WikiAnesthesia - User contributions [en]

Cesarean section

2022-07-20T10:43:13Z

Aharari: added to hematologic effects during pregnancy

{{Infobox surgical case reference
| anesthesia_type = Neuraxial or general
| airway = ETT if general
| lines_access = Large bore IV x2
| monitors = Standard
Fetal heart rate monitor
| considerations_preoperative = Full stomach precautions
Aspiration prophylaxis
Left lateral tilt
| considerations_intraoperative = Have uterotonics available
| considerations_postoperative =
}}
A '''cesarean section''' (also known as '''C-section''') is a surgical procedure where the baby is delivered through an incision in the uterus. C-sections are typically performed when a vaginal delivery would put the mother or baby at risk. In the USA, about 32% of deliveries are via Cesarean section<ref>{{Cite web|date=2021-03-24|title=FastStats|url=https://www.cdc.gov/nchs/fastats/delivery.htm|access-date=2021-05-27|website=www.cdc.gov|language=en-us}}</ref>, and worldwide the figure is approximately 21%.<ref>{{Cite journal|last=Boerma|first=Ties|last2=Ronsmans|first2=Carine|last3=Melesse|first3=Dessalegn Y.|last4=Barros|first4=Aluisio J. D.|last5=Barros|first5=Fernando C.|last6=Juan|first6=Liang|last7=Moller|first7=Ann-Beth|last8=Say|first8=Lale|last9=Hosseinpoor|first9=Ahmad Reza|last10=Yi|first10=Mu|last11=Neto|first11=Dácio de Lyra Rabello|date=2018-10-13|title=Global epidemiology of use of and disparities in caesarean sections|url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31928-7/abstract|journal=The Lancet|language=English|volume=392|issue=10155|pages=1341–1348|doi=10.1016/S0140-6736(18)31928-7|issn=0140-6736|pmid=30322584}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
* Pregnant patients typically have decreased systemic vascular resistance, decreased diastolic pressure, decreased MAP, increased HR, and increased CO.
* Left uterine tilt to minimize aortocaval compression<ref>{{Cite journal|last=Buley|first=R. J.|last2=Downing|first2=4 W.|last3=Brock-Utne|first3=J. G.|last4=Cuerden|first4=C.|date=1977-10|title=Right versus left lateral tilt for Caesarean section|url=https://pubmed.ncbi.nlm.nih.gov/921864/|journal=British Journal of Anaesthesia|volume=49|issue=10|pages=1009–1015|doi=10.1093/bja/49.10.1009|issn=0007-0912|pmid=921864}}</ref>
* Evaluate for pregnancy induced hypertension (PIH)
|-
|Pulmonary
|
* Pregnant patients typically have compensated respiratory alkalosis, increased minute ventilation, decreased FRC, and increased oxygen consumption.
* Decreased FRC results in rapid desaturation if ventilation is compromised.
* Atelectasis can occur secondary to an elevated diaphragm, thereby causing V/Q mismatch and decreased PaO2.
* Increased MV and decreased FRC increase uptake of inhalational agents.
* Mucosal capillary engorgement in upper airway may necessitate smaller endotracheal tube.
|-
|Gastrointestinal / Hepatic
|
* Increased gastric pressure
* Decreased esophageal sphincter tone
* Decreased gastric motility
* Full stomach precautions

* Risk for aspiration
* Liver enzymes may be mildly elevated
** Check for HELLP
|-
|Hematologic
|
* Increased RBC mass, plasma volume, and blood volume
* Leukocytosis
* Iron deficiency anemia + dilutional anemia of pregnancy
* Excessive blood loss possible with uterine atony, multiple gestation, previous C-section, placental pregnancy, placental abruption, pregnancy induced hypertension, or prolonged labor.
*Pregnancy is associated with a hypercoagulable state as a way to blunt the blood loss anticipated during delivery, however, this physiologic adaptation predisposes them to DVT/PE formation.
|-
|Renal
|
*Increased renal blood flow, GFR, and creatinine clearance
* Decreased serum creatinine and BUN
*Dependent edema secondary to increased water and sodium retention
|-
|Other
|
|}

===Labs and studies===

*T&S
*T&C only if significant blood loss anticipated
* Coagulation panel
*Chemistry panel
*Complete Blood Count (CBC)
* Other tests as indicated by H&P

