement, and to the prevention and management of coagulopathy. Blood conservation strategies are described including deliberate hypotension. Both the risk of massive bleeding and the use of deliberate hypotension dictate continuous invasive monitoring of the hemodynamic state of the patient. Since bleeding may continue after surgery, close surveillance of the patient and intensive treatment should be undertaken postoperatively, in a milieu of a high dependency unit, such as postanesthesia care unit or intensive care unit.