WikiAnesthesia - User contributions [en]

Trauma surgery

2025-07-16T18:58:48Z

Asdoyal: added tables. Edited many sections.

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore PIV (14, 16g), Sheath introducers (Cordis), triple lumen central line, arterial line
| monitors =
| considerations_preoperative = Full stomach, airway trauma, hypovolemia
| considerations_intraoperative = bleeding
| considerations_postoperative =
}}

Trauma is a leading cause of death and disability worldwide, particularly in individuals under 45. Anesthetic management of trauma patients requires rapid decision-making, physiologic insight, and close coordination with surgical, emergency, and critical care teams. Hemorrhagic shock remains a primary driver of early mortality, with damage control resuscitation (DCR) principles serving as the cornerstone of early care (Fort & Zack-Guasp 2020).<ref name=":0">{{Cite journal|last=Fort|first=Alexander C.|last2=Zack-Guasp|first2=Richard A.|date=2020-03|title=Anesthesia for Patients with Extensive Trauma|url=https://pubmed.ncbi.nlm.nih.gov/32008648|journal=Anesthesiology Clinics|volume=38|issue=1|pages=135–148|doi=10.1016/j.anclin.2019.10.012|issn=1932-2275|pmid=32008648}}</ref> Anesthetic care begins in the trauma bay and extends through the operating room (OR) to the intensive care unit (ICU), requiring continuity and adaptability (Tobin et al. 2018).<ref name=":1">{{Cite journal|last=Tobin|first=Joshua M.|last2=Barras|first2=William P.|last3=Bree|first3=Stephen|last4=Williams|first4=Necia|last5=McFarland|first5=Craig|last6=Park|first6=Claire|last7=Steinhiser|first7=David|last8=Stone|first8=R. Craig|last9=Stockinger|first9=Zsolt|date=2018-09-01|title=Anesthesia for Trauma Patients|url=https://pubmed.ncbi.nlm.nih.gov/30189066|journal=Military Medicine|volume=183|issue=suppl_2|pages=32–35|doi=10.1093/milmed/usy062|issn=1930-613X|pmid=30189066}}</ref>

== Overview ==

=== Indications ===
Trauma surgery under anesthesia is indicated when patients present with injuries requiring emergent or urgent operative intervention, such as:

* Uncontrolled hemorrhage
* Hollow viscus or solid organ injury
* Penetrating trauma
* Open fractures
* Vascular compromise
* Compartment syndrome

Indications for anesthetic involvement extend beyond the OR, often beginning with airway support, hemodynamic resuscitation, and pain management in the emergency department (Pollock et al. 2023).<ref name=":2">{{Cite journal|last=Pollock|first=Gabriel A.|last2=Lo|first2=Jessie|last3=Chou|first3=Henry|last4=Kissen|first4=Michael S.|last5=Kim|first5=Michelle|last6=Zhang|first6=Vida|last7=Betz|first7=Alexander|last8=Perlman|first8=Ryan|date=2023-01|title=Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review|url=https://pubmed.ncbi.nlm.nih.gov/36096943|journal=British Journal of Anaesthesia|volume=130|issue=1|pages=e80–e91|doi=10.1016/j.bja.2022.07.005|issn=1471-6771|pmid=36096943}}</ref>

=== Surgical procedure ===
Trauma surgery encompasses a wide range of procedures, from exploratory laparotomy and thoracotomy to damage control orthopedics and vascular repair. Procedures are often staged, with initial operations focused on hemorrhage and contamination control, followed by definitive repair after physiologic stabilization (Tobin et al. 2018).<ref name=":1" />

== Preoperative management ==

=== Patient evaluation ===
Initial evaluation follows Advanced Trauma Life Support (ATLS) principles, with a primary survey (ABCDE) to identify and address life-threatening conditions (Fort & Zack-Guasp 2020). <ref name=":0" />

'''A – Airway with cervical spine protection'''

* Assess for patency: look for obstruction, facial trauma, or burns.
* Intervene with suction, airway adjuncts (e.g., oropharyngeal/nasopharyngeal airway), or definitive airway (endotracheal intubation) as needed.
* Always assume cervical spine injury in trauma patients; apply cervical collar and maintain manual in-line stabilization during airway maneuvers.

'''B – Breathing and ventilation'''

* Evaluate chest movement, symmetry, respiratory rate, and effort.
* Auscultate lung fields; identify pneumothorax, hemothorax, or flail chest.
* Provide oxygen; initiate positive pressure ventilation if inadequate.
* Consider needle decompression or chest tube for tension pneumothorax or massive hemothorax.

'''C – Circulation with hemorrhage control'''

* Check pulse rate, blood pressure, capillary refill, and skin perfusion.
* Look for external bleeding; apply direct pressure or tourniquets.
* Establish two large-bore IVs or intraosseous access.
* Initiate fluid resuscitation and activate massive transfusion protocol if needed.
* Perform FAST exam and pelvic X-ray for occult bleeding.

'''D – Disability (neurologic evaluation)'''

* Perform rapid neurologic assessment using the '''Glasgow Coma Scale (GCS)'''.
* Check pupillary size and response.
* Identify signs of traumatic brain injury or spinal cord injury.

'''E – Exposure and environmental control'''

* Fully expose the patient to identify hidden injuries.
* Prevent hypothermia using warm blankets, warming devices, and warmed IV fluids.
* Maintain privacy and dignity once life-threatening injuries are excluded.

Neurologic status should be assessed with the Glasgow Coma Scale (GCS). Patients with traumatic brain injury, thoracic trauma, or unstable hemodynamics require special anesthetic consideration.
{| class="wikitable"
!'''Component'''
!'''Response'''
!'''Score'''
|-
|'''Eye Opening'''
|Spontaneous
|4
|-
|
|To voice
|3
|-
|
|To pain
|2
|-
|
|No response
|1
|-
|'''Verbal Response'''
|Oriented
|5
|-
|
|Confused
|4
|-
|
|Inappropriate words
|3
|-
|
|Incomprehensible sounds
|2
|-
|
|No response
|1
|-
|'''Motor Response'''
|Obeys commands
|6
|-
|
|Localizes pain
|5
|-
|
|Withdraws from pain
|4
|-
|
|Abnormal flexion (decorticate)
|3
|-
|
|Abnormal extension (decerebrate)
|2
|-
|
|No response
|1
|}
{| class="wikitable"
|+
{| class="wikitable"
!'''System'''
!'''Considerations in Trauma and Anesthetic Implications'''
|-
|'''Airway'''
|Facial fractures, airway edema, blood/vomit, cervical spine instability; may require RSI or surgical airway
|-
|'''Neurologic'''
|Traumatic brain injury (TBI), spinal cord injury; avoid hypoxia/hypotension, maintain cerebral perfusion, use GCS
|-
|'''Cardiovascular'''
|Hemorrhagic shock, tamponade, myocardial contusion; requires volume resuscitation, blood products, vasoactive agents
|-
|'''Pulmonary'''
|Pneumothorax, hemothorax, pulmonary contusion, flail chest; manage with chest tubes, lung-protective ventilation
|-
|'''Gastrointestinal'''
|Bowel injury, hepatic/splenic laceration; risk of peritonitis, sepsis, rapid deterioration; damage control laparotomy may be needed
|-
|'''Hematologic'''
|Coagulopathy (trauma-induced or dilutional), massive transfusion; use balanced ratios, TXA, monitor with TEG/ROTEM
|-
|'''Renal'''
|Hypoperfusion, rhabdomyolysis, contrast-induced nephropathy; maintain perfusion, monitor creatinine, avoid nephrotoxins
|-
|'''Endocrine'''
|Adrenal insufficiency (especially in chronic steroid users), hyperglycemia; consider stress-dose steroids, tight glucose control
|-
|'''Other'''
|Hypothermia, acidosis, electrolyte disturbances (esp. hyperkalemia); actively warm patient, correct derangements, monitor closely
|}
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===
Essential investigations include:

* Point-of-care labs (ABG, lactate, Hgb)
* Type and crossmatch
* Coagulation panel
* Focused Assessment with Sonography for Trauma (FAST)
* Chest/pelvis radiographs
* Extended FAST (E-FAST) including lung and cardiac views (Pollock et al. 2023)<ref name=":2" />

Viscoelastic testing (e.g., TEG/ROTEM/QUANTRA) aids in goal-directed blood product administration during active resuscitation (Pollock et al. 2023).<ref name=":2" />

=== Operating room setup ===

=== Patient preparation and premedication ===
Premedication is often avoided in unstable trauma patients due to risk of hypotension and hypoventilation. Preoxygenation should be optimized; apneic oxygenation may be used if necessary (Tobin et al. 2018).<ref name=":1" /> Anticipate difficult airway and cervical spine precautions.

=== Regional and neuraxial techniques ===
Regional anesthesia is increasingly used for trauma, particularly for extremity and rib fractures. Early blockade may improve pain control, decrease opioid exposure, and reduce the risk of chronic pain (Torrie 2022).<ref name=":3">{{Cite journal|last=Torrie|first=Arissa M.|date=2022-10-01|title=Regional anesthesia and analgesia for trauma: an updated review|url=https://pubmed.ncbi.nlm.nih.gov/36044292|journal=Current Opinion in Anaesthesiology|volume=35|issue=5|pages=613–620|doi=10.1097/ACO.0000000000001172|issn=1473-6500|pmid=36044292}}</ref> However, coagulopathy, hypotension, and polytrauma may limit feasibility. Single-shot blocks are preferred in unstable patients (Torrie 2022).<ref name=":3" /><ref name=":4">{{Cite journal|last=Saranteas|first=Theodosios|last2=Koliantzaki|first2=Iosifina|last3=Savvidou|first3=Olga|last4=Tsoumpa|first4=Marina|last5=Eustathiou|first5=Georgia|last6=Kontogeorgakos|first6=Vasileios|last7=Souvatzoglou|first7=Rizos|date=2019-07|title=Acute pain management in trauma: anatomy, ultrasound-guided peripheral nerve blocks and special considerations|url=https://pubmed.ncbi.nlm.nih.gov/30735016|journal=Minerva Anestesiologica|volume=85|issue=7|pages=763–773|doi=10.23736/S0375-9393.19.13145-8|issn=1827-1596|pmid=30735016}}</ref>

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitors are used, but trauma patients often require:

* Arterial line (preferably pre-induction)
* Large-bore IV or intraosseous access
* Central venous access if volume resuscitation is ongoing
* Temperature monitoring
* POCUS or TEE for hemodynamic assessment (Pollock et al. 2023)<ref name=":2" />

=== Induction and airway management ===
Rapid sequence induction (RSI) is standard in trauma to mitigate aspiration risk.

Ketamine and etomidate are commonly used induction agents due to hemodynamic stability; propofol is often avoided in hypovolemic patients (Pillay & Hardcastle 2016).<ref>{{Cite journal|last=Pillay|first=Leressè|last2=Hardcastle|first2=Timothy|date=2017-05|title=Collective Review of the Status of Rapid Sequence Intubation Drugs of Choice in Trauma in Low- and Middle-Income Settings (Prehospital, Emergency Department and Operating Room Setting)|url=https://pubmed.ncbi.nlm.nih.gov/27646281|journal=World Journal of Surgery|volume=41|issue=5|pages=1184–1192|doi=10.1007/s00268-016-3712-x|issn=1432-2323|pmid=27646281}}</ref> RSI with succinylcholine or rocuronium are used for neuromuscular blockade.

In patients with an unstable or uncleared cervical spine need in-line stabilization during intubation. Video Laryngoscopy (VL) may further reduce neck movement during intubation.

In patients with maxillofacial trauma, airway burns, or penetrating neck injuries, surgical airway may be required. Airway ultrasound may aid in identifying the cricothyroid membrane in challenging scenarios (Pollock et al. 2023).<ref name=":2" />

=== Positioning ===
Positioning is dictated by injury and surgical needs, with attention to spinal precautions and pressure point protection.<ref name=":0" /><ref name=":1" />

Positioning should allow for:

* Surgical access
* Hemodynamic optimization
* Prevention of pressure injuries
* Ongoing access to IV lines and monitoring

Trauma patients are often unstable, and movement may precipitate hemodynamic deterioration. Team communication is essential.<ref name=":0" /><ref name=":2" /><ref name=":1" />

=== Maintenance and surgical considerations ===
Maintenance anesthesia is guided by surgical stage and patient physiology. A typical combination of volatile anesthetics, opioids, and adjuncts (e.g., ketamine infusion) is used as tolerated. Continuous reassessment is essential.

Permissive hypotension (SBP 80–90 mmHg) is accepted in select patients without TBI (Fort & Zack-Guasp 2020).<ref name=":0" />

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used for non-compressible torso hemorrhage (Pollock et al. 2023).<ref name=":2" />

=== Emergence ===
Emergence is often delayed in intubated or unstable patients requiring vasopressor support.

If extubation is considered, ensure:

* Adequate reversal of paralysis
* Hemodynamic stability
* Lack of vasopressive agents
* Full return of airway reflexes
* Pain well controlled
* Patient not receiving large volume resuscitation (blood products/crystaloid/colloids)

Otherwise, patients should remain intubated and sedated for ICU transfer.

== Postoperative management ==

=== Disposition ===
Most poly-trauma patients require ICU-level care postoperatively, especially those with ongoing ventilation, multisystem injuries, or high transfusion requirements. Effective handoff communication is essential for continuity of care (Tobin et al. 2018).<ref name=":1" />

=== Pain management ===
Multimodal analgesia should be used, including:

* Opioids
* Acetaminophen, NSAIDs (if renal and bleeding risk acceptable)
* Ketamine
* Lidocaine infusion
* Regional anesthesia if feasible (Torrie 2022)<ref name=":3" /><ref name=":4" />

Chronic pain and opioid dependence are common post-trauma sequelae, so early and adequate pain control is critical.

=== Potential complications ===
Trauma "Triad of Death:"

* Hypothermia
* Acidosis
* Coagulopathy
*
* Rebleeding
* ARDS
* Acute kidney injury
* Sepsis

* Chronic pain and opioid dependence

== Procedure variants ==

While core principles remain the same, anesthetic considerations differ across trauma subtypes:

{| class="wikitable wikitable-horizontal-scroll"
|+
|
|'''Abdominal Trauma'''
|'''Extremity Trauma'''
|'''Thoracic Trauma'''
|'''Burns'''
|'''Pelvic Fractures'''
|'''TBI'''
|-
|'''Unique considerations'''
|Hollow viscus or solid organ injury; contamination risk; risk of abdominal compartment syndrome
|Compartment syndrome, tourniquet use, long bone hemorrhage, external fixator
|May require lung isolation, PEEP titration, and avoidance of nitrous oxide
|Anticipate airway edema and hypermetabolic response
|High risk of hemorrhage; consider early use of REBOA
|Maintain normocapnia, avoid hypotension, optimize cerebral perfusion
|-
|'''Position'''
|Supine; may require arms tucked and wide exposure
|Supine; limb may be prepped/draped independently, traction devices possible
|Supine with single-lung ventilation setup if needed
|Supine; avoid pressure on burns, special pads if needed
|Supine; pelvic binder or external fixator may be in place
|Supine, head midline, 30Â° elevation to optimize venous return
|-
|'''Surgical time'''
|Short for damage control, long for definitive repair
|Often prolonged if multiple fractures or staged fixation
|Varies depending on injury; may be urgent/emergent
|Often prolonged depending on TBSA and grafting
|Staged procedures often required
|Often combined with other injury repair, timing dependent
|-
|'''Estimated Blood Loss (EBL)'''
|High risk of major bleeding, especially with liver/spleen injuries
|Moderate; varies by fracture severity and soft tissue injury
|Can be significant with vascular or pulmonary vessel injury
|Variable; large TBSA burns may lose significant volume
|Very high, particularly with open or unstable fractures
|Usually minimal unless combined with multisystem trauma
|-
|'''Postoperative disposition'''
|ICU for continued resuscitation, possible second-look laparotomy
|Step-down or floor if stable; ICU if polytrauma
|ICU likely for respiratory support and monitoring
|ICU for ventilatory and fluid management, infection monitoring
|ICU for hemodynamic monitoring and ongoing resuscitation
|Neuro ICU; monitor ICP, avoid secondary brain injury
|-
|'''Pain management'''
|Multimodal; systemic opioids, epidural rarely used due to coagulopathy
|Regional (e.g., femoral or fascia iliaca block) plus systemic meds
|Paravertebral, epidural, or serratus plane blocks; minimize opioids
|IV opioids, ketamine, adjunctive anxiolytics; regional rarely feasible
|Systemic opioids, consider lumbar plexus or LFCN blocks
|IV acetaminophen, opioids with caution; avoid sedation masking exam
|-
|'''Potential complications'''
|Sepsis, multi-organ failure, re-bleeding, abdominal compartment syndrome
|Infection, fat embolism, delayed union, neuropathy
|Pneumothorax, hemothorax, respiratory failure
|Airway loss, sepsis, hypothermia, metabolic derangements
|Hemorrhage, coagulopathy, urologic or bowel injury
|Elevated ICP, seizures, neurogenic pulmonary edema
|}