===Operating room setup===

===Patient preparation and premedication===

* Full stomach precautions
*Nonparticulate oral antacid (e.g. sodium citrate) immediately prior to general or regional anesthesia
*Intravenous promotility agent (eg. metoclopramide)
*Intravenous antacids (e.g. ranitidine, famotidine)
* Anxiolysis not typically used unless patient is extremely anxious
*Elevate the right hip to provide left uterine displacement
*Adjunctive azithromycin 500mg IV to standard beta-lactam antibiotics shown to reduce the incidence in endometriosis and wound infection occurring in the first 6 weeks after Cesarean Section<ref>{{Cite journal|last=Tita|first=Alan T.N.|last2=Szychowski|first2=Jeff M.|last3=Boggess|first3=Kim|last4=Saade|first4=George|last5=Longo|first5=Sherri|last6=Clark|first6=Erin|last7=Esplin|first7=Sean|last8=Cleary|first8=Kirsten|last9=Wapner|first9=Ron|last10=Letson|first10=Kellett|last11=Owens|first11=Michelle|date=2016-09-29|title=Adjunctive Azithromycin Prophylaxis for Cesarean Delivery|url=http://www.nejm.org/doi/10.1056/NEJMoa1602044|journal=New England Journal of Medicine|language=en|volume=375|issue=13|pages=1231–1241|doi=10.1056/NEJMoa1602044|issn=0028-4793|pmc=PMC5131636|pmid=27682034}}</ref>.

===Regional and neuraxial techniques===

*Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed
**Check coagulation and platelets prior to neuraxial anesthesia
*Post-operative transversus abdominal block (TAP block) or quadratus lumborum block.
* Post-operative elastomeric pain pumps with local anesthetic may be useful for incisional pain

==Intraoperative management==

=== Monitoring and access===

*Standard monitors

===Induction and airway management===

*Avoid nasal airways due to potential for mucosal capillary engorgement in upper airway

===Positioning===

* Left lateral tilt (15o) to avoid aortocaval compression and supine hypotension.

===Maintenance and surgical considerations===

* Anticipate EBL of 700-1000 mL
** Be prepared for excessive blood loss if underlying risk factors
* Immediately post-partum, ~600-800 mL of blood will enter the central circulation (placental autotransfusion), which will increase cardiac output
*Tranexamic acid 1g administered over 30-60 seconds during the first 3 minutes after birth, and after the uterotonic agent has been administered (e.g. oxytocin) is shown to reduce the incidence of post-operative blood loss > 1000 mL by POD #2 or RBC transfusion<ref>{{Cite journal|last=Sentilhes|first=Loïc|last2=Sénat|first2=Marie V.|last3=Le Lous|first3=Maëla|last4=Winer|first4=Norbert|last5=Rozenberg|first5=Patrick|last6=Kayem|first6=Gilles|last7=Verspyck|first7=Eric|last8=Fuchs|first8=Florent|last9=Azria|first9=Elie|last10=Gallot|first10=Denis|last11=Korb|first11=Diane|date=2021-04-29|title=Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery|url=http://www.nejm.org/doi/10.1056/NEJMoa2028788|journal=New England Journal of Medicine|language=en|volume=384|issue=17|pages=1623–1634|doi=10.1056/NEJMoa2028788|issn=0028-4793}}</ref>.
*Start [[oxytocin]] 30U in 500mL fluid over 3 hours after clamping of umbilical cord
*Monitor for hemodynamic variance (e.g. hypotension) after starting oxytocin
*Additional uterotonics may be requested by surgeon if uterine tone is not adequate (e.g. [[methylergonovine]], [[carboprost]], misoprostol)

