WikiAnesthesia - User contributions [en]

Kidney transplant

2023-07-03T22:35:33Z

CFitzgerald: clarified wording

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2 +/- Arterial line +/- Central line
| monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line
| considerations_preoperative = ESRD patients should have potassium checked preop
| considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time
}}

Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
|-
|Cardiovascular
|CHF is common in undialyzed patients
|-
|Pulmonary
|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
|-
|Gastrointestinal
|Gastroparesis may occur in diabetic patients with autonomic neuropathy
|-
|Hematologic
|Many patients will have chronic anemia as a result of low EPO
|-
|Renal
|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds. Most recipients also suffer from long-standing, HTN and its systemic concequences.
|-
|Endocrine
|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
|-
|Vascular
|Many patients have coronary arterial, cerebrovascular, and peripheral vascular disease in addition to their HTN.
|}

=== Labs and studies ===

* CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)
* BMP (pay attention to K which may be elevated in ESRD)

=== Operating room setup ===

* Prepare arterial line setup
* Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
*May need steroid and/or anti-thymocyte globulin prepared

=== Patient preparation and premedication ===

* Midazolam, Tylenol

=== Regional and neuraxial techniques ===

* Epidural or CSE may be used for postop pain management
*Pre-emergence TAP catheter vs single-shot

== Intraoperative management ==

=== Monitoring and access ===

* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
* Arterial line for blood pressure monitoring and frequent lab draws
*IVs and arterial lines should avoid the side of AV fistula if present

=== Induction and airway management ===

* If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used

=== Positioning ===

* Supine
* Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.

=== Maintenance and surgical considerations ===

* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
**Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline
***Historically normal saline was the fluid of choice. Recent study showed are lower rates of delayed graft function (30 versus 40 percent in NS group; BEST-Fluids trial<ref>{{Cite journal|last=Collins MG, Fahim MA, Pascoe EM, et al|title=Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial|url=https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00642-6.pdf|journal=Lancet}}</ref>). Additionally, many institutions have changed to balanced electrolyte solutions due to high rates of hyperchloremic metabolic acidosis<ref>{{Cite journal|last=Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E.|date=Jan 2015|title=An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial.|url=https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/01000/An_Acetate_Buffered_Balanced_Crystalloid_Versus.19.aspx|journal=Anesthesia & Analgesia|via=doi: 10.1213/ANE.0000000000000419}}</ref> seen in large volume NS administration (leading to similar intracellular K+ rates). NS also increased need for vasoactives intraop in this study.
*Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates
* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
*Anticipate prolonged drug effects for renally metabolized/excreted medications
** Avoid meperidine (which may accumulate as normeperidine > CNS toxicity)
* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
*Will be instructed to clamp Foley by surgeons
*May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection

=== Emergence ===

* Patients are usually extubated in the OR
* Ensure adequate NMB reversal

== Postoperative management ==

=== Disposition ===

* Usually to PACU
* Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU

=== Pain management ===

* PCA
* Epidural
*TAP block

=== Potential complications ===

* Fistula thrombosis if improperly padded
* Hemorrhage
* Delayed urine output, dialysis may be necessary until renal function returns
* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Kidney transplant

2023-07-03T22:28:20Z

CFitzgerald: IV fluid choice discussion, fixed spelling typo, added section on maintenace of normothermia

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2 +/- Arterial line +/- Central line
| monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line
| considerations_preoperative = ESRD patients should have potassium checked preop
| considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time
}}

Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
|-
|Cardiovascular
|CHF is common in undialyzed patients
|-
|Pulmonary
|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
|-
|Gastrointestinal
|Gastroparesis may occur in diabetic patients with autonomic neuropathy
|-
|Hematologic
|Many patients will have chronic anemia as a result of low EPO
|-
|Renal
|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds. Most recipients also suffer from long-standing, HTN and its systemic concequences.
|-
|Endocrine
|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
|-
|Vascular
|Many patients have coronary arterial, cerebrovascular, and peripheral vascular disease in addition to their HTN.
|}

=== Labs and studies ===

* CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)
* BMP (pay attention to K which may be elevated in ESRD)

=== Operating room setup ===

* Prepare arterial line setup
* Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
*May need steroid and/or anti-thymocyte globulin prepared

=== Patient preparation and premedication ===

* Midazolam, Tylenol

=== Regional and neuraxial techniques ===

* Epidural or CSE may be used for postop pain management
*Pre-emergence TAP catheter vs single-shot

== Intraoperative management ==

=== Monitoring and access ===

* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
* Arterial line for blood pressure monitoring and frequent lab draws
*IVs and arterial lines should avoid the side of AV fistula if present

=== Induction and airway management ===

* If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used

=== Positioning ===

* Supine
* Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.