== References ==

[[Category:Surgical procedures]]

Trauma surgery

2025-07-16T18:35:10Z

Asdoyal: This is the initial write up of an empty page

Pancreatic Islet Cell Transplant

2024-11-12T15:57:48Z

Asdoyal:

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}Pancreatic islet cell transplantation involves removing the entire pancreas (total pancreatectomy) and then reinfusing the extracted islet cells into the patient’s portal vein. After the pancreas is removed, islet cells are isolated and suspended in a solution for infusion. This autotransplantation procedure helps patients achieve better glycemic control, reducing complications and enhancing quality of life for those with type 1 diabetes.<ref>{{Cite journal|last=Desai|first=Chirag S.|last2=Stephenson|first2=Derek A.|last3=Khan|first3=Khalid M.|last4=Jie|first4=Tun|last5=Gruessner|first5=Angelika C.|last6=Rilo|first6=Horacio L.|last7=Gruessner|first7=Rainer W.G.|date=2011-12|title=Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients|url=https://journals.lww.com/00019464-201112000-00023|journal=Journal of the American College of Surgeons|language=en|volume=213|issue=6|pages=e29–e34|doi=10.1016/j.jamcollsurg.2011.09.008|issn=1072-7515}}</ref>

==Overview==
===Indications===
Pancreatic islet cell transplantation is indicated primarily for patients with type 1 diabetes who experience severe hypoglycemia despite intensive diabetes management and education. According to the American Diabetes Association, allogeneic islet transplantation is specifically indicated for adults with type 1 diabetes who are unable to achieve their A1C goals due to recurrent severe hypoglycemia.<ref>{{Cite journal|last=American Diabetes Association Professional Practice Committee|last2=ElSayed|first2=Nuha A.|last3=Aleppo|first3=Grazia|last4=Bannuru|first4=Raveendhara R.|last5=Bruemmer|first5=Dennis|last6=Collins|first6=Billy S.|last7=Ekhlaspour|first7=Laya|last8=Gaglia|first8=Jason L.|last9=Hilliard|first9=Marisa E.|last10=Johnson|first10=Eric L.|last11=Khunti|first11=Kamlesh|date=2024-01-01|title=9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2024|url=https://diabetesjournals.org/care/article/47/Supplement_1/S158/153955/9-Pharmacologic-Approaches-to-Glycemic-Treatment|journal=Diabetes Care|language=en|volume=47|issue=Supplement_1|pages=S158–S178|doi=10.2337/dc24-S009|issn=0149-5992|pmc=PMC10725810|pmid=38078590}}</ref>

Additionally, autologous islet cell transplantation is indicated for patients undergoing total pancreatectomy for medically refractory chronic pancreatitis to prevent postsurgical diabetes. This procedure is also considered for patients with benign or borderline pancreatic tumors, hereditary/genetic pancreatitis, and high-risk pancreatic stump. <ref>{{Cite journal|last=Jabłońska|first=Beata|last2=Mrowiec|first2=Sławomir|date=2021-06-20|title=Total Pancreatectomy with Autologous Islet Cell Transplantation—The Current Indications|url=https://www.mdpi.com/2077-0383/10/12/2723|journal=Journal of Clinical Medicine|language=en|volume=10|issue=12|pages=2723|doi=10.3390/jcm10122723|issn=2077-0383|pmc=PMC8235694|pmid=34202998}}</ref><ref>{{Cite journal|last=Balzano|first=Gianpaolo|last2=Maffi|first2=Paola|last3=Nano|first3=Rita|last4=Zerbi|first4=Alessandro|last5=Venturini|first5=Massimo|last6=Melzi|first6=Raffaella|last7=Mercalli|first7=Alessia|last8=Magistretti|first8=Paola|last9=Scavini|first9=Marina|last10=Castoldi|first10=Renato|last11=Carvello|first11=Michele|date=2013-08|title=Extending Indications for Islet Autotransplantation in Pancreatic Surgery|url=https://journals.lww.com/00000658-201308000-00003|journal=Annals of Surgery|language=en|volume=258|issue=2|pages=210–218|doi=10.1097/SLA.0b013e31829c790d|issn=0003-4932}}</ref>

===Surgical procedure<ref>{{Cite journal|last=Desai|first=Chirag S.|last2=Stephenson|first2=Derek A.|last3=Khan|first3=Khalid M.|last4=Jie|first4=Tun|last5=Gruessner|first5=Angelika C.|last6=Rilo|first6=Horacio L.|last7=Gruessner|first7=Rainer W.G.|date=2011-12|title=Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients|url=https://journals.lww.com/00019464-201112000-00023|journal=Journal of the American College of Surgeons|language=en|volume=213|issue=6|pages=e29–e34|doi=10.1016/j.jamcollsurg.2011.09.008|issn=1072-7515}}</ref>===

==== '''1. Total Pancreatectomy''' ====

* '''Patient Preparation''': The patient is positioned and prepped for surgery under general anesthesia.
* '''Pancreas Removal''': The surgeon performs a total pancreatectomy, carefully removing the pancreas while preserving other vital structures, such as the spleen (if possible) and adjacent blood vessels.
* '''Pancreas Transport''': The excised pancreas is quickly transported to an islet processing lab, ideally within the same facility, to minimize ischemia time.

==== 2. '''Islet Cell Isolation and Purification''' ====

* '''Enzymatic Digestion''': The excised pancreas is treated with digestive enzymes to break down the tissue and isolate the islet cells, which are clusters of insulin-producing beta cells.
* '''Islet Cell Purification''': Using density gradient centrifugation, islet cells are separated from the surrounding pancreatic tissue. This step requires precision to yield a high concentration of viable islet cells.
* '''Suspension Preparation''': The purified islet cells are suspended in a sterile solution, creating an infusion-ready preparation to be delivered to the patient.

==== 3. '''Portal Vein Infusion of Islet Cells''' ====

* '''Portal Vein Access''': During or immediately after surgery, the patient is brought to an interventional radiology suite (or similar setting) where a catheter is inserted into the portal vein, typically via percutaneous access to the liver or through a small surgical incision.
* '''Islet Cell Infusion''': The islet cell suspension is slowly infused into the portal vein, allowing the cells to travel into the liver. Within the liver, these cells ideally lodge in the small blood vessels and start producing insulin.
* '''Monitoring for Complications''': The infusion process is carefully monitored to prevent portal vein thrombosis (blood clots), a known risk of islet cell infusion.

==Preoperative management==
===Patient evaluation<ref>{{Cite journal|last=Desai|first=Chirag S.|last2=Stephenson|first2=Derek A.|last3=Khan|first3=Khalid M.|last4=Jie|first4=Tun|last5=Gruessner|first5=Angelika C.|last6=Rilo|first6=Horacio L.|last7=Gruessner|first7=Rainer W.G.|date=2011-12|title=Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients|url=https://journals.lww.com/00019464-201112000-00023|journal=Journal of the American College of Surgeons|language=en|volume=213|issue=6|pages=e29–e34|doi=10.1016/j.jamcollsurg.2011.09.008|issn=1072-7515}}</ref>===
Preoperative evaluation for patients undergoing pancreatic islet cell autotransplantation after total pancreatectomy is critical to optimize surgical outcomes and assess eligibility, especially since these patients often have chronic pancreatitis and complex metabolic needs. The evaluation typically involves a multidisciplinary approach, including thorough assessment of metabolic, endocrine, and psychological health.

=== 1. '''Medical and Surgical History''' ===

* '''Chronic Pancreatitis Severity''': Evaluating the history and severity of chronic pancreatitis, including frequency of pain episodes, previous surgeries, and use of pain medications. This assessment helps to predict the potential benefits of surgery.
* '''Diabetes and Glycemic Control''': Since many patients with chronic pancreatitis have altered insulin production, a detailed assessment of blood glucose levels, insulin use, and any history of hypoglycemia or hyperglycemia is essential. Patients with longstanding diabetes may have fewer islet cells available for autotransplantation.

=== 2. '''Endocrine and Metabolic Assessment''' ===

* '''Islet Cell Function Testing''': Tests like fasting blood glucose, HbA1c, and C-peptide levels provide information about residual pancreatic islet function, which can indicate how much islet cell mass might be available for autotransplantation.
* '''Insulin Sensitivity and Resistance''': Assessing insulin sensitivity is essential, as patients with higher insulin resistance may have different postoperative glycemic control needs.

=== 3. '''Imaging Studies''' ===

* '''Pancreatic Imaging''': MRI or CT scans of the pancreas are crucial to assess pancreatic anatomy, ductal structures, and identify any areas of fibrosis or calcifications, which may impact the islet cell yield.
* '''Portal Vein and Liver Imaging''': Since the portal vein will be the route for islet infusion, it is examined through ultrasound or Doppler imaging to ensure there is no thrombosis or obstruction.

=== 4. '''Liver Function Tests''' ===

* '''Liver Function Panel''': Evaluating liver enzymes, bilirubin, albumin, and coagulation status provides an understanding of liver function, which is vital since the transplanted islets will engraft in the liver and produce insulin there.
* '''Portal Hypertension Screening''': For patients with long-standing pancreatic disease, it is important to evaluate for signs of portal hypertension, as this could complicate the infusion procedure.

=== 5. '''Nutritional and Gastrointestinal Evaluation''' ===

* '''Nutritional Status''': Many patients with chronic pancreatitis have malnutrition or deficiencies due to malabsorption. Nutritional evaluation with serum vitamin levels, albumin, and prealbumin, as well as consultation with a nutritionist, helps to optimize nutrition pre-surgery.
* '''Gastrointestinal Function''': Assessment of exocrine pancreatic insufficiency and history of steatorrhea can indicate the need for enzyme replacement therapy postoperatively.

=== 6. '''Psychological Evaluation''' ===

* '''Mental Health Screening''': Chronic pain and long-term management of diabetes or pancreatitis can impact mental health. Psychological evaluation helps identify any existing mental health issues, such as depression or anxiety, and ensures the patient is prepared for the postoperative recovery process.
* '''Assessment of Expectations''': Counseling patients regarding the limitations and potential outcomes of islet cell autotransplantation is important for setting realistic expectations.

=== 7. '''Anesthesia and Surgical Risk Assessment''' ===

* '''Cardiovascular and Pulmonary Evaluation''': Patients are assessed for cardiovascular and pulmonary health, especially if they have a history of smoking or other risk factors. Standard evaluations may include ECG, chest X-ray, and, if necessary, stress tests.
* '''Pain Management Planning''': Preoperative consultation with an anesthesiologist and pain management specialist helps develop a strategy to manage perioperative and postoperative pain, which is often significant in patients with chronic pancreatitis.

=== 8. '''Laboratory Testing''' ===

* '''Complete Blood Count and Coagulation Panel''': Baseline blood work is needed to identify any anemia, thrombocytopenia, or coagulopathy that may impact the surgery.
* '''Kidney Function Tests''': Renal function assessment is important, as kidney impairment can impact drug dosing and postoperative management.

In summary, preoperative evaluation for pancreatic islet cell autotransplantation includes comprehensive assessment of pancreatic function, metabolic and nutritional status, liver health, imaging studies, psychological readiness, and surgical risk. This multidisciplinary approach helps identify candidates likely to benefit most from the procedure and reduces the risk of postoperative complications
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Assess for potential difficulties in airway management due to history of smoking or chronic pancreatitis-related malnutrition, which can affect respiratory function.
- Evaluate the risk of aspiration, especially if the patient has delayed gastric emptying (common in chronic pancreatitis).
|-
|Neurologic
| - Evaluate for any history of diabetic neuropathy or chronic pain, as these may affect perioperative pain management and postoperative recovery.
- Perform a mental health screening to assess for chronic pain-related depression or anxiety, which can influence postoperative outcomes and adherence to medical guidance.
- Assess for hepatic encephalopathy if any liver dysfunction is present, as the liver will host the transplanted islets.
|-
|Cardiovascular
|Conduct cardiovascular assessment, especially if there is a history of diabetes, which increases risk for coronary artery disease.
- Evaluate for hypertension and possible portal hypertension.
- Perform ECG and other cardiac tests as needed, given the risk of intraoperative hypotension due to anesthetic agents and chronic malnutrition.
|-
|Pulmonary
|Assess lung function and smoking history; chronic pancreatitis patients may have compromised respiratory function due to malnutrition or chronic illness.
- Screen for restrictive lung disease if patients have undergone previous abdominal surgeries.
- Consider perioperative pulmonary function tests, especially in patients with reduced exercise tolerance or respiratory issues.
|-
|Gastrointestinal
| - Assess for delayed gastric emptying, which is common in chronic pancreatitis and can increase the risk of aspiration.
- Evaluate nutritional status and existing deficiencies, as many patients have malabsorption and may require nutritional support.
- Discuss the need for pancreatic enzyme replacement therapy postoperatively, as the pancreas is being removed.
|-
|Hematologic
|Assess for anemia and coagulopathy, which may be due to chronic disease or liver dysfunction.
- Perform a complete blood count (CBC) and coagulation studies to identify any risk of bleeding or thrombosis.
- Evaluate platelet count, especially important in patients with portal hypertension, as splenomegaly can cause thrombocytopenia.
|-
|Renal
| - Evaluate kidney function, especially important in patients with diabetes or those requiring frequent use of NSAIDs for chronic pain.
- Check electrolyte levels, as chronic malnutrition or gastrointestinal issues may lead to imbalances.
- Assess for any history of renal dysfunction, which could impact postoperative medication metabolism and dosing.
|-
|Endocrine
| - Assess insulin production, sensitivity, and glycemic control with HbA1c and fasting blood glucose levels; many patients may already have insulin-dependent diabetes.
- Evaluate for hypoglycemic unawareness, which is crucial for managing postoperative blood glucose fluctuations.
- Screen for other endocrine disorders related to chronic pancreatitis, such as adrenal insufficiency.
|-
|Other
| - Pain Management: Plan for perioperative pain management, as these patients often have a high opioid requirement due to chronic pain.
- Psychological: Assess for psychological readiness and support needs, given the impact of chronic illness on mental health.
- Infectious Disease: Screen for infections due to immunocompromised states from malnutrition and chronic illness.
- Immunology: Prepare for immune modulation in case of any complications, although immunosuppression is not typically required for autotransplantation.
|}

=== Operating room setup  ===
Fluid warmers and patient warming devices

=== Patient preparation and premedication  ===
Standard premedications

=== Regional and neuraxial techniques  ===
Possible Thoracolumbar Epidural or TAP block

== Intraoperative management ==
=== Monitoring and access===
2 large bore PIV (16 g or larger) or central line (8 Fr or 9 Fr double lumen)

Arterial line

Foley catheter

NG tube (remains in place post-op)
=== Induction and airway management  ===
Standard induction and airway management

=== Positioning  ===
Supine

=== Maintenance and surgical considerations  ===
Type and cross for 4 units PRBC's

Cell saver

Cefoxitin antibiotic of choice

Plasmalyte crystalloid of choice

Blood glucose monitoring q30 min after pancreatectomy for goal of 110-130 using insulin infusion.

Heparin drip may be started after islet cell infusion is complete

During the islet cell infusion, portal venous pressures will be monitored off the arterial line transducer (need male-to-male connection). If pressures exceed 25 cmH20, the infusion will be held until pressures returns below at least 12 cmH20.
=== Emergence  ===
Remain intubated (if surgeon's preference) and go to ICU.