===Emergence===

==Postoperative management==

===Disposition===

*L&D PACU
*Operating room PACU

===Pain management===

*Epidural [[morphine]] 1-3mg for long acting post-partum pain relief<ref>{{Cite journal|last=Fuller|first=John G.|last2=McMorland|first2=Graham H.|last3=Douglas|first3=M. Joanne|last4=Palmer|first4=Lynne|date=1990-09|title=Epidural morphine for analgesia after Caesarean section: a report of 4880 patients|url=http://link.springer.com/10.1007/BF03006481|journal=Canadian Journal of Anaesthesia|language=en|volume=37|issue=6|pages=636–640|doi=10.1007/BF03006481|issn=0832-610X}}</ref><ref>{{Cite journal|last=Bollag|first=Laurent|last2=Lim|first2=Grace|last3=Sultan|first3=Pervez|last4=Habib|first4=Ashraf S.|last5=Landau|first5=Ruth|last6=Zakowski|first6=Mark|last7=Tiouririne|first7=Mohamed|last8=Bhambhani|first8=Sumita|last9=Carvalho|first9=Brendan|date=2021-05|title=Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean|url=https://journals.lww.com/10.1213/ANE.0000000000005257|journal=Anesthesia & Analgesia|language=en|volume=132|issue=5|pages=1362–1377|doi=10.1213/ANE.0000000000005257|issn=0003-2999}}</ref>
*IT morphine 50-150mcg for long acting post-partum pain relief if spinal performed<ref>{{Cite journal|last=Bollag|first=Laurent|last2=Lim|first2=Grace|last3=Sultan|first3=Pervez|last4=Habib|first4=Ashraf S.|last5=Landau|first5=Ruth|last6=Zakowski|first6=Mark|last7=Tiouririne|first7=Mohamed|last8=Bhambhani|first8=Sumita|last9=Carvalho|first9=Brendan|date=2021-05|title=Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean|url=https://journals.lww.com/10.1213/ANE.0000000000005257|journal=Anesthesia & Analgesia|language=en|volume=132|issue=5|pages=1362–1377|doi=10.1213/ANE.0000000000005257|issn=0003-2999}}</ref>
*IV [[acetaminophen]]
*[[Ibuprofen]] PO post-op
*± [[Ketorolac]] (dependent upon surgeon preference and total blood loss)
* ± Wound infiltration
* ± Transversus abdominal block (TAP block) or quadratus lumborum block (for patients undergoing general anesthesia or neuroaxial without intrathecal opioid administration)
*± Continuous local anesthetic pain pump

===Potential complications===

*Ureteral injury
*Post-partum hemorrhage

==Procedure variants==

{| class="wikitable"
|+
!
!Neuraxial
!General
|-
|Unique considerations
|
*Decreased BP common with spinal anesthesia
*Given fluid pre-load or co-load
*Be prepared to provide bolus as vasopressors as needed
|
*GA normally used when neuraxial contraindicated or when there is not enough time to perform a block due to obstetric emergency

*Rapid sequence induction (RSI)
|-
|Position
|Left lateral tilt
|Left lateral tilt
|-
|Surgical time
|45-90min
|30-45min (given emergency delivery indications)
|-
|EBL
|500-1000mL
|500-1000mL
|-
|Postoperative disposition
|L&D PACU
|L&D or OR PACU
|-
|Pain management
|4
|6
|-
|Potential complications
|[[Post-dural-puncture headache]]
|
*Aspiration
*Difficult Airway
|}

==References==

[[Category:Surgical procedures]]
[[Category:Obstetric and gynecologic surgery]]

<references />

Hip arthroplasty

2022-07-18T19:29:04Z

Aharari:

{{Infobox surgical procedure
| anesthesia_type = General or spinal
± Regional
| airway = ETT if general
| lines_access = Large bore IV
± Arterial line
| monitors = Standard
± ABP
| considerations_preoperative =
| considerations_intraoperative = Risk for bone cement implantation syndrome (BCIS)
| considerations_postoperative = Multimodal analgesia
}}'''Hip arthroplasty''' ('''THA''') has become one of the most common orthopedic surgical procedures performed since 1960, and it is often one of the most successful. Indications for total hip arthroplasty include osteoarthritis, traumatic arthritis, avascular necrosis, post-proximal fracture arthrosis, and congenital hip dislocation. It is typically performed in patients ages 60 and over, but has been performed in patients of all ages depending on etiology. Older patients tend to require hip arthroplasty for indications like hip fracture and subsequent arthrosis/arthritis, osteoarthritis, while patients of all ages may require hip arthroplasty for indications such as traumatic arthritis and (juvenile) rheumatoid arthritis.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|RA pts: assess for cervical nerve root compression and antlanto-occipital instability. Imaging (lateral film XR) and exam performed as this will alter airway and positioning plans.

If regional planned: assess for presence of neurologic conditions (MS, neuropathies, existing nerve injuries) that may be relative contraindications
|-
|Cardiovascular
|Standard evaluation: more important for older patients with more cardiovascular risk factors. Often will need pharmacologic stress testing as pain and arthritis limit exercise capacity.
RA patients, consider increased risk for conduction abnormalities, valvular pathology (AR, valvular fibrosis), pericardial effusion.
|-
|Pulmonary
|Standard exercise capacity evaluation. In obese patients, evaluate for OSA and potential for resultant pHTN. In RA patients, consider pulmonary fibrosis, effusions, glottic narrowing. For all patients with arthritis, evaluate mouth opening (arthriticTMJ).
|-
|Gastrointestinal
|Standard evaluation including NPO status
|-
|Hematologic
|Consider patient anticoagulation status and direct for proper holding of anticoagulation, particularly as regional is used often in these cases. Preoperative hemoglobin should be obtained, as well as type and screen. Consider preoperative blood order (especially if revision).
|-
|Renal
|Preoperative kidney function (Cr, electrolytes) may be considered (effects on drug clearance; more important in geriatric populations).
|-
|Endocrine
|Standard evaluation, blood sugar control important for postoperative wound healing
|-
|Other
|Consider home pain medication regimen; will help guide perioperative analgesic plan.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P.
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start.
* If procedure is to be a revision, strongly consider ordering preoperative packed red blood cells (PRBCs).

=== Operating room setup ===
Standard operating room setup. Airway setup, suction, IV setup, induction medications, emergency drugs, analgesic agents should be prepared and readily accessible.

Tranexamic acid prior to incision and at closure being used in greater frequency for blood loss control<ref>{{Cite journal|last=Rajesparan|first=K.|last2=Biant|first2=L. C.|last3=Ahmad|first3=M.|last4=Field|first4=R. E.|date=2009-06|title=The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement|url=https://pubmed.ncbi.nlm.nih.gov/19483232|journal=The Journal of Bone and Joint Surgery. British Volume|volume=91|issue=6|pages=776–783|doi=10.1302/0301-620X.91B6.22393|issn=2044-5377|pmid=19483232}}</ref><ref>{{Cite journal|last=Peng Zhang|first=M. M.|last2=Jifeng Li|first2=M. M.|last3=Xiao Wang|first3=M. M.|date=2017-07|title=Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials|url=https://pubmed.ncbi.nlm.nih.gov/28602763|journal=International Journal of Surgery (London, England)|volume=43|pages=171–180|doi=10.1016/j.ijsu.2017.05.065|issn=1743-9159|pmid=28602763}}</ref>

Antibiotics considerations: Beta-lactam (cefazolin) +/- glycopeptide (vancomycin)

=== Patient preparation and premedication ===

* Multimodal analgesic technique recommended.
* Preoperative COX-2 inhibitors, gabapentin, and acetaminophen can be considered.
* Enhanced recovery protocols<ref>{{Cite journal|last=Wainwright|first=Thomas W.|last2=Gill|first2=Mike|last3=McDonald|first3=David A.|last4=Middleton|first4=Robert G.|last5=Reed|first5=Mike|last6=Sahota|first6=Opinder|last7=Yates|first7=Piers|last8=Ljungqvist|first8=Olle|date=2020-01-02|title=Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations|url=https://doi.org/10.1080/17453674.2019.1683790|journal=Acta Orthopaedica|volume=91|issue=1|pages=3–19|doi=10.1080/17453674.2019.1683790|issn=1745-3674|pmc=PMC7006728|pmid=31663402}}</ref> are using PO multimodal medications with greater frequency

=== Regional and neuraxial techniques ===
Advantages to neuraxial and regional techniques:

* improved postoperative pain control

* decreased risk of DVT/PE
* decreased intraoperative blood loss.