== Postoperative management ==
=== Disposition  ===
ICU for glucose management

=== Pain management  ===

* '''Epidural Analgesia''': An epidural catheter is often placed before surgery to provide continuous local anesthetic infusion, typically a combination of a local anesthetic (e.g., bupivacaine) with a small dose of opioid (e.g., fentanyl or hydromorphone). This can significantly reduce the need for systemic opioids postoperatively.
* '''Regional Nerve Blocks''': Transversus abdominis plane (TAP) blocks or quadratus lumborum blocks may be used to target the abdominal wall nerves, reducing incisional pain. These are typically administered by the anesthesia team.
* '''IV Lidocaine and Ketamine''': Intravenous lidocaine and low-dose ketamine may be used intraoperatively to provide additional analgesia and reduce the risk of chronic pain postoperatively. Ketamine has both analgesic and opioid-sparing effects, particularly helpful in patients with a history of opioid tolerance.
* '''Patient-Controlled Analgesia (PCA)''': If an epidural is not used or after it is removed, a PCA pump with opioids (e.g., morphine or hydromorphone) is often provided, allowing patients to control their pain relief within safe dosing limits.
* '''Scheduled Non-Opioid Analgesics''': Non-opioid medications, such as acetaminophen and NSAIDs (if not contraindicated), are scheduled regularly to provide a baseline level of pain control.
* '''Gabapentinoids''': Gabapentin or pregabalin may be included as part of the regimen to control neuropathic pain, especially in patients with a history of chronic pain.
* '''Adjuvant Medications''': Adjuvant medications, including tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors (SNRIs), can be considered for patients with neuropathic pain or mood-related pain components.
* '''Psychological Support''': Pain management also includes psychological support, as chronic pain patients often benefit from coping strategies, relaxation techniques, or cognitive behavioral therapy (CBT) to help manage both pain and the psychological impact of long-term illness.

=== Potential complications  ===

===== 1. '''Surgical Complications''' =====

* '''Bleeding''': The pancreas is highly vascular, and total pancreatectomy can lead to significant blood loss. Intraoperative or postoperative bleeding is a risk, especially if patients have underlying coagulopathy or portal hypertension.
* '''Infection''': Surgical site infections, abscesses, and sepsis are potential complications due to the extensive nature of the surgery. Pancreatitis patients are often at higher risk for infections.
* '''Anastomotic Leak''': If any gastrointestinal reconnections are made (e.g., bile duct anastomosis), there’s a risk of leakage at the surgical site, leading to peritonitis and other complications.
* '''Pancreatic Fistula''': Though less common in total pancreatectomy than in partial resections, pancreatic duct leaks can sometimes occur and require drainage or further surgery.

===== 2. '''Metabolic and Glycemic Complications''' =====

* '''Diabetes Mellitus''': With the pancreas removed, most patients develop diabetes due to the loss of insulin-producing islet cells. Although autotransplanted islet cells aim to provide some insulin production, not all patients achieve full insulin independence.
* '''Hypoglycemia''': Especially early postoperatively, transplanted islets may produce unpredictable insulin levels, leading to hypoglycemia. Patients may also develop hypoglycemia unawareness due to reduced insulin stability.
* '''Hyperglycemia''': Ineffective islet cell function or insufficient cell mass can result in hyperglycemia, requiring insulin therapy or medication adjustments.
* '''Electrolyte Imbalances''': Removal of the pancreas can lead to changes in blood electrolytes, such as calcium and magnesium, which require monitoring and correction.

===== 3. '''Portal Vein Complications from Islet Infusion''' =====

* '''Portal Vein Thrombosis''': The infusion of islet cells into the portal vein can increase the risk of thrombosis (clot formation) in the portal venous system. This may lead to complications such as portal hypertension, liver dysfunction, or infarction in severe cases.
* '''Hepatic Steatosis''': The liver can accumulate fat as a response to insulin production by islet cells engrafted within it. Over time, this may progress to hepatic steatosis (fatty liver), which can impair liver function.
* '''Hepatic Enzyme Elevation''': Transient elevations in liver enzymes (e.g., AST, ALT) are common after islet infusion and generally resolve with time, though persistent elevation may indicate a problem.

===== 4. '''Endocrine Complications''' =====

* '''Exocrine Pancreatic Insufficiency''': Removal of the pancreas results in loss of digestive enzymes, leading to exocrine insufficiency and symptoms like malabsorption, diarrhea, and weight loss. Patients typically require lifelong pancreatic enzyme replacement therapy.
* '''Nutritional Deficiencies''': Due to malabsorption, patients may develop deficiencies in fat-soluble vitamins (A, D, E, K) and other nutrients, leading to complications such as osteoporosis, anemia, or delayed wound healing if not managed with supplements.

===== 5. '''Pain and Chronic Pain Recurrence''' =====

* '''Chronic Abdominal Pain''': Despite the removal of the pancreas, some patients continue to experience chronic pain due to nerve sensitization or post-surgical nerve damage, requiring ongoing pain management.
* '''Opioid Dependence''': Many patients with chronic pancreatitis have a history of high-dose opioid use. After surgery, managing and weaning off opioids can be challenging, and patients may experience withdrawal or require long-term pain management plans.

===== 6. '''General Surgical and Postoperative Complications''' =====

* '''Delayed Gastric Emptying''': Surgery involving the pancreas often affects gastric motility, resulting in delayed gastric emptying or "gastroparesis." This can lead to nausea, vomiting, bloating, and prolonged hospital stays.
* '''Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)''': Long surgical times and limited postoperative mobility increase the risk of thromboembolic events like DVT or PE.
* '''Psychological Impact''': Patients often experience significant emotional distress, including anxiety and depression, due to chronic pain, diabetes management, and the physical challenges of recovery. Mental health support is essential for a positive long-term outcome.

===== 7. '''Long-term Complications''' =====

* '''Insufficient Islet Cell Function''': Over time, the autotransplanted islet cells may lose function, potentially leading to increased dependence on insulin therapy.
* '''Fatty Liver Disease''': As transplanted islets produce insulin within the liver, fatty liver disease can develop over the long term, impacting liver health and function.

== Procedure variants  ==

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

== References ==

[[Category:Surgical procedures]]

Pancreatic Islet Cell Transplant

2024-11-12T15:26:44Z

Asdoyal: Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }}Provide a brief summary here. ==Overview== ===Indications=== ===Surgical procedure=== ==Preoperative management== ===Patient evaluat..."

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}Provide a brief summary here.

==Overview==
===Indications===
===Surgical procedure===

==Preoperative management==
===Patient evaluation ===
{| class="wikitable"
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!System
!Considerations
|-
|Airway
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|-
|Neurologic
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|-
|Cardiovascular
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|Pulmonary
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|Gastrointestinal
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|Hematologic
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|Endocrine
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|Other
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=== Labs and studies  ===
=== Operating room setup  ===
=== Patient preparation and premedication  ===
=== Regional and neuraxial techniques  ===

== Intraoperative management ==
=== Monitoring and access  ===

=== Induction and airway management  ===

=== Positioning  ===

=== Maintenance and surgical considerations  ===

=== Emergence  ===

== Postoperative management ==
=== Disposition  ===

=== Pain management  ===

=== Potential complications  ===

== Procedure variants  ==

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

== References ==

[[Category:Surgical procedures]]

Liver transplant

2024-11-12T15:24:58Z

Asdoyal:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore IVs
Arterial line
Central line
Introducer / PAC
| monitors = Standard
5-lead ECG
Temperature
Urine output
ABP
CVP
PAP
EEG
TEE
| considerations_preoperative = Encepholapthy
Multi-organ system derangements
| considerations_intraoperative = Decreased anesthetic requirement
Systemic vasodilation
Decreased hepatic metabolism
Hemorrhage
Thrombocytopenia
Coagulopathy
Renal insufficiency
Hypo/hyperglycemia
| considerations_postoperative = Hemorrhage
}}A '''liver transplant''' is performed in adult or pediatric patients with end-stage liver disease (ESLD).

For living donor hepatic resection, see [https://wikianesthesia.org/wiki/Hepatic_resection#Hepatectomy_for_living_donor_liver_transplant Hepatectomy for living donor liver transplant]

Liver transplantation at its core, this surgery is a "big-belly" case that requires management of severe physiologic derangements (such large fluid/volume changes, temperature changes, coagulopathy, cardiovascular issues, and pulmonary issues), and the secondary effects of ESLD (such as portal HTN, portopulmonary HTN, hepatopulmonary syndrome, hepatorenal syndrome, cirrhotic cardiomyopathy, coagulopathies, electrolyte disturbances ascites, varices, and encephalopathy). The key portions of the transplant surgery include the 1. hepatic dissection/resection, 2. major vascular/IVC clamping, 3. portal vein and IVC unclamping/liver reperfusion, and 4. hepatic artery & bile duct reconstruction.

==Overview==
===Indications===
Liver transplant is indicated in patients with end-stage liver failure. Reasons for liver failure are many and include acute fulminant hepatitis, inborn errors of metabolism, primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, chronic hepatitis B or C, alpha-1 antitrypsin disease, Wilson's disease, and hepatocellular carcinoma.
===Surgical procedure===
Liver transplantation is a complex surgical procedure that can be separated into three distinct phases <ref>{{Cite web|title=Anesthesiologist's Manual of Surgical Procedures|url=https://www.wolterskluwer.com/en/solutions/ovid/anesthesiologists-manual-of-surgical-procedures-5433|access-date=2021-11-22|website=www.wolterskluwer.com|language=en}}</ref><ref>{{Cite journal|last=Brezeanu|first=Lavinia Nicoleta|last2=Brezeanu|first2=Radu Constantin|last3=Diculescu|first3=Mircea|last4=Droc|first4=Gabriela|date=2020-05-06|title=Anaesthesia for Liver Transplantation: An Update|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216023/|journal=The Journal of Critical Care Medicine|volume=6|issue=2|pages=91–100|doi=10.2478/jccm-2020-0011|issn=2393-1809|pmc=7216023|pmid=32426515}}</ref>:

#'''Dissection (hepatectomy, pre-anhepatic) phase'''
#*This encompasses everything from skin incision to clamping of the IVC, portal vein, and hepatic artery.
#*The predominant portion of this case involves dissection of the recipient's native liver.
#*Blood loss during this phase of the surgery is significant and may be worse in patients with severe portal hypertension, coagulopathy, previous abdominal operations, recent recurrent or severe peritonitis, or history of upper abdominal radiation therapy.
#*Mobilization of the liver during dissection may partially or completely occlude the IVC causing a drop in blood pressure
#'''Anhepatic phase'''
#*This encompasses the time from clamping of hepatic venous inflow until the graft is portal venous reperfusion.
#*During this stage of the operation, the donor liver is implanted into the recipient.
#*The IVC may be completely or partially clamped during this phase of the operation, limiting venous return to the right atrium.
#*Hemodynamically unstable patients may benefit from
#**Veno-veno bypass.
#***Involves placement of cannulas in the femoral and portal veins that empty into the axillary or jugular vein, which maintains venous return.
#**Surgical "piggyback" technique
#***The recipient's IVC is preserved and the donor's IVC is anastomosed with the recipient's hepatic veins.
#'''Post-revascularization (neo-hepatic) phase'''
#*This phase begins with removal of the vascular clamps.
#*Reperfusion of the liver may result in a temporarily hyperkalemia from liver cell lysis, and preservative solution.
#*Massive air embolism is also a major immediate concern during reperfusion.
#*This stage may rarely be complicated by severe pulmonary HTN resulting in right heart failure and low systemic pressures.
#*Reperfusion also frequently results in systemic hypotension likely from kinins, and cytokines from the liver allograft.
#*Prior to reperfusion patients are given 250-1000mg of methylprednisolone or hydrocortisone that acts as an immunosuppressant and helps to blunt the effects of ischemia-reperfusion injury of the liver.
#*After initial stabilization, this phase involves hepatic artery and bile duct reconstruction.
#*Following hepatic artery reconstruction, MAP should be maintained above 65 mm Hg to prevent hepatic artery thrombosis.
#*A feeding G-tube may be placed at the end of the case. An OG or NG tube is typically placed and confirmed prior the end of this phase.
==Preoperative management ==

=== Patient evaluation===
Patient with advanced and decompensated liver disease suffer secondary injury and varying degrees of dysfunction in the majority of vital organs and organ processes. It is essential to thoroughly review laboratory, imaging, additional diagnostics, history, and recent medical course, to best anticipate this dysfunction and optimally manage your patient in the operating theatre. Our preoperative checklist provides a step-wise and systemic approach to preoperative evaluation of these patients.