Neuraxial techniques (particularly spinal anesthesia) have been used with success in patients undergoing THA and especially beneficial in patients who may have a complicated or difficult airway. See [[Topic:Wbvci9l4oaxluxwj|discussion on drug choice]].
{| class="wikitable wikitable-horizontal-scroll"
|+
!Drug
!Conc.
!Baricity
!Dose
!Duration*
(min)
!Unique
Side-Effects
|-
|Bupivicaine<ref name=":0">{{Cite journal|last=Frey|first=K.|last2=Holman|first2=S.|last3=Mikat-Stevens|first3=M.|last4=Vazquez|first4=J.|last5=White|first5=L.|last6=Pedicini|first6=E.|last7=Sheikh|first7=T.|last8=Kao|first8=T. C.|last9=Kleinman|first9=B.|last10=Stevens|first10=R. A.|date=1998-03|title=The recovery profile of hyperbaric spinal anesthesia with lidocaine, tetracaine, and bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/9570604|journal=Regional Anesthesia and Pain Medicine|volume=23|issue=2|pages=159–163|doi=10.1097/00115550-199823020-00008|issn=1098-7339|pmid=9570604}}</ref><ref name=":1">{{Cite journal|last=Malinovsky|first=J. M.|last2=Charles|first2=F.|last3=Kick|first3=O.|last4=Lepage|first4=J. Y.|last5=Malinge|first5=M.|last6=Cozian|first6=A.|last7=Bouchot|first7=O.|last8=Pinaud|first8=M.|date=2000-12|title=Intrathecal anesthesia: ropivacaine versus bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/11094000|journal=Anesthesia and Analgesia|volume=91|issue=6|pages=1457–1460|doi=10.1097/00000539-200012000-00030|issn=0003-2999|pmid=11094000}}</ref>
|0.75%
|Hyperbaric
|12-16mg
|90-120
|
|-
|Bupivicaine<ref name=":0" /><ref name=":1" />
|0.5%
|Isobaric
|12-16mg
|90-120
|
|-
|Lidocaine<ref name=":0" /><ref>{{Cite journal|last=Liam|first=B. L.|last2=Yim|first2=C. F.|last3=Chong|first3=J. L.|date=1998-07|title=Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery|url=https://pubmed.ncbi.nlm.nih.gov/9717596|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=45|issue=7|pages=645–650|doi=10.1007/BF03012094|issn=0832-610X|pmid=9717596}}</ref><ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref>
|1-2%
5%
|Isobaric;
hyperbaric
|60-80mg
|60-90
|TNS (7%)
|-
|Mepivicaine<ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref><ref>{{Cite journal|last=Pawlowski|first=J.|last2=Sukhani|first2=R.|last3=Pappas|first3=A. L.|last4=Kim|first4=K. M.|last5=Lurie|first5=J.|last6=Gunnerson|first6=H.|last7=Corsino|first7=A.|last8=Frey|first8=K.|last9=Tonino|first9=P.|date=2000-09|title=The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/10960380|journal=Anesthesia and Analgesia|volume=91|issue=3|pages=580–584|doi=10.1097/00000539-200009000-00015|issn=0003-2999|pmid=10960380}}</ref><ref>{{Cite journal|last=Zayas|first=V. M.|last2=Liguori|first2=G. A.|last3=Chisholm|first3=M. F.|last4=Susman|first4=M. H.|last5=Gordon|first5=M. A.|date=1999-11|title=Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique|url=https://pubmed.ncbi.nlm.nih.gov/10553828|journal=Anesthesia and Analgesia|volume=89|issue=5|pages=1167–1171|issn=0003-2999|pmid=10553828}}</ref><ref>{{Cite journal|last=Schwenk|first=Eric S.|last2=Kasper|first2=Vincent P.|last3=Smoker|first3=Jordan D.|last4=Mendelson|first4=Andrew M.|last5=Austin|first5=Matthew S.|last6=Brown|first6=Scot A.|last7=Hozack|first7=William J.|last8=Cohen|first8=Alexa J.|last9=Li|first9=Jonathan J.|last10=Wahal|first10=Christopher S.|last11=Baratta|first11=Jaime L.|date=2020-10-01|title=Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation|url=https://pubmed.ncbi.nlm.nih.gov/32852904|journal=Anesthesiology|volume=133|issue=4|pages=801–811|doi=10.1097/ALN.0000000000003480|issn=1528-1175|pmid=32852904}}</ref>
|1.5%
|Isobaric
|50-80mg
|100-120
|TNS (7%)
|-
|Chloroprocaine<ref>{{Cite journal|last=Goldblum|first=E.|last2=Atchabahian|first2=A.|date=2013-05|title=The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia|url=http://doi.wiley.com/10.1111/aas.12071|journal=Acta Anaesthesiologica Scandinavica|language=en|volume=57|issue=5|pages=545–552|doi=10.1111/aas.12071}}</ref><ref>{{Cite journal|last=Lacasse|first=Marie-Andrée|last2=Roy|first2=Jean-Denis|last3=Forget|first3=Josée|last4=Vandenbroucke|first4=Franck|last5=Seal|first5=Robert F.|last6=Beaulieu|first6=Danielle|last7=McCormack|first7=Michael|last8=Massicotte|first8=Luc|date=2011-04|title=Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial|url=http://link.springer.com/10.1007/s12630-010-9450-x|journal=Canadian Journal of Anesthesia/Journal canadien d'anesthésie|language=en|volume=58|issue=4|pages=384–391|doi=10.1007/s12630-010-9450-x|issn=0832-610X}}</ref><ref>{{Cite journal|last=Kouri|first=Mary E.|last2=Kopacz|first2=Dan J.|date=2004-01|title=Spinal 2-Chloroprocaine: A Comparison with Lidocaine in Volunteers:|url=http://journals.lww.com/00000539-200401000-00020|journal=Anesthesia & Analgesia|language=en|pages=75–80|doi=10.1213/01.ANE.0000093228.61443.EE|issn=0003-2999}}</ref><ref>{{Cite journal|last=Smith|first=Kristin N.|last2=Kopacz|first2=Dan J.|last3=McDonald|first3=Susan B.|date=2004-01|title=Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine|url=https://pubmed.ncbi.nlm.nih.gov/14693591|journal=Anesthesia and Analgesia|volume=98|issue=1|pages=81–88, table of contents|doi=10.1213/01.ane.0000093361.48458.6e|issn=0003-2999|pmid=14693591}}</ref>
|2%
|Hyperbaric
|30-60mg
|30-50 (2-level regression)
60-90 (motor)