{| class="wikitable"
|+
!System
! Considerations
|-
|Neurologic
|
*Patients with liver disease are at risk for encephalopathy.
*Mental status may be further depressed by coexisting metabolic derangements, including hyponatremia and hypoglycemia.
*The failure of hepatic clearance of various toxins, such as ammonia, can lead to alterations in endogenous neurotransmitters and neuro-signaling pathways, largely involving y-aminobutyric acid (GABA), glutamate and nitric oxide.
*Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
*Acute fulminant hepatic failure may be accompanied by elevated intracranial pressure and varying degrees of coma.
*Preoperative placement of intracranial pressure monitors may guide peri-operative neuroprotective strategies, with the goal to maintain adequate cerebral perfusion pressure.
*Patients may be unable to consent for surgery, and may exhibit delayed emergence following anesthesia.
*A thorough baseline neurologic and mental status exam is necessary prior to surgery, to assist with assessment following transplantation and anesthetic exposure.
|-
|Cardiovascular
|
* Systemic circulatory changes result in a hyperkinetic blood flow in most vascular beds, resulting in increased cardiac output and elevated circulating blood volume. Nitric oxide, cannabinoids, and cGMP have been implicated in the pathogenesis of this state. This is often further associated with lower PVR to accommodate this dynamic circulatory state.<ref>{{Cite journal|last=Møller|first=Søren|last2=Bendtsen|first2=Flemming|date=2018-04|title=The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis|url=https://onlinelibrary.wiley.com/doi/10.1111/liv.13589|journal=Liver International|language=en|volume=38|issue=4|pages=570–580|doi=10.1111/liv.13589}}</ref>
*Systemic vasodilation results from circulation of vasoactive mediators and vasodilators, as well as low grade endotoxin, which are not cleared by the compromised liver.
*Due to high circulating blood volume, many patients will have elevated filling pressures, reflected as high CVP, PCWP and PADP. However, transpulmonary pressure gradients are often normal.
*Decompensated liver failure is often accompanied by some degree of diastolic dysfunction, chronotropic incompetence and catecholamine insensitivity.
*A common finding on ECG is prolongation of QTc. When pronounced care must be taken to avoid medications known to prolong the QT interval. Magnesium levels should be maintained greater than 2 mg/dl.
*A subset of patients will manifest signs of cirrhotic cardiomyopathy, further characterized by conduction abnormalities/rhythm disturbances, alterations in calcium handling at the myocyte level and depressed myocardial performance.
*A very small subset of patients will have pulmonary hypertension, a pathological condition defined as a mean pulmonary artery pressure (mPAP) of greater than 25 mm Hg at rest, with a PCWP less than 15 mm Hg, and elevated pulmonary vascular resistance. Portopulmonary hypertension (PPHTN) further includes presence of portosystemic shunt. It is essential for portopulmonary hypertension (PPHTN) to be identified early, as significant perioperative mortality exists in patients with severe disease (mPAP>45, with associated elevation in PVR). There is a general consensus that there is a prohibitively high risk of intra and postoperative mortality in patients with mPAP> 45 mm Hg and PVR that exceeds 250 dynes/s/cm-5 .
*Early referral for initiation of pulmonary vasodilators (ie prostacyclin, PDE5 inhibitor, endothelin antagonist) is recommended, to evaluate response to therapy/disease reversibility and candidacy for future liver transplantation. Associated right ventricular dysfunction may recover, but correlates with severity of pressure overload.
* Echocardiography is routinely performed to evaluate RV function, LV systolic function, and measure RVSP. In the presence of elevated RVSP, right heart catheterization will be performed to assess RV function, measure cardiac output, and determine presence of elevation in pulmonary vascular resistance. If the diagnosis of PPHTN is made, treatment can be initiated and transplantation may be deferred. A favorable response to vasodilators is ideal, as this indicates presence of a reactive pulmonary bed and confers potential therapeutic options in the event of a precipitous rise in pulmonary artery pressures intraoperatively (application of inhaled nitric oxide or epoprostenol).
*Dobutamine stress echocardiography is an ideal preoperative screening assessment, as it can identify metabolic imbalance and ischemic risk, as well as underlying structural abnormalities. This test has a negative predictive value of 92-97%, with a negative test predicting good prognosis and low likelihood of major adverse cardiac events (Donovan et al, 1996; Cotton et al, 2002). If ischemic changes are present, a left heart catheterization should be performed to determine presence of severe coronary arteriopathy that may warrant intervention (angioplasty/stent v revascularization) prior to transplantation.
*The presence of coronary artery disease is associated with higher morbidity and mortality (Plotkin et al, 1996).
|-
| Pulmonary
|
*Pulmonary abnormalities are common in patients with advanced liver disease. Presence of intrapulmonary shunt, ventilation-perfusion defects, and abnormalities in lung compliance are frequently encountered. Many transplant recipients are of advanced age, and thus have changes in FRC, closing capacity, and lung elasticity which may result in challenges with ventilation and gas exchange.
*Restrictive lung disease, largely secondary to presence of ascites and pleural effusions, may be noted during positive pressure ventilation. Careful attention is necessary during induction of anesthesia, to optimize patient position and pre-oxygenation, to mitigate ensuing hypoxemia that may occur during brief apnea.
*Lung protective ventilation with appropriately calculated tidal volume (6-8 cc/kg PBW) and application of PEEP should be employed during surgery, to minimize ventilator induced lung injury.
*Hypoxemia may be present secondary to hepatopulmonary syndrome (HPS) which, if severe, may persist for months following transplantation.
*HPS may present as asymptomatic cyanosis, though patients often endorse platypnea and orthodeoxia. Etiology is likely related to elaboration of vasoactive mediators (ie nitric oxide), which result in formation of abnormal pulmonary vascular communications, resulting in A-V shunt. This diagnosis can be confirmed by echocardiogram with “bubble” study, which will reveal presence of bubbles/agitated saline in the left atrium, 3-5 cycles after injection. Some correction of hypoxemia with 100% oxygen confers a favorable post-operative prognosis.
|-
|Gastrointestinal
|
*Portal hypertension is present in the majority of patients receiving liver transplantation. This may manifest as severe GI bleed, gastric and esophageal varices, ascites, and previous portosystemic shunts. All patients with decompensated liver disease are at risk for delayed gastric emptying and, as such, rapid sequence intubation is strongly encouraged. Close attention to ascitic drainage during dissection is essential, and volume replacement with colloid rich solution is generally pursued to minimize hemodynamic changes associated with rapid fluid shifts. The presence of severe cirrhosis and portal hypertension often leads to engorgement of collateral vessels in the splanchnic and portal circulation, which may increase risk of massive bleeding during the dissection phase and vascular/hepatic mobilization. Ongoing GI bleed may continue intra-operatively. Some clinicians advocate management with octreotide to mitigate bleeding risk. Appropriate blood product transfusions and volume replacement is necessary in response to signs of ongoing bleeding and hypovolemia.
|-
|Hematologic
|
*The predominant hematologic abnormality in patients awaiting liver transplantation is anemia. This results from occult or clinical bleeding, malnutrition/malabsorption, hemolysis, and reduced production red blood cells production, often exacerbated by co-existing renal disease.
*Thrombocytopenia secondary to thrombopoietin deficiency and splenic sequestration is common in patients with portal hypertension, and functional platelet defects may be exacerbated by uremia.
*Coagulation defects result from reduced production of clotting factors and inhibitors, vitamin K deficiency, abnormalities in fibrinolysis, and reduced clearance of activated factors (Amitrano et al, 2002; Kawasaki at al, 1999; Ingeberg et al 1985; Rubin et al, 1979).
*Associated trauma (secondary to surgery), sepsis, bleeding, or shock, may result in secondary fibrinolysis and disseminated intravascular coagulation (DIC).
*Deficiencies in inhibitors and serine proteases, such as plasminogen activator inhibitor, may increase risk for thrombosis in certain patients.
*Many individuals with biliary disease and associated autoimmune pathology, may have concomitant hypercoagulable conditions, increasing risk of vascular thrombosis after re-perfusion.
*Due to the complexity of hematologic derangements, it is imperative to approach transfusion strategies in a data-driven and clinically influenced manner. Interpretation of TEG, as well as clinical bleeding or hypercoagulability in the surgical field, should be primary variables used to impact decisions regarding transfusion with plasma, platelets, cryoprecipitate and administration of recombinant synthetic factors.
*Catastrophic consequences of inappropriate transfusion strategies include hepatic artery thrombosis with subsequent graft failure.
|-
|Renal
|
*Many patients with end-stage liver disease will have associated renal insufficiency or renal failure.
* Generally patients with chronic renal failure will be listed for combined liver-kidney transplantation.
*Etiology of renal failure is often multifactorial, and related to relative hypoperfusion of the renal bed with acute kidney injury, acute tubular necrosis related to medication administration (contrast, etc), and possible acute interstitial nephritis.
*Patients may carry the diagnosis of hepatorenal syndrome (HRS), which occurs as a result of intense renal vasoconstriction prompted by renin-angiotensin activation in response to profound splanchnic vasodilation. HRS is often reversible with liver transplantation.
*Some patients will require acute hemodialysis in the period prior to transplantation.
*It is essential to determine associated anuria/oliguria, clinical response to diuretic therapy, associated metabolic derangements, and volume status in this patient population. Patients may require dialysis prior to commencement of transplant.
* It is rare to utilize intraoperative RRT, however, acute changes in potassium secondary to transfusion and reduced clearance, may warrant this therapy.
*Our strategy to manage this select patient population involves: limitation of exogenous potassium administration, red blood cell washing by perfusion prior to administration, gentle supplementation with bicarbonate containing fluids, possible diuretic challenge, and close monitoring of electrolytes.
*Crystalloid administration may be limited in this patient population in the presence of clinical hypervolemia with associated portal hypertension.
|-
|Endocrine
|
*A myriad of metabolic perturbations may be present in the liver transplant recipient.
* Hypoglycemia is common in patients with advanced disease, due to impairment in gluconeogenesis.
*Patients may require supplementation with dextrose prior to surgery.
*A sign of graft function in the neohepatic phase, is hyperglycemia/insulin requirement in response to steroid administration.
*Patients often present with impaired temperature regulation resulting in hypothermia, prior to reperfusion of the new graft.
*As previously detailed, careful attention to application of external body warmers and warmed fluid administration, is essential to maintain normothermia and optimize hemostatic conditions.
*On occasion, patients with severe portal hypertension may also present with hyponatremia. This can occur as a result of altered renal free water handling/elimination and water retention resulting from activation of ADH in the setting of splanchnic vasodilation. These derangements may be exacerbated by concomitant sodium dietary restriction and use of diuretic therapy.
*Rapid correction of sodium intra-operatively should be avoided, to reduce clinical risk of CPM. This may involve supplementation of solute-rich colloid administration with hypotonic fluids intra-operatively, to maintain baseline sodium levels.
|-
|ID
|
*Patients with end-stage liver disease are at high risk of infections. Altered hepatic clearance and dysregulation of Kupffer cell function, combined with poor underlying nutritional status, result in a functional immunocompromised state.
*Not uncommonly, these patients are treated, at the time of transplant, for biliary infections, spontaneous bacterial peritonitis (SBP), aspiration pneumonia, or cellulitis. Active septicemia or severe infection without treatment/source control, are contraindications to transplant.
* Appropriate selection of antimicrobials is necessary, and should be guided by infection source, probable or confirmed infectious pathogens, and patient history (previous infectious culprits/colonization). Standard antimicrobial prophylaxis is: cefazolin/metronidazole, or cefotetan.
*If there is concern for SBP at the time of transplantation, or if donor variables present concerns for possible infection/contamination, antimicrobial selection should be adjusted accordingly.
*Re-dosing of antibiotics should be guided by agent selection, blood loss, and recipient renal function.
|}

===Labs and studies===

* Full workup prior to transplant.
** CBC
** CMP
**Coagulation panel
** CXR
** EKG
** Cardiac evaluation possibly including stress test or TTE
**Thromboelastogram/viscoelastogram (TEG, ROTEM, Hemosonics Quantra)

===Operating room setup===

*Alaris brain with multiple channels -- Possible infusions include: Vasopressin, Epinephrine, Norepinephrine, Insulin, Carrier fluid, Antibiotics, Calcium Chloride
*Belmont or Level 1 Rapid Infuser for aggressive resuscitation
*RBC salvage machine, Cellsaver

===Patient preparation and premedication===

* Generally sedative premedication is avoided due to patient susceptibility to exacerbation of underlying hepatic encephalopathy.

===Regional and neuraxial techniques===

* Avoided due to coagulopathy.

== Intraoperative management<ref>{{Cite journal|last=Adelmann|first=Dieter|last2=Kronish|first2=Kate|last3=Ramsay|first3=Michael A.|date=2017-09|title=Anesthesia for Liver Transplantation|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227517300472|journal=Anesthesiology Clinics|language=en|volume=35|issue=3|pages=491–508|doi=10.1016/j.anclin.2017.04.006}}</ref>==

===Monitoring and access===

* Large bore PIVs
* arterial line (at some institutions it is common to place two arterial lines)
* Central access (often large-bore volume line and an infusion line).
** Common practice can include introducer catheter for volume and a triple lumen catheter for infusions.
** CVP monitoring.
* Intraoperative TEE and/or pulmonary artery catheter are routine in many centers

===Induction and airway management===

* Increased intra-abdominal pressure and high probability of gastroparesis necessitate rapid sequence induction.
* Induction dose of propofol should be reduced in patients with severe liver disease due to altered pharmacodynamics (low albumin level), and increased sensitivity.
* Non depolarizing neuromuscular blocking agents should be chosen with patients organ function in mind. Often Cis-atricurium is chosen due to its predictable metabolism.

===Positioning===

* Supine

===Maintenance and surgical considerations===

* Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
* Mental status may be further depressed by coexisting metabolic derangements, including hyponatremia and hypoglycemia.
* Limited hepatic clearance of various toxins, such as ammonia, can lead to alterations in endogenous neurotransmitters and neuro-signaling pathways, largely involving y-aminobutyric acid (GABA), glutamate and nitric oxide.
*Reperfusion is typically most complicated step, as old ischemic liver blood rushes into the new patient's bloodstream, causing hypotension, bradycardia, RV stunning. Treating with baby epinephrine pushes is common (10 mcg/mL syringe, several cc's at a time).

===Emergence===

==Postoperative management==

===Disposition===

* ICU
** Generally patients require additional fluid resuscitation and/or blood products.
** Frequent monitoring of hemoglobin, fibrinogen, glucose, and phosphate is required.
** Renal duplex ultrasound is also needed.

=== Pain management===

* PCA, typically fentanyl or hydromorphone
* Consider acetaminophen after communication with transplant team

===Potential complications===

* These patients are at risk for further clinical deterioration post-operatively, as graft function improves and SVR normalizes, resulting in increased afterload to a susceptible myocardium. Careful extended monitoring should be considered.

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

<references />
[[Category:General surgery]]
[[Category:Hepatic surgery]]
[[Category:Transplant surgery]]

Endovascular aortic repair

2024-11-12T14:57:40Z

Asdoyal:

{{Infobox surgical procedure
| anesthesia_type = General
Neuraxial (for abdominal aneurysm)
Local with MAC (rare)
| airway = ETT if general
| lines_access = PIV x 2 (at least 1 large bore (14-16 G)
Arterial line (right sided preferred)
| monitors = Standard ASA monitors
5-lead EKG
Arterial line
TEE (for thoracic aneurysm)
| considerations_preoperative = Assess co-existing cardiovascular comorbidities
| considerations_intraoperative = Heparin for anticoagulation
Consider decrease BP immediately prior to stent deployment and/or increase BP post-deployment
| considerations_postoperative = Monitor for spinal/intraabdominal ischemia due to graft occlusion
}}

'''Endovascular aortic repair''' is a surgical procedure by which a stent graft is deployed along the extent of an aortic lesion through vascular access, typically via the common femoral vessels. The stent graft protects the aneurysmal wall from high blood pressure in the aorta decreasing the risk of rupture.

Aortic repair is indicated when an aneurysm is at high risk of rupture, which is defined as<ref>{{Cite book|url=https://www.worldcat.org/oclc/1280374077|title=Stoelting's anesthesia and co-existing disease|date=2022|others=Roberta L. Hines, Stephanie B. Jones, Robert K. Stoelting|isbn=978-0-323-71861-5|edition=Eighth edition|location=Philadelphia, PA|oclc=1280374077}}</ref><ref name=":0">{{Cite journal|last=Cheruku|first=Sreekanth|last2=Huang|first2=Norman|last3=Meinhardt|first3=Kyle|last4=Aguirre|first4=Marco|date=2019-12|title=Anesthetic Management for Endovascular Repair of the Thoracic Aorta|url=https://pubmed.ncbi.nlm.nih.gov/31677680|journal=Anesthesiology Clinics|volume=37|issue=4|pages=593–607|doi=10.1016/j.anclin.2019.07.001|issn=1932-2275|pmid=31677680}}</ref>:

*Size larger than 5.5 cm
*Growth of 10 mm or more per year

The procedure involves obtaining vascular access to allow the introduction of the stent deployment apparatus. Prior to the introduction of stent deployment apparatus, systemic heparinization is provided. Fluoroscopy is performed with IV contrast to evaluate vascular anatomy and guide stent placement. Once the stent graft is deployed and placement confirmed with fluoroscopy/TEE without the presence of endoleak or aortic dissection, the stent graft introducer is removed and vascular access sites are closed<ref name=":0" />.

== Preoperative management==

===Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Assess for presence of history cerebrovascular disease or carotid stenosis by obtaining baseline neurologic exam, especially strength of lower extremities and auscultation.
|-
|Cardiovascular
|Assess baseline functional status and evaluate for myocardial ischemia, previous myocardial infarction, valvular dysfunction, heart failure and peripheral arterial disease.
|-
|Pulmonary
|Assess for COPD, cigarette smoking, and reversible pulmonary pathology.

Smoking cessation of at least 8 weeks is optimal.
|-
|Renal
|Preoperative hydration and avoidance of nephrotoxic drugs during the perioperative period are important to reduce the risk of kidney injury due to IV contrast used during the procedure.
|}

===Labs and studies===

*Type and screen
*Contrast-enhanced spiral CT scans of the thorax and thoracic aortography to assess the dimensions of the aneurysms
**This allows for the assessment of adequate proximal and distal neck for surgical planning. The CT scan also helps assess the adequacy of the vessel used for vascular access for the stent introducer system
* EKG to assess for any myocardial ischemia or previous infarction
*TTE to assess valvular disease, size and extent of aneurysm, and LV function
* Exercise or pharmacologic stress testing or radionuclide imaging may be warranted

=== Operating room setup===

* Arterial catheter and transducer
* Hotline on fluid warmer
* Infusion pumps
* Vasopressor infusions available (usually norepinephrine on pump)
* Push dose pressors drawn up
* Heparin and protamine
* +/- lumbar drain setup
* Heated circuit (if available)

===Patient preparation and premedication===

*IV midazolam (+/- Fentanyl) for anxiety
*PO acetaminophen for pain control

===Regional and neuraxial techniques===
Spinal and/or epidural may be considered for endovascular abdominal aortic aneurysm repair <ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>

If lumbar drain needed, usually placed by VIR and capped the day prior. When entering the OR, attach the lumbar drain chamber tubing to the lumbar drain before laying the patient down to ensure adequate CSF flow. Once the patient is supine on the OR bed, check again that CSF is freely flowing. At this point, make sure the transducer is zeroed to the level of the subarachnoid space (typically even with the level of the ear).

== Intraoperative management==

===Monitoring and access===

*Standard ASA monitors
*5-lead EKG
* Arterial line is required as it allows prompt vasopressor titration in response to blood pressure change, particularly just prior to stent deployment and post stent deployment
**Right sided preference as left sided vascular access from the surgical team may be needed allowing for an easier approach to the aorta compared to right sided approach. Also, the stent graft may block the L subclavian artery leading to false reading <ref name=":1" />
*TEE used to assist in the identification of aneurysm necks, monitor the deployment of the stent graft, endoleaks status post deployment, and aortic dissection (Endovascular Thoracic Aneurysm Repair)
*Urine output monitoring in the setting of possible renal vessel occlusion from deployment of stent graft and contrast induced nephropathy
*Spinal drain (a.k.a. lumbar drain) CSF draining and pressure monitoring if placed for high risk patient undergoing endovascular thoracic aneurysm stent grafting
*Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) may be used to assess for spinal ischemia for patient undergoing endovascular thoracic stent grafting<ref name=":0" />
*At Least 1 large bore IV (14-16G) given risk of vascular injury or rupture

===Induction and airway management===

*Most common anesthesia type is general anesthesia
**May need to reverse neuromuscular blockade if neuromonitoring is used
*If neuraxial anesthesia is chosen, supplement with minimal to deep sedation as needed
*Rarely, local anesthetic placement by the surgical team with monitored anesthesia care is used, depending on patient cooperativity.