100-130 (ambulation)
|Flu-like symptoms
and back ache with

epinephrine addition
|}
Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken. Additional considerations for post operative mobilization. Some surgical teams and fast tracking joint replacement centers may mobilize patients as early as 2-4 hours postoperatively to help prevent DVT. <ref>Chua, Matthew J et al. “Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.” ''PloS one'' vol. 12,6 e0179820. 27 Jun. 2017, doi:10.1371/journal.pone.0179820</ref>

Time of procedure should also be considered, as spinal anesthesia has a limited duration of action (typically 2-3 hours, depending on agents used).

Intrathecal long-acting morphine can be considered for postoperative pain control with an understanding that patient selection is important for administration of this medication given the risk for respiratory depression and long duration of action.

Single shot peripheral regional nerve blocks can be used to improve postoperative analgesia, but are not sufficient as a primary anesthetic. Patients must be able to assume the position required to place these blocks. Blocks can help reduce postoperative opiate requirements. Blocks used include:

* femoral
* lumbar plexus
* quadratus lumborum (QL)
* fascia iliaca
*lumbar ESP (Erector spinae plane) block

== Intraoperative management ==

=== Monitoring and access===
Standard ASA monitoring. Consider addition of intraoperative EEG monitoring (BIS or similar).

2 large-bore PIV should be obtained. Arterial line for hemodynamic monitoring should be considered for revision procedures, cases with predicted significant blood loss, and for patients with significant cardiopulmonary disease.

=== Induction and airway management===
Induction can be tailored to individual patient comorbidities and acuity. RSI induction is indicated for trauma patients or those without proper fasting per ASA guidelines. For patients with rheumatoid arthritis, special consideration should be given to the airway and potential for cervical (atlanto-occipital) instability. In these cases, videolaryngoscopy or fiberoptic intubation should be considered and utilized.

Induction and intubation on the preoperative bed prior to moving to the operating room table should be considered if possible for patients in whom it would cause significant pain (and resultant physiologic and emotional stress) to execute this move.

=== Positioning===
{| class="wikitable wikitable-horizontal-scroll"
|+
!Surgical Approach
!Lateral
!Posterior
!Anterior/Anterolateral
|-
|Position
|Lateral decubitus
|Lateral decubitus
|Supine
|-
|Special Equipment
|Axillary roll/bean bag
|Axillary roll/bean bag
|Hana Table
Traction boots attachment to Hana table
|-
|Positioning Concerns
|Brachial plexus injury
Neck positioning

Check PIV flow
|Brachial plexus injury
Neck positioning

Check PIV flow
|
|}
If lateral positioning, a beanbag and axillary roll are typically used. Additional blankets/pillows/foam will be needed for under the patients head (to ensure neutral positioning of cervical spine) and to cushion the upper extremities. Reassess padding of pressure points, eye/ear position, monitors, and PIV patency after positioning is complete and prior to case start.

=== Neuraxial vs General Anesthesia ===
Observations studies have suggested improved outcomes if neuraxial (particularly spinal) anesthesia is utilized as primary anesthetic over general anesthesia. A recent randomized trial out of NEJM with 1600 patients age >50 compared spinal anesthesia vs general anesthesia (GA) and found:

* Death or inability to walk independently at 60 days: 18.5% in spinal vs 18.0% in GA (RR 1.03, 95%CI .84-1.27, P=.83)
* Death by day 60: 3.9% in spinal vs 4.1% in GA (RR 0.97, 95%CI .59-1.57)
* Inability to walk at day 60: 15.2% in spinal vs 14.4% in GA (RR 1.06, 95%CI .82-1.36)
* New onset delirium: 20.5% in spinal vs 19.7% in GA (RR 1.04, 95%CI .84-1.30)
* Median time to discharge in US: 3 days in spinal vs 3 days in GA (RR 1.06, 95%CI .96-1.16)