===Positioning===

*Supine +/- slight right lateral decubitus (endovascular thoracic aortic aneurysm repair)

===Maintenance and surgical considerations===

*Volatile anesthetics supplemented with opioids for analgesia if neuromonitoring is not used
*If neuromonitoring is used, 0.5 MAC of volatile anesthetic supplemented by IV anesthetic/opioids or TIVA and avoiding neuromuscular blockade after intubating dose
*Administration of heparin prior to introducer insertion

*Verification of activated clotting time (ACT) throughout the case with goal of 200 seconds until introducer is removed <ref name=":0" />
* Maintenance of baseline MAP as this patient population have increase risk of CVA, MI, aortic dissection, and paraplegia
*Just prior to stent deployment, BP must be decrease to reduce the risk of graft migration during deployment with vasodilators
*Post stent graft deployment, BP is increased to ensure perfusion especially if there is a risk of spinal ischemia with vasopressor
*Closed loop communication with surgical team regarding heparinization and ACT monitoring
*'''Spinal cord ischemia is a rare, but devastating complication of both open and endovascular aortic aneurysm repair. Incidence in EVAR has been reported as 0.21%'''<ref>Koda Y, Yamanaka K, Omura A, Gentsu T, Yamaguchi M, Okada K. Spinal cord ischemia after elective endovascular abdominal aortic aneurysm repair in a patient with multiple occlusions of the intercostal and internal iliac arteries. J Vasc Surg Cases Innov Tech. 2022 Jul 9;8(3):447-449. doi: 10.1016/j.jvscit.2022.06.007. PMID: 36016702; PMCID: PMC9395748.</ref> '''and up to 6.9% in TEVAR'''<ref>Toshifumi Hiraoka, Tatsuhiko Komiya, Hiroshi Tsuneyoshi, Takeshi Shimamoto, Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair, ''Interactive CardioVascular and Thoracic Surgery'', Volume 27, Issue 1, July 2018, Pages 54–59, <nowiki>https://doi.org/10.1093/icvts/ivy037</nowiki></ref>
*'''Remember that spinal cord perfusion pressure is equal to the mean arterial pressure minus the cerebral spinal cord pressure (SCPP = MAP - ICP)'''
*'''The most common mitigation strategy is blood pressure augmentation (increasing MAP) with MAP goals usually >90'''
**SCI is multifactorial, but in endovascular repair, it is usually thought to be the result of the permanent interruption, by covering with the stent, of sufficient sources of cord blood supply to render a portion of the cord nonviable - these sources include the segmental arteries, artery of Adamkiewicz, subclavian, and hypogastric arteries - as well as decrease of pressure in those arteries, by major bleeding or other causes of shock<ref name=":03">Randall B. Griepp, Eva B. Griepp, Spinal cord protection in surgical and endovascular repair of thoracoabdominal aortic disease, The Journal of Thoracic and Cardiovascular Surgery, Volume 149, Issue 2, Supplement, 2015, Pages S86-S90, ISSN 0022-5223, <nowiki>https://doi.org/10.1016/j.jtcvs.2014.10.056</nowiki>. (<nowiki>https://www.sciencedirect.com/science/article/pii/S002252231401561X</nowiki>)</ref>
**Episodes of delayed paraplegia/paraparesis have been reversed by increasing blood pressure and cardiac output. Clearly, both an increase in arterial pressure and a decrease in CSF pressure result in a net increase in perfusion of the spinal cord. Similarly, because central venous pressure and CSF pressure are—at least in part—additive in increasing outflow pressure from the spinal canal, it is important to avoid hemodynamic management strategies that entail high venous pressure<ref name=":03" />
*Larger grafts will cover more of the arteries that supply the spinal cord and, therefore, increase the risk of ischemia. '''In these higher risk cases, a lumbar drain can be used to drain CSF, lowering the ICP, and, therefore, increasing the spinal cord perfusion pressure.''' Whether CSF drainage improves outcomes is not entirely clear<ref>Wong C S, Healy D, Canning C, Coffey J C, Boyle J R, Walsh S R. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg. 2012;56(05):1438–1447.</ref>
**Drainage can be set to an ICP threshold after the drain transducer is "zeroed" to the patients spine (i.e., the drain will drain CSF when the ICP is greater than 12mmHg)
**Drainage can be set as a volume per hour (i.e., drain 10ml per hour)
**Overly aggressive CSF drainage carries a risk of intracranial hemorrhage (related to tearing bridging vessels). This risk can be minimized by not draining more than 20ml per hour and/or targeting ICP of 8-10mmHg<ref>Ellauzi H, Arora H, Elefteriades JA, Zaffar MA, Ellauzi R, Popescu WM. Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons. Aorta (Stamford). 2022 Dec;10(6):290-297. doi: 10.1055/s-0042-1757792. Epub 2022 Dec 20. PMID: 36539146; PMCID: PMC9767776.</ref>
*Occasionally (rarely at UNC), somatosensory evoked potentials (SSEPs) and/or motor evoked potentials (MEPs) may be used to monitor for SCI<ref>Cheruku, Sreekanth; Huang, Norman; Meinhardt, Kyle; Aguirre, Marco (2019-12). "Anesthetic Management for Endovascular Repair of the Thoracic Aorta". ''Anesthesiology Clinics''. 37 (4): 593–607. doi:10.1016/j.anclin.2019.07.001. ISSN 1932-2275. <nowiki>PMID 31677680</nowiki>.</ref>
*Because of its more tenuous blood supply, the anterior two-thirds of the spinal cord are most at risk for ischemia which presents as a painful myelopathy known as anterior spinal artery syndrome

===Emergence===

*PONV prophylaxis
*Reversal of neuromuscular blockade if used
*Assessment of hip flexion if spinal cord is at risk for ischemia
* Reversal of heparin with protamine with confirmation of ACT returning to normal value
*Maintain BP goals

==Postoperative management==

===Disposition===

*PACU then floor
* Consider ICU if intraoperative complications occur

===Pain management===

*Postoperative pain is usually mild

*Multimodal pain management
**PO/IV acetaminophen
**PO/IV opioid
**Local anesthetic at vascular access sites
**Epidural analgesia if chosen as anesthetic technique
**Usually avoiding NSAID due to pre-existing renal disease or potential renal injury

===Potential complications===

*Endoleaks
*Vascular injury
*Graft migration
* Stent frame fractures
*Breakdown of graft material
*Spinal cord ischemia or infarction secondary to occlusion of intercostal arteries
* Intraabdominal ischemia secondary to occlusion of vessels supplying the gastro-intestinal organ including the celiac artery, superior mesenteric artery, inferior mesenteric artery, and renal arteries

*Bleeding from groin site or retroperitoneal bleeding
*Contrast induced nephropathy

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Thoracic Aortic Aneurysms
!Abdominal Aortic Aneurysms
|-
|Unique considerations
|Use of TEE and possible neuromonitoring and lumbar drain
|Neuraxial anesthesia possible
|-
|Position
|Supine +/- slight right lateral decubitus
|Supine
|-
|Surgical time
|1-3 hours
|1-3 hours
|-
|EBL
|Minimal, unless vascular injury
|Minimal, unless vascular injury
|-
|Postoperative disposition
|Usually PACU to the floor, possible ICU
|Usually PACU to the floor
|-
|Pain management
| Multimodal
|Multimodal
|-
|Potential complications
|Paraplegia
|Intraabdominal ischemia/infarction
|}

==References==

[[Category:Surgical procedures]]
<references />

Baroreflex activation device implant (Barostim)

2024-11-12T14:37:03Z

Asdoyal: various changes

Baroreflex activation therapy (BAT) Barostim is an advanced device that leverages the principles of baroreflex activation therapy to modulate the autonomic nervous system and treat conditions like resistant hypertension and heart failure with reduced ejection fraction (HFrEF). The device currently implanted by our vascular surgeons is the Barostim Neo2 designed by CVRX. A lead is placed on the carotid sinus via a small cutdown, tunneled under the subcutaneous tissue, and connected to a generator that is placed in the chest and can be controlled by an external programmer. Heart failure with reduced ejection fraction involves disturbances of the autonomic nervous system characterized by decreased baroreceptor sensitivity, increased sympathetic tone, and decreased parasympathetic tone<ref>John S. Floras, Sympathetic Nervous System Activation in Human Heart Failure: Clinical Implications of an Updated Model, Journal of the American College of Cardiology, Volume 54, Issue 5, 2009, Pages 375-385, ISSN 0735-1097, <nowiki>https://doi.org/10.1016/j.jacc.2009.03.061</nowiki>.</ref>. Baroreflex activation therapy (BAT) aims to restore balance to the autonomic nervous system by increasing parasympathetic output via electrical stimulation of the carotid baroreceptors. In clinical trials BAT has been shown to be safe and significantly improved QOL, exercise capacity, and NT-proBNP<ref>Zile MR, Lindenfeld J, Weaver FA, Zannad F, Galle E, Rogers T, Abraham WT. Baroreflex Activation Therapy in Patients With Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol. 2020 Jul 7;76(1):1-13. doi: 10.1016/j.jacc.2020.05.015. PMID: 32616150.</ref> in patients with HFrEF. This approach helps mitigate the progression of heart failure by reducing neurohormonal activation.<ref>{{Cite journal|last=Zucker|first=Irving H.|last2=Hackley|first2=Johnnie F.|last3=Cornish|first3=Kurtis G.|last4=Hiser|first4=Bradley A.|last5=Anderson|first5=Nicholas R.|last6=Kieval|first6=Robert|last7=Irwin|first7=Eric D.|last8=Serdar|first8=David J.|last9=Peuler|first9=Jacob D.|last10=Rossing|first10=Martin A.|date=2007-11|title=Chronic Baroreceptor Activation Enhances Survival in Dogs With Pacing-Induced Heart Failure|url=https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.107.095216|journal=Hypertension|language=en|volume=50|issue=5|pages=904–910|doi=10.1161/HYPERTENSIONAHA.107.095216|issn=0194-911X}}</ref><ref>{{Cite journal|last=Zile|first=Michael R.|last2=Abraham|first2=William T.|last3=Weaver|first3=Fred A.|last4=Butter|first4=Christian|last5=Ducharme|first5=Anique|last6=Halbach|first6=Marcel|last7=Klug|first7=Didier|last8=Lovett|first8=Eric G.|last9=Müller‐Ehmsen|first9=Jochen|last10=Schafer|first10=Jill E.|last11=Senni|first11=Michele|date=2015-10|title=Baroreflex activation therapy for the treatment of heart failure with a reduced ejection fraction: safety and efficacy in patients with and without cardiac resynchronization therapy|url=https://onlinelibrary.wiley.com/doi/10.1002/ejhf.299|journal=European Journal of Heart Failure|language=en|volume=17|issue=10|pages=1066–1074|doi=10.1002/ejhf.299|issn=1388-9842}}</ref><ref>{{Cite journal|last=Abraham|first=William T.|last2=Zile|first2=Michael R.|last3=Weaver|first3=Fred A.|last4=Butter|first4=Christian|last5=Ducharme|first5=Anique|last6=Halbach|first6=Marcel|last7=Klug|first7=Didier|last8=Lovett|first8=Eric G.|last9=Müller-Ehmsen|first9=Jochen|last10=Schafer|first10=Jill E.|last11=Senni|first11=Michele|date=2015-06|title=Baroreflex Activation Therapy for the Treatment of Heart Failure With a Reduced Ejection Fraction|url=https://linkinghub.elsevier.com/retrieve/pii/S2213177915001250|journal=JACC: Heart Failure|language=en|volume=3|issue=6|pages=487–496|doi=10.1016/j.jchf.2015.02.006}}</ref>

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
+/- Arterial line
| monitors = Standard
BIS
+/- ABP
| considerations_preoperative = Heart failure symptoms
| considerations_intraoperative = Avoid baroreflex blunting medications
| considerations_postoperative = Standard
}}

== Overview ==

=== Indications ===

* Barostim is indicated for patients who are NYHA Class III or Class II (who had a recent history of Class III) despite treatment with guideline-directed medical therapies (medications and devices), have a left ventricular ejection fraction of ≤ 35% and a NT-proBNP <1600 pg/ml.<ref>{{Cite journal|last=Zile|first=Michael R.|last2=Lindenfeld|first2=JoAnn|last3=Weaver|first3=Fred A.|last4=Zannad|first4=Faiez|last5=Galle|first5=Elizabeth|last6=Rogers|first6=Tyson|last7=Abraham|first7=William T.|date=2020-07|title=Baroreflex Activation Therapy in Patients With Heart Failure With Reduced Ejection Fraction|url=https://linkinghub.elsevier.com/retrieve/pii/S0735109720352980|journal=Journal of the American College of Cardiology|language=en|volume=76|issue=1|pages=1–13|doi=10.1016/j.jacc.2020.05.015}}</ref><ref>{{Cite journal|last=Coats|first=Andrew J.S.|last2=Abraham|first2=William T.|last3=Zile|first3=Michael R.|last4=Lindenfeld|first4=Joann A.|last5=Weaver|first5=Fred A.|last6=Fudim|first6=Marat|last7=Bauersachs|first7=Johann|last8=Duval|first8=Sue|last9=Galle|first9=Elizabeth|last10=Zannad|first10=Faiez|date=2022-09|title=Baroreflex activation therapy with the Barostim ™ device in patients with heart failure with reduced ejection fraction: a patient level meta‐analysis of randomized controlled trials|url=https://onlinelibrary.wiley.com/doi/10.1002/ejhf.2573|journal=European Journal of Heart Failure|language=en|volume=24|issue=9|pages=1665–1673|doi=10.1002/ejhf.2573|issn=1388-9842|pmc=PMC9796660|pmid=35713888}}</ref><ref>{{Cite journal|last=Heidenreich|first=Paul A.|last2=Bozkurt|first2=Biykem|last3=Aguilar|first3=David|last4=Allen|first4=Larry A.|last5=Byun|first5=Joni J.|last6=Colvin|first6=Monica M.|last7=Deswal|first7=Anita|last8=Drazner|first8=Mark H.|last9=Dunlay|first9=Shannon M.|last10=Evers|first10=Linda R.|last11=Fang|first11=James C.|date=2022-05-03|title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063|journal=Circulation|language=en|volume=145|issue=18|doi=10.1161/CIR.0000000000001063|issn=0009-7322}}</ref><ref>{{Cite journal|last=Heidenreich|first=Paul A.|last2=Bozkurt|first2=Biykem|last3=Aguilar|first3=David|last4=Allen|first4=Larry A.|last5=Byun|first5=Joni J.|last6=Colvin|first6=Monica M.|last7=Deswal|first7=Anita|last8=Drazner|first8=Mark H.|last9=Dunlay|first9=Shannon M.|last10=Evers|first10=Linda R.|last11=Fang|first11=James C.|date=2022-05|title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure|url=https://linkinghub.elsevier.com/retrieve/pii/S0735109721083959|journal=Journal of the American College of Cardiology|language=en|volume=79|issue=17|pages=e263–e421|doi=10.1016/j.jacc.2021.12.012}}</ref>
* Refractory hypertension or inability to tolerate antihypertensive agents
* Contraindications to LVAD, heart transplant
* Autonomic Imbalance and Sympathetic Hyperactivity/POTS/Tachycardia

=== Contraindications ===

* Patient eligible for cardiac resynchronization therapy
* Bilateral carotid bifurcations located above the level of the mandible
* Baroreflex failure or autonomic neuropathy
* Uncontrolled, symptomatic cardiac bradyarrhythmias
* Carotid artery stenosis greater than 50% caused by atherosclerosis, as determined by ultrasound or angiographic evaluation
* Pregnancy
* Local or systemic infection
*Device to device interactions possible (e.g. AICD)<ref>{{Cite journal|last=Weipert|first=Kay F.|last2=Andrick|first2=Jens|last3=Chasan|first3=Ritvan|last4=Gemein|first4=Christopher|last5=Most|first5=Astrid|last6=Hamm|first6=Christian W.|last7=Erkapic|first7=Damir|last8=Schmitt|first8=Joern|date=2018-01|title=Baroreceptor stimulation in a patient with preexisting subcutaneous implantable cardioverter defibrillator|url=https://onlinelibrary.wiley.com/doi/10.1111/pace.13115|journal=Pacing and Clinical Electrophysiology|language=en|volume=41|issue=1|pages=90–92|doi=10.1111/pace.13115|issn=0147-8389}}</ref>

=== Controversy ===
Barostim’s cost-effectiveness in refractory hypertension patients is debated and battery replacement costs are a significant economic factor. <ref>{{Cite journal|last=Soto|first=Marcelo|last2=Sampietro-Colom|first2=Laura|last3=Sagarra|first3=Joan|last4=Brugada-Terradellas|first4=Josep|date=2016-06|title=InnovaSEC in Action: Cost-effectiveness of Barostim in the Treatment of Refractory Hypertension in Spain|url=https://pubmed.ncbi.nlm.nih.gov/26907729|journal=Revista Espanola De Cardiologia (English Ed.)|volume=69|issue=6|pages=563–571|doi=10.1016/j.rec.2015.11.027|issn=1885-5857|pmid=26907729}}</ref><ref>{{Cite journal|last=Borisenko|first=Oleg|last2=Beige|first2=Joachim|last3=Lovett|first3=Eric G.|last4=Hoppe|first4=Uta C.|last5=Bjessmo|first5=Staffan|date=2014-03|title=Cost-effectiveness of Barostim therapy for the treatment of resistant hypertension in European settings|url=https://journals.lww.com/00004872-201403000-00030|journal=Journal of Hypertension|language=en|volume=32|issue=3|pages=681–692|doi=10.1097/HJH.0000000000000071|issn=0263-6352}}</ref>

=== Surgical procedure ===
The procedure is well described by Weaver et al<ref>Weaver FA, Abraham WT, Little WC, Butter C, Ducharme A, Halbach M, Klug D, Lovett EG, Madershahian N, Müller-Ehmsen J, Schafer JE, Senni M, Swarup V, Wachter R, Zile MR. Surgical Experience and Long-term Results of Baroreflex Activation Therapy for Heart Failure With Reduced Ejection Fraction. Semin Thorac Cardiovasc Surg. 2016 Summer;28(2):320-328. doi: 10.1053/j.semtcvs.2016.04.017. Epub 2016 Jun 2. PMID: 28043438.</ref>

===== Exposure =====
The first step in the procedure is exposing the carotid artery.

* The carotid bifurcation is exposed via a cutdown
** The right carotid is preferentially used as it has been shown to be more sensitive<ref>de Leeuw PW, Alnima T, Lovett E, Sica D, Bisognano J, Haller H, Kroon AA. Bilateral or unilateral stimulation for baroreflex activation therapy. Hypertension. 2015 Jan;65(1):187-92. doi: 10.1161/HYPERTENSIONAHA.114.04492. Epub 2014 Oct 20. PMID: 25331845.</ref>

===== Mapping =====
The next step is to map the carotid sinus by testing the baroreceptor reflex at different areas.

* The surgeons will stimulate different areas of the carotid sinus with an electrode to test for a decrease in heart rate and/or systolic blood pressure
** Mapping requires a lot of communication between surgery and anesthesia teams
** Before the initiation of mapping, a stable baseline heart rate and blood pressure should be established
** Peak responses in heart rate and pressure generally occur within 30-120 seconds of initiating stimulation
* '''Many common anesthetic medications can cause blunting of the baroreceptor reflex'''
** '''Maintenance of anesthesia should be tailored to the patient to safely avoid baroreceptor blunting medications (see intraoperative management)'''

===== Anchoring and tunneling =====
The next step is to anchor the electrode to the point of maximal stimulus and tunnel the lead into the chest wall where it is attached to the generator.

===== Testing and closure =====
The next step is to test the lead and generator for adequate function and close the chest wall pocket and cutdown.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
!System
!Considerations
|-
|Cardiovascular
|Only patients with significant heart failure history undergo BAT. They should be assessed for evidence of volume overload or current heart failure exacerbation. All patients will likely be on a beta blocker and should take it perioperatively
|-
|Pulmonary
|SOB may be evidence of worsening heart failure or exacerbation. Patients with baseline orthopnea may require different positioning prior to induction
|-
|Hematologic
|Likely anemic. Given proximity to great vessels, an active type and screen is recommended
|-
|Renal
|HFrEF patients may have concomitant CKD
|-
|Endocrine
|HFrEF patients may have concomitant diabetes
|}

=== Labs and studies ===

* Type and Screen
* +/- TTE, TEE, EKG, Stress test

=== Operating room setup ===

* Arterial catheter and transducer
* Infusion and syringe pumps
* Vasopressor infusions available
* Push dose pressors drawn up

=== Patient preparation and premedication ===

* Cardiovascular medications are stopped 4-6 hours before surgery with the exception of beta-blocker therapy, which is down-titrated 1-2 days in advance to a level at which intraoperative bradycardia is not expected to interfere with observation of the baroreflex response
* If the patient is on DAPT or other anticoagulants they are held for the appropriate time given the indication and risk, as guided by discussion between surgeon and cardiologist
* Likely a lower than normal threshold for benzodiazepine use in elderly patients as the sedative hypnotics options are limited by baroreceptor reflex concerns

=== Regional and neuraxial techniques ===

* Regional anesthesia is NOT recommended in BAT implantation cases due to concerns for local anesthetic blunting of the baroreceptor reflex

== Intraoperative management ==

=== Monitoring and access ===

* PIV x2
* Standard monitors
* BIS
* +/- Arterial line

=== Induction and airway management ===

* Standard induction for heart failure patient, ETT

=== Positioning ===

* Supine
* Arms usually tucked

=== Maintenance and surgical considerations ===

* '''Many of the medications routinely used for maintenance of general anesthesia modulate the baroreceptor reflex; including propofol'''<ref>Sato M, Tanaka M, Umehara S, Nishikawa T. Baroreflex control of heart rate during and after propofol infusion in humans. Br J Anaesth. 2005 May;94(5):577-81. doi: 10.1093/bja/aei092. Epub 2005 Feb 18. PMID: 15722386.</ref>''', volatile anesthetics (in a dose dependent fashion)'''<ref>Ebert, Thomas J. MD, PhD; Harkin, Christopher P. MD; Muzi, Michael MD. Cardiovascular Responses to Sevoflurane: A Review. Anesthesia & Analgesia 81(6S):p 11S-22S, December 1995.</ref>''', ketamine (in rabbits)'''<ref>Van Leeuwen AF, Evans RG, Ludbrook J. Effects of halothane, ketamine, propofol and alfentanil anaesthesia on circulatory control in rabbits. Clin Exp Pharmacol Physiol. 1990 Nov;17(11):781-98. doi: 10.1111/j.1440-1681.1990.tb01280.x. PMID: 2078906.</ref>''', and dexmedetomidine'''<ref>Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000 Aug;93(2):382-94. doi: 10.1097/00000542-200008000-00016. PMID: 10910487.</ref>
** Importantly, opioids<ref>Kotrly KJ, Ebert TJ, Vucins EJ, Roerig DL, Stadnicka A, Kampine JP. Effects of fentanyl-diazepam-nitrous oxide anaesthesia on arterial baroreflex control of heart rate in man. Br J Anaesth. 1986 Apr;58(4):406-14. doi: 10.1093/bja/58.4.406. PMID: 3954921.</ref>, benzodiazepines<ref>Win NN, Kohase H, Yoshikawa F, Wakita R, Takahashi M, Kondo N, Ushito D, Umino M. Haemodynamic changes and heart rate variability during midazolam-propofol co-induction. Anaesthesia. 2007 Jun;62(6):561-8. doi: 10.1111/j.1365-2044.2007.04990.x. PMID: 17506733.</ref>, etomidate<ref>Ebert TJ, Muzi M, Berens R, Goff D, Kampine JP. Sympathetic responses to induction of anesthesia in humans with propofol or etomidate. Anesthesiology. 1992 May;76(5):725-33. doi: 10.1097/00000542-199205000-00010. PMID: 1575340.</ref>, and nitrous oxide<ref>Tanaka, M., and T. Nishikawa. "Effects of nitrous oxide on baroreflex gain and heart rate variability." ''Acta anaesthesiologica scandinavica'' 48.9 (2004): 1163-1167.</ref> all minimally affect the baroreceptor reflex
* Initial protocols for BAT device implantation recommend avoiding any of the blunting agents: Etomidate induction, benzodiazepine, opioid (as a bolus or infusion), and paralytic maintenance
** These protocols are based on the theoretical benefit. There is no published data on the success or failure of baroreflex mapping with different regimens [source needed]. The device manufacturers also make suggestions, however, there are no sure recommendations
* BAT devices have been successfully implanted with different regimens. Safely achieving amnesia and immobility, while avoiding baroreflex blunting is the goal
** Propofol is a reasonable choice for induction. While it does blunt the reflex, if used only for induction, the blunting effect dissipates in ~10 minutes - usually plenty of time to allow for draping, timeouts, and cutdown
** Volatile anesthetics below 0.5 MAC limit blunting, are titratable, and allow for a more efficient emergence and recovery
** Supplement with a remifentanil infusion, fentanyl boluses, or nitrous oxide to ensure adequate depth of anesthesia. Use BIS to help titrate medications
** Avoid blunting agents which convey little benefit to efficiency and safety of the anesthetic (i.e., ketamine, dexmedetomidine)
** Each strategy will of course have its drawbacks. A pure benzo-opioid regimen in a frail, elderly patient could necessitate a long recovery phase and increase the potential for delirium while using some of the blunting agents may require changing strategies mid-operation and/or risk failure
* During the mapping phase the goal is a stable dose of anesthetic, so that changes in HR and SBP can be attributed to sinus stimulation and not changes in medications. You will have transient bradycardia and hypotension during mapping. Be patient, but be prepared to intervene if the patient does not recover after stimulation ceases

=== Emergence ===

* Standard

== Postoperative management ==

=== Disposition ===

* PACU barring complications

=== Pain management ===

* Mild pain procedure, low dose opioids generally sufficient

=== Potential complications ===

* Local discomfort at the implantation site (most common)<ref>{{Cite journal|last=Wallbach|first=Manuel|last2=Böhning|first2=Enrico|last3=Lehnig|first3=Luca-Yves|last4=Schroer|first4=Charlotte|last5=Müller|first5=Gerhard Anton|last6=Wachter|first6=Rolf|last7=Lüders|first7=Stephan|last8=Zenker|first8=Dieter|last9=Koziolek|first9=Michael Johann|date=2018-08|title=Safety profile of baroreflex activation therapy (NEO) in patients with resistant hypertension|url=https://journals.lww.com/00004872-201808000-00021|journal=Journal of Hypertension|language=en|volume=36|issue=8|pages=1762–1769|doi=10.1097/HJH.0000000000001753|issn=0263-6352}}</ref>
*Bradycardia, hypotension intraoperatively/postoperatively<ref>{{Cite journal|last=Wallbach|first=Manuel|last2=Böhning|first2=Enrico|last3=Lehnig|first3=Luca-Yves|last4=Schroer|first4=Charlotte|last5=Müller|first5=Gerhard Anton|last6=Wachter|first6=Rolf|last7=Lüders|first7=Stephan|last8=Zenker|first8=Dieter|last9=Koziolek|first9=Michael Johann|date=2018-08|title=Safety profile of baroreflex activation therapy (NEO) in patients with resistant hypertension|url=https://journals.lww.com/00004872-201808000-00021|journal=Journal of Hypertension|language=en|volume=36|issue=8|pages=1762–1769|doi=10.1097/HJH.0000000000001753|issn=0263-6352}}</ref>
* Other arrythmias<ref>{{Cite journal|last=Wallbach|first=Manuel|last2=Böhning|first2=Enrico|last3=Lehnig|first3=Luca-Yves|last4=Schroer|first4=Charlotte|last5=Müller|first5=Gerhard Anton|last6=Wachter|first6=Rolf|last7=Lüders|first7=Stephan|last8=Zenker|first8=Dieter|last9=Koziolek|first9=Michael Johann|date=2018-08|title=Safety profile of baroreflex activation therapy (NEO) in patients with resistant hypertension|url=https://journals.lww.com/00004872-201808000-00021|journal=Journal of Hypertension|language=en|volume=36|issue=8|pages=1762–1769|doi=10.1097/HJH.0000000000001753|issn=0263-6352}}</ref>
* Pneumothorax (during tunneling or pouch creation)
* Bleeding, hematoma
*Hypertensive Crisis<ref>{{Cite journal|last=Wallbach|first=Manuel|last2=Böhning|first2=Enrico|last3=Lehnig|first3=Luca-Yves|last4=Schroer|first4=Charlotte|last5=Müller|first5=Gerhard Anton|last6=Wachter|first6=Rolf|last7=Lüders|first7=Stephan|last8=Zenker|first8=Dieter|last9=Koziolek|first9=Michael Johann|date=2018-08|title=Safety profile of baroreflex activation therapy (NEO) in patients with resistant hypertension|url=https://journals.lww.com/00004872-201808000-00021|journal=Journal of Hypertension|language=en|volume=36|issue=8|pages=1762–1769|doi=10.1097/HJH.0000000000001753|issn=0263-6352}}</ref>
* Infection
* Lead displacement
* Nerve injury
*Stroke if combined with carotid surgery<ref>{{Cite journal|last=Weipert|first=Kay F.|last2=Most|first2=Astrid|last3=Doerr|first3=Oliver|last4=Koshty|first4=Ahmed|last5=Hamm|first5=Christian W.|last6=Erkapic|first6=Damir|last7=Schmitt|first7=Joern|date=2016-10|title=Barostim Implantation with Ipsilateral Carotid Endarterectomy as a One-Stage Procedure|url=https://pubmed.ncbi.nlm.nih.gov/27423727|journal=Annals of Vascular Surgery|volume=36|pages=295.e9–295.e11|doi=10.1016/j.avsg.2016.03.026|issn=1615-5947|pmid=27423727}}</ref>
*Safe with concurrent use of AICD<ref>{{Cite journal|last=Weipert|first=Kay F.|last2=Andrick|first2=Jens|last3=Chasan|first3=Ritvan|last4=Gemein|first4=Christopher|last5=Most|first5=Astrid|last6=Hamm|first6=Christian W.|last7=Erkapic|first7=Damir|last8=Schmitt|first8=Joern|date=2018-01|title=Baroreceptor stimulation in a patient with preexisting subcutaneous implantable cardioverter defibrillator|url=https://pubmed.ncbi.nlm.nih.gov/28543399|journal=Pacing and clinical electrophysiology: PACE|volume=41|issue=1|pages=90–92|doi=10.1111/pace.13115|issn=1540-8159|pmid=28543399}}</ref>
*In patients with ESRD, parasthesias and dysphagia reported<ref>{{Cite journal|last=Beige|first=Joachim|last2=Koziolek|first2=Michael J.|last3=Hennig|first3=Gert|last4=Hamza|first4=Amir|last5=Wendt|first5=Ralph|last6=Müller|first6=Gerhard A.|last7=Wallbach|first7=Manuel|date=2015-11|title=Baroreflex activation therapy in patients with end-stage renal failure: proof of concept|url=https://journals.lww.com/00004872-201511000-00024|journal=Journal of Hypertension|language=en|volume=33|issue=11|pages=2344–2349|doi=10.1097/HJH.0000000000000697|issn=0263-6352}}</ref>

== References ==

[[Category:Surgical procedures]]

Baroreflex activation device implant (Barostim)

2024-11-09T00:09:03Z

Asdoyal: added references. Will keep working on it.