In general according to this study, '''spinal anesthesia was not superior to general anesthesia''' with respect to 60 day survival and ambulation. Additional postoperative delirium was similar between spinal and GA. <ref>{{Cite journal|last=Neuman|first=Mark D.|last2=Feng|first2=Rui|last3=Carson|first3=Jeffrey L.|last4=Gaskins|first4=Lakisha J.|last5=Dillane|first5=Derek|last6=Sessler|first6=Daniel I.|last7=Sieber|first7=Frederick|last8=Magaziner|first8=Jay|last9=Marcantonio|first9=Edward R.|last10=Mehta|first10=Samir|last11=Menio|first11=Diane|date=2021-11-25|title=Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults|url=https://doi.org/10.1056/NEJMoa2113514|journal=New England Journal of Medicine|volume=385|issue=22|pages=2025–2035|doi=10.1056/NEJMoa2113514|issn=0028-4793}}</ref>

=== Evidence for TXA ===
Tranexamic acid (TXA) is an antifibrinolytic agent often used in cardiac and trauma surgery to reduce clot breakdown and subsequent bleeding. TXA has been introduced into procedures with bleeding risk and has been shown to help decrease transfusions and overall blood loss.

Meta analysis of TXA use in total hip arthroplasty reveled strong evidence to reduce blood loss and risk of transfusion.<ref>Yale A. Fillingham, Dipak B. Ramkumar, David S. Jevsevar, Adolph J. Yates, Peter Shores, Kyle Mullen, Stefano A. Bini, Henry D. Clarke, Emil Schemitsch, Rebecca L. Johnson, Stavros G. Memtsoudis, Siraj A. Sayeed, Alexander P. Sah, Craig J. Della Valle,

The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-analysis,

The Journal of Arthroplasty,

Volume 33, Issue 10,

2018,

Pages 3083-3089.e4,

ISSN 0883-5403,

<nowiki>https://doi.org/10.1016/j.arth.2018.06.023</nowiki>.

(<nowiki>https://www.sciencedirect.com/science/article/pii/S088354031830593X</nowiki>)</ref> When compared with placebo, IV administration of TXA reduced blood loss by 504 mL and decreased the number of units transfused per patient by 1.43 units. In this meta-analysis, 14 of 15 studies used low doses (10 to 50 mg/kg) of TXA, and the remaining study used a high-dose (150 mg/kg) regimen.<ref>Yang ZG, Chen WP, Wu LD: Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: A meta-analysis. J Bone Joint Surg Am 2012;94(13):1153–1159.</ref>

=== Maintenance and surgical considerations ===
Standard maintenance. Neuromuscular blockade required if GA, as this facilitates good operating conditions and allows the surgical team to properly test and place the prostethic(s).

=== Emergence ===
Standard emergence. PONV prophylaxis dependent on patient risk factors, usually ondansetron 4mg IV.

== Postoperative management ==

=== Disposition ===
Typically PACU.

Specialty centers are conducting same-day discharge<ref>{{Cite journal|last=Amundson|first=Adam W.|last2=Panchamia|first2=Jason K.|last3=Jacob|first3=Adam K.|date=2019-06|title=Anesthesia for Same-Day Total Joint Replacement|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227519300060|journal=Anesthesiology Clinics|language=en|volume=37|issue=2|pages=251–264|doi=10.1016/j.anclin.2019.01.006}}</ref><ref>{{Cite journal|last=Li|first=Jinlei|last2=Rubin|first2=Lee E.|last3=Mariano|first3=Edward R.|date=2019-10|title=Essential elements of an outpatient total joint replacement programme|url=https://journals.lww.com/10.1097/ACO.0000000000000774|journal=Current Opinion in Anaesthesiology|language=en|volume=32|issue=5|pages=643–648|doi=10.1097/ACO.0000000000000774|issn=0952-7907}}</ref> for pre-screened populations<ref>{{Cite journal|last=Ziemba-Davis|first=Mary|last2=Caccavallo|first2=Peter|last3=Meneghini|first3=R. Michael|date=2019-07|title=Outpatient Joint Arthroplasty—Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score|url=https://linkinghub.elsevier.com/retrieve/pii/S0883540319300348|journal=The Journal of Arthroplasty|language=en|volume=34|issue=7|pages=S40–S43|doi=10.1016/j.arth.2019.01.007}}</ref> with low-comorbidities and with adequate home support structure

ICU disposition depending on acuity, co-morbidities, and procedure planned (consider this especially with trauma patients or revision cases that have the potential for massive transfusion.

=== Pain management ===
Multimodal regimen, consider long-acting opioid agents if no contraindications or risk factors (pulmonary status). Ketamine bolus at induction or low-dose continuous infusion can act as analgesic adjunct. Consider supplementing with single shot peripheral nerve block (fascia iliaca, QL, lumbar plexus, femoral) if no contraindications and patient can tolerate positioning required for block.