Baroreflex activation therapy (BAT) Barostim is an advanced device that leverages the principles of baroreflex activation therapy to modulate the autonomic nervous system and treat conditions like resistant hypertension and heart failure with reduced ejection fraction (HFrEF). The device currently implanted by our vascular surgeons is the Barostim Neo2 designed by CVRX. A lead is placed on the carotid sinus via a small cutdown, tunneled under the subcutaneous tissue, and connected to a generator that is placed in the chest and can be controlled by an external programmer. Heart failure with reduced ejection fraction involves disturbances of the autonomic nervous system characterized by decreased baroreceptor sensitivity, increased sympathetic tone, and decreased parasympathetic tone<ref>John S. Floras, Sympathetic Nervous System Activation in Human Heart Failure: Clinical Implications of an Updated Model, Journal of the American College of Cardiology, Volume 54, Issue 5, 2009, Pages 375-385, ISSN 0735-1097, <nowiki>https://doi.org/10.1016/j.jacc.2009.03.061</nowiki>.</ref>. Baroreflex activation therapy (BAT) aims to restore balance to the autonomic nervous system by increasing parasympathetic output via electrical stimulation of the carotid baroreceptors. In clinical trials BAT has been shown to be safe and significantly improved QOL, exercise capacity, and NT-proBNP<ref>Zile MR, Lindenfeld J, Weaver FA, Zannad F, Galle E, Rogers T, Abraham WT. Baroreflex Activation Therapy in Patients With Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol. 2020 Jul 7;76(1):1-13. doi: 10.1016/j.jacc.2020.05.015. PMID: 32616150.</ref> in patients with HFrEF. This approach helps mitigate the progression of heart failure by reducing neurohormonal activation.<ref>{{Cite journal|last=Zucker|first=Irving H.|last2=Hackley|first2=Johnnie F.|last3=Cornish|first3=Kurtis G.|last4=Hiser|first4=Bradley A.|last5=Anderson|first5=Nicholas R.|last6=Kieval|first6=Robert|last7=Irwin|first7=Eric D.|last8=Serdar|first8=David J.|last9=Peuler|first9=Jacob D.|last10=Rossing|first10=Martin A.|date=2007-11|title=Chronic Baroreceptor Activation Enhances Survival in Dogs With Pacing-Induced Heart Failure|url=https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.107.095216|journal=Hypertension|language=en|volume=50|issue=5|pages=904–910|doi=10.1161/HYPERTENSIONAHA.107.095216|issn=0194-911X}}</ref><ref>{{Cite journal|last=Zile|first=Michael R.|last2=Abraham|first2=William T.|last3=Weaver|first3=Fred A.|last4=Butter|first4=Christian|last5=Ducharme|first5=Anique|last6=Halbach|first6=Marcel|last7=Klug|first7=Didier|last8=Lovett|first8=Eric G.|last9=Müller‐Ehmsen|first9=Jochen|last10=Schafer|first10=Jill E.|last11=Senni|first11=Michele|date=2015-10|title=Baroreflex activation therapy for the treatment of heart failure with a reduced ejection fraction: safety and efficacy in patients with and without cardiac resynchronization therapy|url=https://onlinelibrary.wiley.com/doi/10.1002/ejhf.299|journal=European Journal of Heart Failure|language=en|volume=17|issue=10|pages=1066–1074|doi=10.1002/ejhf.299|issn=1388-9842}}</ref><ref>{{Cite journal|last=Abraham|first=William T.|last2=Zile|first2=Michael R.|last3=Weaver|first3=Fred A.|last4=Butter|first4=Christian|last5=Ducharme|first5=Anique|last6=Halbach|first6=Marcel|last7=Klug|first7=Didier|last8=Lovett|first8=Eric G.|last9=Müller-Ehmsen|first9=Jochen|last10=Schafer|first10=Jill E.|last11=Senni|first11=Michele|date=2015-06|title=Baroreflex Activation Therapy for the Treatment of Heart Failure With a Reduced Ejection Fraction|url=https://linkinghub.elsevier.com/retrieve/pii/S2213177915001250|journal=JACC: Heart Failure|language=en|volume=3|issue=6|pages=487–496|doi=10.1016/j.jchf.2015.02.006}}</ref>

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
+/- Arterial line
| monitors = Standard
BIS
+/- ABP
| considerations_preoperative = Heart failure symptoms
| considerations_intraoperative = Avoid baroreflex blunting medications
| considerations_postoperative = Standard
}}

== Overview ==

=== Indications ===

* Barostim is indicated for patients who are NYHA Class III or Class II (who had a recent history of Class III) despite treatment with guideline-directed medical therapies (medications and devices), have a left ventricular ejection fraction of ≤ 35% and a NT-proBNP <1600 pg/ml.<ref>{{Cite journal|last=Zile|first=Michael R.|last2=Lindenfeld|first2=JoAnn|last3=Weaver|first3=Fred A.|last4=Zannad|first4=Faiez|last5=Galle|first5=Elizabeth|last6=Rogers|first6=Tyson|last7=Abraham|first7=William T.|date=2020-07|title=Baroreflex Activation Therapy in Patients With Heart Failure With Reduced Ejection Fraction|url=https://linkinghub.elsevier.com/retrieve/pii/S0735109720352980|journal=Journal of the American College of Cardiology|language=en|volume=76|issue=1|pages=1–13|doi=10.1016/j.jacc.2020.05.015}}</ref><ref>{{Cite journal|last=Coats|first=Andrew J.S.|last2=Abraham|first2=William T.|last3=Zile|first3=Michael R.|last4=Lindenfeld|first4=Joann A.|last5=Weaver|first5=Fred A.|last6=Fudim|first6=Marat|last7=Bauersachs|first7=Johann|last8=Duval|first8=Sue|last9=Galle|first9=Elizabeth|last10=Zannad|first10=Faiez|date=2022-09|title=Baroreflex activation therapy with the Barostim ™ device in patients with heart failure with reduced ejection fraction: a patient level meta‐analysis of randomized controlled trials|url=https://onlinelibrary.wiley.com/doi/10.1002/ejhf.2573|journal=European Journal of Heart Failure|language=en|volume=24|issue=9|pages=1665–1673|doi=10.1002/ejhf.2573|issn=1388-9842|pmc=PMC9796660|pmid=35713888}}</ref><ref>{{Cite journal|last=Heidenreich|first=Paul A.|last2=Bozkurt|first2=Biykem|last3=Aguilar|first3=David|last4=Allen|first4=Larry A.|last5=Byun|first5=Joni J.|last6=Colvin|first6=Monica M.|last7=Deswal|first7=Anita|last8=Drazner|first8=Mark H.|last9=Dunlay|first9=Shannon M.|last10=Evers|first10=Linda R.|last11=Fang|first11=James C.|date=2022-05-03|title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063|journal=Circulation|language=en|volume=145|issue=18|doi=10.1161/CIR.0000000000001063|issn=0009-7322}}</ref><ref>{{Cite journal|last=Heidenreich|first=Paul A.|last2=Bozkurt|first2=Biykem|last3=Aguilar|first3=David|last4=Allen|first4=Larry A.|last5=Byun|first5=Joni J.|last6=Colvin|first6=Monica M.|last7=Deswal|first7=Anita|last8=Drazner|first8=Mark H.|last9=Dunlay|first9=Shannon M.|last10=Evers|first10=Linda R.|last11=Fang|first11=James C.|date=2022-05|title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure|url=https://linkinghub.elsevier.com/retrieve/pii/S0735109721083959|journal=Journal of the American College of Cardiology|language=en|volume=79|issue=17|pages=e263–e421|doi=10.1016/j.jacc.2021.12.012}}</ref>
* Refractory hypertension or inability to tolerate antihypertensive agents
* Contraindications to LVAD, heart transplant
* Autonomic Imbalance and Sympathetic Hyperactivity/POTS/Tachycardia

=== Contraindications ===

* Patient eligible for cardiac resynchronization therapy
* Bilateral carotid bifurcations located above the level of the mandible
* Baroreflex failure or autonomic neuropathy
* Uncontrolled, symptomatic cardiac bradyarrhythmias
* Carotid artery stenosis greater than 50% caused by atherosclerosis, as determined by ultrasound or angiographic evaluation
* Pregnancy
* Local or systemic infection

=== Surgical procedure ===
The procedure is well described by Weaver et al<ref>Weaver FA, Abraham WT, Little WC, Butter C, Ducharme A, Halbach M, Klug D, Lovett EG, Madershahian N, Müller-Ehmsen J, Schafer JE, Senni M, Swarup V, Wachter R, Zile MR. Surgical Experience and Long-term Results of Baroreflex Activation Therapy for Heart Failure With Reduced Ejection Fraction. Semin Thorac Cardiovasc Surg. 2016 Summer;28(2):320-328. doi: 10.1053/j.semtcvs.2016.04.017. Epub 2016 Jun 2. PMID: 28043438.</ref>

===== Exposure =====
The first step in the procedure is exposing the carotid artery.

* The carotid bifurcation is exposed via a cutdown
** The right carotid is preferentially used as it has been shown to be more sensitive<ref>de Leeuw PW, Alnima T, Lovett E, Sica D, Bisognano J, Haller H, Kroon AA. Bilateral or unilateral stimulation for baroreflex activation therapy. Hypertension. 2015 Jan;65(1):187-92. doi: 10.1161/HYPERTENSIONAHA.114.04492. Epub 2014 Oct 20. PMID: 25331845.</ref>

===== Mapping =====
The next step is to map the carotid sinus by testing the baroreceptor reflex at different areas.

* The surgeons will stimulate different areas of the carotid sinus with an electrode to test for a decrease in heart rate and/or systolic blood pressure
** Mapping requires a lot of communication between surgery and anesthesia teams
** Before the initiation of mapping, a stable baseline heart rate and blood pressure should be established
** Peak responses in heart rate and pressure generally occur within 30-120 seconds of initiating stimulation
* '''Many common anesthetic medications can cause blunting of the baroreceptor reflex'''
** '''Maintenance of anesthesia should be tailored to the patient to safely avoid baroreceptor blunting medications (see intraoperative management)'''

===== Anchoring and tunneling =====
The next step is to anchor the electrode to the point of maximal stimulus and tunnel the lead into the chest wall where it is attached to the generator.

===== Testing and closure =====
The next step is to test the lead and generator for adequate function and close the chest wall pocket and cutdown.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
!System
!Considerations
|-
|Cardiovascular
|Only patients with significant heart failure history undergo BAT. They should be assessed for evidence of volume overload or current heart failure exacerbation. All patients will likely be on a beta blocker and should take it perioperatively
|-
|Pulmonary
|SOB may be evidence of worsening heart failure or exacerbation. Patients with baseline orthopnea may require different positioning prior to induction
|-
|Hematologic
|Likely anemic. Given proximity to great vessels, an active type and screen is recommended
|-
|Renal
|HFrEF patients may have concomitant CKD
|-
|Endocrine
|HFrEF patients may have concomitant diabetes
|}

=== Labs and studies ===

* Type and Screen
* +/- TTE, TEE, EKG, Stress test

=== Operating room setup ===

* Arterial catheter and transducer
* Infusion and syringe pumps
* Vasopressor infusions available
* Push dose pressors drawn up

=== Patient preparation and premedication ===

* Cardiovascular medications are stopped 4-6 hours before surgery with the exception of beta-blocker therapy, which is down-titrated 1-2 days in advance to a level at which intraoperative bradycardia is not expected to interfere with observation of the baroreflex response
* If the patient is on DAPT or other anticoagulants they are held for the appropriate time given the indication and risk, as guided by discussion between surgeon and cardiologist
* Likely a lower than normal threshold for benzodiazepine use in elderly patients as the sedative hypnotics options are limited by baroreceptor reflex concerns

=== Regional and neuraxial techniques ===

* Regional anesthesia is NOT recommended in BAT implantation cases due to concerns for local anesthetic blunting of the baroreceptor reflex

== Intraoperative management ==

=== Monitoring and access ===

* PIV x2
* Standard monitors
* BIS
* +/- Arterial line

=== Induction and airway management ===

* Standard induction for heart failure patient, ETT

=== Positioning ===

* Supine
* Arms usually tucked

=== Maintenance and surgical considerations ===

* '''Many of the medications routinely used for maintenance of general anesthesia modulate the baroreceptor reflex; including propofol'''<ref>Sato M, Tanaka M, Umehara S, Nishikawa T. Baroreflex control of heart rate during and after propofol infusion in humans. Br J Anaesth. 2005 May;94(5):577-81. doi: 10.1093/bja/aei092. Epub 2005 Feb 18. PMID: 15722386.</ref>''', volatile anesthetics (in a dose dependent fashion)'''<ref>Ebert, Thomas J. MD, PhD; Harkin, Christopher P. MD; Muzi, Michael MD. Cardiovascular Responses to Sevoflurane: A Review. Anesthesia & Analgesia 81(6S):p 11S-22S, December 1995.</ref>''', ketamine (in rabbits)'''<ref>Van Leeuwen AF, Evans RG, Ludbrook J. Effects of halothane, ketamine, propofol and alfentanil anaesthesia on circulatory control in rabbits. Clin Exp Pharmacol Physiol. 1990 Nov;17(11):781-98. doi: 10.1111/j.1440-1681.1990.tb01280.x. PMID: 2078906.</ref>''', and dexmedetomidine'''<ref>Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000 Aug;93(2):382-94. doi: 10.1097/00000542-200008000-00016. PMID: 10910487.</ref>
** Importantly, opioids<ref>Kotrly KJ, Ebert TJ, Vucins EJ, Roerig DL, Stadnicka A, Kampine JP. Effects of fentanyl-diazepam-nitrous oxide anaesthesia on arterial baroreflex control of heart rate in man. Br J Anaesth. 1986 Apr;58(4):406-14. doi: 10.1093/bja/58.4.406. PMID: 3954921.</ref>, benzodiazepines<ref>Win NN, Kohase H, Yoshikawa F, Wakita R, Takahashi M, Kondo N, Ushito D, Umino M. Haemodynamic changes and heart rate variability during midazolam-propofol co-induction. Anaesthesia. 2007 Jun;62(6):561-8. doi: 10.1111/j.1365-2044.2007.04990.x. PMID: 17506733.</ref>, etomidate<ref>Ebert TJ, Muzi M, Berens R, Goff D, Kampine JP. Sympathetic responses to induction of anesthesia in humans with propofol or etomidate. Anesthesiology. 1992 May;76(5):725-33. doi: 10.1097/00000542-199205000-00010. PMID: 1575340.</ref>, and nitrous oxide<ref>Tanaka, M., and T. Nishikawa. "Effects of nitrous oxide on baroreflex gain and heart rate variability." ''Acta anaesthesiologica scandinavica'' 48.9 (2004): 1163-1167.</ref> all minimally affect the baroreceptor reflex
* Initial protocols for BAT device implantation recommend avoiding any of the blunting agents: Etomidate induction, benzodiazepine, opioid (as a bolus or infusion), and paralytic maintenance
** These protocols are based on the theoretical benefit. There is no published data on the success or failure of baroreflex mapping with different regimens [source needed]. The device manufacturers also make suggestions, however, there are no sure recommendations
* BAT devices have been successfully implanted with different regimens. Safely achieving amnesia and immobility, while avoiding baroreflex blunting is the goal
** Propofol is a reasonable choice for induction. While it does blunt the reflex, if used only for induction, the blunting effect dissipates in ~10 minutes - usually plenty of time to allow for draping, timeouts, and cutdown
** Volatile anesthetics below 0.5 MAC limit blunting, are titratable, and allow for a more efficient emergence and recovery
** Supplement with a remifentanil infusion, fentanyl boluses, or nitrous oxide to ensure adequate depth of anesthesia. Use BIS to help titrate medications
** Avoid blunting agents which convey little benefit to efficiency and safety of the anesthetic (i.e., ketamine, dexmedetomidine)
** Each strategy will of course have its drawbacks. A pure benzo-opioid regimen in a frail, elderly patient could necessitate a long recovery phase and increase the potential for delirium while using some of the blunting agents may require changing strategies mid-operation and/or risk failure
* During the mapping phase the goal is a stable dose of anesthetic, so that changes in HR and SBP can be attributed to sinus stimulation and not changes in medications. You will have transient bradycardia and hypotension during mapping. Be patient, but be prepared to intervene if the patient does not recover after stimulation ceases

=== Emergence ===

* Standard

== Postoperative management ==

=== Disposition ===

* PACU

=== Pain management ===

* Mild pain procedure, low dose opioids generally sufficient

=== Potential complications ===

* Bradycardia, hypotension intraoperatively/postoperatively
* Other arrythmias
* Pneumothorax (during tunneling or pouch creation)
* Bleeding, hematoma
* Infection
* lead displacement
* Nerve injury

== References ==

[[Category:Surgical procedures]]

Cesarean section

2024-10-12T13:21:54Z

Asdoyal: Tests possibly needed.

{{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''' or '''cesarean delivery''' ) 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. Often women who have had a cesarean delivery will have a subsequent or ''repeat'' cesarean delivery to prevent the possibility of uterine rupture during labor. 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
|
* Seizures or cerebrovascular accident in patients who progress to eclampsia
|-
|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 and increased O2 consumption 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 inhalation 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, e.g. Rotem, Platelet Function, Fibrinogen level

===Operating room setup===

===Patient preparation and premedication===

* Full stomach precautions typically employed if the mother has been laboring prior to cesarean section. There is some controversy regarding whether non-laboring parturients (eg, elective C-section) should be considered "full stomachs".
*Nonparticulate oral antacid (e.g. sodium citrate) immediately prior to general or regional anesthesia.
*Intravenous promotility agent (eg. 10 mg metoclopramide given over 5-10 minutes). Patients may experience akathisia if given too rapidly.
*Intravenous antacids (e.g. ranitidine, famotidine). Onset of action 30 minutes.
* Anxiolysis (benzodiazepines or opiates) not typically used unless patient is extremely anxious due to concern for fetal respiratory depression from placental transfer
*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===

*Neuraxial anesthesia is preferred unless there are strict contraindications (eg, patient refusal, inadequate anesthesia with existing epidural in an emergency situation, thrombocytopenia in the setting of pre-eclampsia or HELLP). General anesthesia with volatile anesthetics exposes the mother to the risk of difficult airway secondary to upper airway edema and increased bleeding due to uterine relaxation.
**Elective C-section
***Spinal anesthesia employed with 10-12.5 mg of hyperbaric bupivacaine (0.75% in dextrose), 15 mcg of fentanyl, and 100-200 mcg of morphine.
***If risk factors for prolonged duration of surgery are present such as obesity, prior C-section, or prior abdominal surgery, 5 mcg of epinephrine can be added to the spinal anesthetic dose to prolong duration of blockade.
**Urgent C-section in laboring parturient
***Existing labor epidural should be utilized and dosed with 2% lidocaine for rapid achievement of surgical anesthesia to the level of T4.
****2 mL of bicarbonate and 5 mcg of epinephrine can be added to the lidocaine to speed the onset of action.
****0.5% bupivacaine can also be utilized if there is adequate time for its onset of action (10-15 minutes).
****100 mcg of epidural fentanyl can be administered to increase the density of the block.
***Spinal anesthesia should be attempted if there is sufficient time (stability of fetal heart rate tracing)
**Emergency C-section
***20 mL of 3% chloroprocaine should be administered through an existing epidural catheter to achieve rapid surgical anesthesia (roughly 8 minutes to peak effect)
***General anesthesia should be employed if surgical anesthesia cannot be obtained with an existing epidural or if there is no epidural in place.
****RSI with propofol and succinylcholine (etomidate if concern for cardiovascular instability).
****Smaller ETT size generally used (6.0-6.5) due to concern for maternal airway edema in the setting of labor.
****Sevoflurane used for maintenance of anesthesia initially and 70% nitrous oxide in 30% oxygen after delivery of the fetus to reduce the amount of sevoflurane (which has a higher tendency to produce tocolysis and increase bleeding). Opiates (eg, hydromorphone) can be administered after delivery of the fetus.
*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 of
*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 />

Transjugular intrahepatic portosystemic shunts

2022-08-05T18:15:06Z

Asdoyal: editing, editing, editing

{{Infobox surgical case reference
| anesthesia_type = General or MAC sedation
| airway = ETT
| lines_access = Two large PIV, consider central line
| monitors = Standard Monitors, Arterial Line, possible Central Line
| considerations_preoperative = Coagulopathies from liver dysfunction, possible full stomach,
| considerations_intraoperative = Possible large blood loss, altered drug effect, complete heart block
| considerations_postoperative = Hepatic encephalopathy, PV thrombosis, hepatic infarction, hemorrhage, fluid/electrolyte imbalance.
}}

Insertion of low-resistance percutaneous shunt between the portal and systemic venous circulations.

TIPS is a procedure for patients with portal hypertension (typically from cirrhosis) and associated large gastric/esophageal varices or ascites. A percutaneous shunt between the portal and systemic circulations is created. An esophageal variceal bleed has a high mortality (30-80%).<ref>{{Cite journal|last=Wipassakornwarawuth|first=Suchart|last2=Opasoh|first2=Manus|last3=Ammaranun|first3=Kasiri|last4=Janthawanit|first4=Pathomporn|date=2002-06|title=Rate and associated risk factors of rebleeding after endoscopic variceal band ligation|url=https://pubmed.ncbi.nlm.nih.gov/12322843|journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet|volume=85|issue=6|pages=698–702|issn=0125-2208|pmid=12322843}}</ref>

As the name suggests, the right IJ is accessed and a guidewire/catheter is inserted in the right hepatic vein. Carbon dioxide is wedged in the hepatic veins, through the sinusoids, and into the portal vein, thus creating a map. A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein. This tract is dilated with an angioplasty balloon and a self-expanding stent is deployed. This creates a shunt from the high pressure portal system into the low pressure central venous system.<ref>{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref> This drop in portal pressure lowers the risk of esophageal variceal bleeding and decreases ascites. <ref>{{Cite journal|last=Chana|first=A.|last2=James|first2=M.|last3=Veale|first3=P.|date=2016-12-01|title=Anaesthesia for transjugular intrahepatic portosystemic shunt insertion|url=https://www.bjaed.org/article/S2058-5349(17)30002-1/abstract|journal=BJA Education|language=English|volume=16|issue=12|pages=405–409|doi=10.1093/bjaed/mkw022|issn=2058-5349}}</ref> TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites that necessitates paracentesis<ref>{{Cite journal|last=Narahara|first=Yoshiyuki|last2=Kanazawa|first2=Hidenori|last3=Fukuda|first3=Takeshi|last4=Matsushita|first4=Yoko|last5=Harimoto|first5=Hirotomo|last6=Kidokoro|first6=Hideko|last7=Katakura|first7=Tamaki|last8=Atsukawa|first8=Masanori|last9=Taki|first9=Yasuhiko|last10=Kimura|first10=Yuu|last11=Nakatsuka|first11=Katsuhisa|date=2011-01|title=Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial|url=https://pubmed.ncbi.nlm.nih.gov/20632194|journal=Journal of Gastroenterology|volume=46|issue=1|pages=78–85|doi=10.1007/s00535-010-0282-9|issn=1435-5922|pmid=20632194}}</ref> as well as when used to control variceal bleeding. <ref>{{Cite journal|last=García-Pagán|first=Juan Carlos|last2=Caca|first2=Karel|last3=Bureau|first3=Christophe|last4=Laleman|first4=Wim|last5=Appenrodt|first5=Beate|last6=Luca|first6=Angelo|last7=Abraldes|first7=Juan G.|last8=Nevens|first8=Frederik|last9=Vinel|first9=Jean Pierre|last10=Mössner|first10=Joachim|last11=Bosch|first11=Jaime|date=2010-06-24|title=Early use of TIPS in patients with cirrhosis and variceal bleeding|url=https://pubmed.ncbi.nlm.nih.gov/20573925|journal=The New England Journal of Medicine|volume=362|issue=25|pages=2370–2379|doi=10.1056/NEJMoa0910102|issn=1533-4406|pmid=20573925}}</ref>

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Hepatic Encephalopathy may be present and these patients are very sensitive to hypnotics and narcotics.
|-
|Cardiovascular
|Often hyperdynamic low PVR. Cardiomyopathy and CAD common in this population.
|-
|Pulmonary
|Large volume ascites may lead to low FRC, atelectasis, pulmonary shunting and hypoxemia. Hepatopulmonary syndrome may be present. Pleural effusions common. Hepatic encephalopathy may cause hyperventilation, hypocapnia, and respiratory alkalosis with metabolic compensation.
|-
|Gastrointestinal
|Possible full stomach.
|-
|Hematologic
|May need to correct coagulopathies due to liver dysfunction. May require PRBC/FFP/CRYO/PLTs intraoperatively. Ideally plt>50, INR<1.5
|-
|Renal
|Possible hepatorenal syndrome
|-
|Other
|If ascites drained, must be replaced with 25% albumin (8g per 2.5L drained)
|}

===Labs and studies===

*T&S
*T&C 2 units PRBC
*CBC, complete blood count
*CMP, comprehensive metabolic panel
*Coagulation panel (PT/INR, PTT, Fibrinogen)
*Thromboelastogram (TEG, ROTEM) if indicated
*Pre-op Echocardiography preferred
*Further cardiopulmonary studies as indicated

===Operating room setup===

*Fluid/blood warmer, LR/NS/PL/Albumin, possible rapid infuser (e.g. Belmont or Level 1)
*Arterial line, CVP as indicated

===Patient preparation and premedication===

*Consider reversing any coagulopathies
*Use caution with benzodiazepines and narcotics

==Intraoperative management==

===Monitoring and access===

*Large bore PIV x2
*Arterial Line
*CVP if indicated

===Induction and airway management===

*Typically GETA, but may be done as a MAC sedation.
*RSI indicated in gastroparesis, encephalopathy, variceal bleed, severe ascites

===Positioning===

*Supine, head tilted to the left. Typical access is the right internal jugular.

===Maintenance and surgical considerations===

*Potential ''intraprocedural'' complications 1) Portal vein rupture; intra-abdominal hemorrhage may be massive and require emergency surgery 2) Liver capsule perforation 3) Complete heart block, especially in patients with LBBB.
*Patient may have markedly reduced drug metabolism, anticipate prolonged medication effects. Low albumin levels may alter pharmacokinetics of heavily protein-bound medications.

===Emergence===

*Possibility of delayed emergence
*Extubate when fully awake and protecting airways

==Postoperative management==

===Disposition===

*PACU, ICU or step down ICU as indicated

===Pain management===

*Multimodal analgesia, avoid lidocaine gtt
*IV narcotics, avoid morphine

===Potential complications===
Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), stent migration, sepsis, fluid/electrolyte disturbance, biliary tree injury.

==Procedure variants==

{| class="wikitable"
|+
!
!TIPS
!DIPS
|-
|Unique considerations
|Transjugular Intrahepatic Portosystemic Shunt
|Direct IVC to Portal Shunt
|-
|Surgical access
|Right internal jugular vein

*Fluoroscopic guidance using CO2 contrast from hepatic vein, through liver into the PV
|Internal jugular and femoral vein

*IV ultrasound guides needle puncture from IVC, through caudate lobe, into PV
|-
|Surgical time
|
|
|-
|EBL
|0-3000 mL
|0-3000 mL
|-
|Postoperative disposition
|PACU to stepdown or ICU
|PACU to stepdown or ICU
|-
|Pain management
|Multimodal analgesics
|Multimodal analgesics
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]
<references />

Transjugular intrahepatic portosystemic shunts

2022-08-04T20:06:02Z

Asdoyal: starting work on this topic.

{{Infobox surgical case reference
| anesthesia_type = General or MAC sedation
| airway = ETT
| lines_access = Two large PIV, consider central line
| monitors = Standard Monitors, Arterial Line, possible Central Line
| considerations_preoperative = Coagulopathies from liver dysfunction
| considerations_intraoperative = Possible large blood loss
| considerations_postoperative =
}}

Insertion of low-resistance percutaneous shunt between the portal and systemic venous circulations.

TIPS is a procedure for patients with portal hypertension (typically from cirrhosis) and associated large gastric/esophageal varices or ascites. A percutaneous shunt between the portal and systemic circulations is created. An esophageal variceal bleed has a high mortality (30-80%).<ref>{{Cite journal|last=Wipassakornwarawuth|first=Suchart|last2=Opasoh|first2=Manus|last3=Ammaranun|first3=Kasiri|last4=Janthawanit|first4=Pathomporn|date=2002-06|title=Rate and associated risk factors of rebleeding after endoscopic variceal band ligation|url=https://pubmed.ncbi.nlm.nih.gov/12322843|journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet|volume=85|issue=6|pages=698–702|issn=0125-2208|pmid=12322843}}</ref>

As the name suggests, the right IJ is accessed and a guidewire/catheter is inserted in the right hepatic vein. Carbon dioxide is wedged in the hepatic veins, through the sinusoids, and into the portal vein, creating a map. A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein. This tract is then dilated with an angioplasty balloon and a self-expanding stent is deployed, creating a shunt from the high pressure portal system into the low pressured central venous system<ref>{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>. This decrease in portal pressure decreases the risk of esophageal variceal bleeding and decreases ascites. <ref>{{Cite journal|last=Chana|first=A.|last2=James|first2=M.|last3=Veale|first3=P.|date=2016-12-01|title=Anaesthesia for transjugular intrahepatic portosystemic shunt insertion|url=https://www.bjaed.org/article/S2058-5349(17)30002-1/abstract|journal=BJA Education|language=English|volume=16|issue=12|pages=405–409|doi=10.1093/bjaed/mkw022|issn=2058-5349}}</ref> TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites<ref>{{Cite journal|last=Narahara|first=Yoshiyuki|last2=Kanazawa|first2=Hidenori|last3=Fukuda|first3=Takeshi|last4=Matsushita|first4=Yoko|last5=Harimoto|first5=Hirotomo|last6=Kidokoro|first6=Hideko|last7=Katakura|first7=Tamaki|last8=Atsukawa|first8=Masanori|last9=Taki|first9=Yasuhiko|last10=Kimura|first10=Yuu|last11=Nakatsuka|first11=Katsuhisa|date=2011-01|title=Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial|url=https://pubmed.ncbi.nlm.nih.gov/20632194|journal=Journal of Gastroenterology|volume=46|issue=1|pages=78–85|doi=10.1007/s00535-010-0282-9|issn=1435-5922|pmid=20632194}}</ref> as well as when used to control variceal bleeding. <ref>{{Cite journal|last=García-Pagán|first=Juan Carlos|last2=Caca|first2=Karel|last3=Bureau|first3=Christophe|last4=Laleman|first4=Wim|last5=Appenrodt|first5=Beate|last6=Luca|first6=Angelo|last7=Abraldes|first7=Juan G.|last8=Nevens|first8=Frederik|last9=Vinel|first9=Jean Pierre|last10=Mössner|first10=Joachim|last11=Bosch|first11=Jaime|date=2010-06-24|title=Early use of TIPS in patients with cirrhosis and variceal bleeding|url=https://pubmed.ncbi.nlm.nih.gov/20573925|journal=The New England Journal of Medicine|volume=362|issue=25|pages=2370–2379|doi=10.1056/NEJMoa0910102|issn=1533-4406|pmid=20573925}}</ref>

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Hepatic Encephalopathy may be present and these patients are very sensitive to hypnotics and narcotics.
|-
|Cardiovascular
|Often hyperdynamic low PVR. Cardiomyopathy and CAD common in this population.
|-
|Pulmonary
|Large volume ascites may lead to low FRC, atelectasis, pulmonary shunting and hypoxemia. Hepatopulmonary syndrome may be present. Pleural effusions common. Hepatic encephalopathy may cause hyperventilation, hypocapnia, and respiratory alkalosis with metabolic compensation.
|-
|Gastrointestinal
|Possible full stomach.
|-
|Hematologic
|May need to correct coagulopathies due to liver dysfunction. May require PRBC/FFP/CRYO/PLTs intraoperatively. Ideally plt>50, INR<1.5
|-
|Renal
|Possible hepatorenal syndrome
|-
|Other
|If ascites drained, must be replaced with 25% albumin (8g per 2.5L drained)
|}

===Labs and studies===

*T&S
*T&C 2 units PRBC
*CBC, complete blood count
*CMP, comprehensive metabolic panel
*Coagulation panel (PT/INR, PTT, Fibrinogen)
*Thromboelastogram (TEG, ROTEM) if indicated
*Pre-op Echocardiography preferred
*Further cardiopulmonary studies as indicated

===Operating room setup===

*Fluid/blood warmer, LR/NS/PL/Albumin, possible rapid infuser (e.g. Belmont or Level 1)
*Arterial line, CVP as indicated

===Patient preparation and premedication===

*Consider reversing any coagulopathies
*Use caution with benzodiazepines and narcotics

==Intraoperative management==

===Monitoring and access===

*Large bore PIV x2
*Arterial Line
*CVP if indicated

===Induction and airway management===

*Typically GETA, but may be done as a MAC sedation.
*RSI indicated in gastroparesis, encephalopathy, variceal bleed, severe ascites

===Positioning===

*Supine, head tilted to the left. Typical access is the right internal jugular.

===Maintenance and surgical considerations===

*Potential ''intraprocedural'' complications 1) Portal vein rupture; intra-abdominal hemorrhage may be massive and require emergency surgery 2) Liver capsule perforation 3) Complete heart block, especially in patients with LBBB.
*Patient may have markedly reduced drug metabolism, anticipate prolonged medication effects. Low albumin levels may alter pharmacokinetics of heavily protein-bound medications.

===Emergence===

*Possibility of delayed emergence
*Extubate when fully awake and protecting airways

==Postoperative management==

===Disposition===

*PACU, ICU or step down ICU as indicated

===Pain management===

*Multimodal analgesia, avoid lidocaine gtt
*IV narcotics, avoid morphine

===Potential complications===
Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), hepatic infarction, stent migration, sepsis, fluid/electrolyte disturbance.

==Procedure variants==

{| class="wikitable"
|+
!
!TIPS
!DIPS
|-
|Unique considerations
|Transjugular Intrahepatic Portosystemic Shunt
|Direct IVC to Portal Shunt
|-
|Surgical access
|Right internal jugular vein

*Fluoroscopic guidance using CO2 contrast from hepatic vein, through liver into the PV
|Internal jugular and femoral vein

*IV ultrasound guides needle puncture from IVC, through caudate lobe, into PV
|-
|Surgical time
|
|
|-
|EBL
|0-3000 mL
|0-3000 mL
|-
|Postoperative disposition
|PACU to stepdown or ICU
|PACU to stepdown or ICU
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]
<references />

Transjugular intrahepatic portosystemic shunts

2022-08-04T14:38:34Z

Asdoyal: starting work on this topic.

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = Two large PIV, consider central line
| monitors = Standard Monitors, Arterial Line
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Insertion of low-resistance percutaneous shunt between the portal and systemic circulations.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]