=== Potential complications ===

* Bone Cement Implantation Syndrome (BCIS)--if pressurized insertion of bone cement (methylmethacrylate) is used ( while hammering of femoral head into acetabulum). Signs can range from mild hypoxia and hypotension to full cardiovascular collapse. Pathophysiology is incompletely understood, but is likely multifactorial in nature consisting of microembolic showering (of air, fat, bone, cement), histamine release/hypersensitivity, complement activation. Treatment is supportive (fluids, vasopressor support, and ACLS in complete cardiovascular collapse), therefore immediate recognition and intervention is important.
* Venous Air Embolism (VAE)
* Venous Fat Embolism
* Blood Loss
* DVT
* Femoral Fracture

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
* Depending upon surgical approach. Anterior/anterolateral approaches are performed supine, while lateral or posterior approaches are usually performed in lateral decubitus.
!
!Unipolar or Bipolar
!Revision of THA
!Anterior Approach
|-
|Unique considerations
|'''unipolar''': only femoral head replaced

'''bipolar''': femoral and acetabular side are both replaced
|blood loss
|
|-
|Position
|supine vs lateral decubitus (surgical side up)*
| --
|
|-
|Surgical time
|2-3hrs
|3+ hours
|
|-
|EBL
|250-750cc
|>1000cc
|
|-
|Postoperative disposition
|PACU
|PACU vs ICU (depending on transfusion needs or acuity may need to remain intubated)
|
|-
|Pain management
|multimodal
|multimodal; if infected prosthetic, regional may be avoided depending on extent of infection, overlying infected tissue.
|
|-
|Potential complications
|see above
|see above
|Femoral artery injury
during dissection between vastus lateralis and sartorius
|}

=== Enhanced Recovery after Surgery (ERAS): ===

== References ==
<references />
[[Category:Surgical procedures]]
[[Category:Orthopedic surgery]]
[[Category:Hip surgery]]
[[Category:Joint replacement surgery]]

Upper GI endoscopy

2022-07-14T22:26:02Z

Aharari:

{{Infobox surgical procedure
| anesthesia_type = MAC vs. GA
| airway = Natural airway
| lines_access = 1 PIV
| monitors = Standard ASA
| considerations_preoperative = GERD, unstable airway from upper GI bleed
| considerations_intraoperative = Aspiration risk
| considerations_postoperative =
}}

An '''upper GI endoscopy''' (or '''EGD''') is a procedure where a flexible scope is inserted through the mouth to diagnose and treat problems with the upper GI tract (esophagus, stomach, duodenum). It is commonly used to further work up patients with:

* upper GI bleed
* severe GERD
* dysphagia
* intractable vomiting
* non-cardiac chest/abdominal pain
* unexplained weight loss

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Especially important to assess risk of patient obstructing upon induction when GA with natural airway or MAC is the anesthetic plan.
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Review risk factors for OSA i.e STOP BANG
|-
|Gastrointestinal
|
|-
|Hematologic
|Patients may be acutely anemic from upper gi bleed, assess appropriateness of transfusing PRBC prior to procedure
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===
Preoperative Hgb for patients with severe bleeding.

=== Operating room setup ===

* Nasal cannula
* Propofol drip
*Prepare to manage airway if severe hypoxemia develop, with ability to provide positive pressure ventilation with 100% oxygen.
*Succinylcholine for treatment of laryngospasm

=== Patient preparation and premedication ===
Consider using an antisialagogue such as glycopyrrolate for patients considered high risk for increased secretions.

=== Regional and neuraxial techniques ===
N/A

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* 1 PIV

=== Induction and airway management ===
GA w/ natural airway vs MAC sedation. The insertion of the scope itself can be quite stimulating, and many patients may not be able to tolerate this with MAC sedation. Use nasal cannula for oxygenation. Nasal CPAP or High flow oxygen may be appropriate for patients at high risk of obstructing and becoming hypoxemic.

For patients with severe upper GI bleed or severe GERD who are at risk of aspiration, consider RSI with ETT to secure airway.

=== Positioning ===
Generally left lateral decubitus

=== Maintenance and surgical considerations ===

* Propofol drip
*intermittent boluses of propofol may be used in shorter duration cases

=== Emergence ===

== Postoperative management ==

=== Disposition ===
To PACU and generally safe discharge to home/floor within hours.

=== Pain management ===
Minimal pain

=== Potential complications ===
Patients can be high aspiration risk if there is severe upper GI bleed or severe GERD.

Hypoxemia

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]