=== Maintenance and surgical considerations ===

* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
**Choice of fluids: balanced electrolyte solution vs normal saline
***Historically normal saline was the fluid of choice. Some surgeons may prefer NS due to lower rates of delayed graft function in one RCT (30 versus 40 percent; BEST-Fluids trial<ref>{{Cite journal|last=Collins MG, Fahim MA, Pascoe EM, et al|title=Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial|url=https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00642-6.pdf|journal=Lancet}}</ref>). However, many institutions have changed to balanced electrolyte solutions (Plasmalyte, Normosol, or Lactated Ringer) due to high rates of hyperchloremic metabolic acidosis<ref>{{Cite journal|last=Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E.|date=Jan 2015|title=An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial.|url=https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/01000/An_Acetate_Buffered_Balanced_Crystalloid_Versus.19.aspx|journal=Anesthesia & Analgesia|via=doi: 10.1213/ANE.0000000000000419}}</ref> seen in large volume NS administration (NS also increased need for vasoactives intraop).
*Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates
* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
*Anticipate prolonged drug effects for renally metabolized/excreted medications
** Avoid meperidine (which may accumulate as normeperidine > CNS toxicity)
* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
*Will be instructed to clamp Foley by surgeons
*May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection

=== Emergence ===

* Patients are usually extubated in the OR
* Ensure adequate NMB reversal

== Postoperative management ==

=== Disposition ===

* Usually to PACU
* Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU

=== Pain management ===

* PCA
* Epidural
*TAP block

=== Potential complications ===

* Fistula thrombosis if improperly padded
* Hemorrhage
* Delayed urine output, dialysis may be necessary until renal function returns
* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Kidney transplant

2023-07-03T21:55:39Z

CFitzgerald: added regional anesthesia consideration

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2 +/- Arterial line +/- Central line
| monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line
| considerations_preoperative = ESRD patients should have potassium checked preop
| considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time
}}

Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
|-
|Cardiovascular
|CHF is common in undialyzed patients
|-
|Pulmonary
|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
|-
|Gastrointestinal
|Gastroparesis may occur in diabetic patients with autonomic neuropathy
|-
|Hematologic
|Many patients will have chronic anemia as a result of low EPO
|-
|Renal
|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds
|-
|Endocrine
|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
|-
|Other
|
|}

=== Labs and studies ===

* CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)
* BMP (pay attention to K which may be elevated in ESRD)

=== Operating room setup ===

* Prepare arterial line setup
* Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
*May need steroid and/or anti-thymocyte globulin prepared

=== Patient preparation and premedication ===

* Midazolam, Tylenol

=== Regional and neuraxial techniques ===

* Epidural or CSE may be used for postop pain management
*Pre-emergence TAP catheter vs single-shot

== Intraoperative management ==

=== Monitoring and access ===

* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
* Arterial line for blood pressure monitoring and frequent lab draws
*IVs and arterial lines should avoid the side of AV fistula if present

=== Induction and airway management ===

* If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used

=== Positioning ===

* Supine
* Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.

=== Maintenance and surgical considerations ===

* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
*Anticipate prolonged drug effects for renally metabolized/excreted medications
** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)
* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
*Will be instructed to clamp Foley by surgeons
*May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection

=== Emergence ===

* Patients are usually extubated in the OR
* Ensure adequate NMB reversal

== Postoperative management ==

=== Disposition ===

* Usually to PACU
* Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU

=== Pain management ===

* PCA
* Epidural
*TAP block

=== Potential complications ===

* Fistula thrombosis if improperly padded
* Hemorrhage
* Delayed urine output, dialysis may be necessary until renal function returns
* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Kidney transplant

2023-07-03T21:52:02Z

CFitzgerald: BP monitoring options

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2 +/- Arterial line +/- Central line
| monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line
| considerations_preoperative = ESRD patients should have potassium checked preop
| considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time
}}

Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
|-
|Cardiovascular
|CHF is common in undialyzed patients
|-
|Pulmonary
|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
|-
|Gastrointestinal
|Gastroparesis may occur in diabetic patients with autonomic neuropathy
|-
|Hematologic
|Many patients will have chronic anemia as a result of low EPO
|-
|Renal
|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds
|-
|Endocrine
|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
|-
|Other
|
|}

=== Labs and studies ===

* CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)
* BMP (pay attention to K which may be elevated in ESRD)

=== Operating room setup ===

* Prepare arterial line setup
* Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
*May need steroid and/or anti-thymocyte globulin prepared

=== Patient preparation and premedication ===

* Midazolam, Tylenol

=== Regional and neuraxial techniques ===

* Epidural or CSE may be used for postop pain management

== Intraoperative management ==

=== Monitoring and access ===

* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
* Arterial line for blood pressure monitoring and frequent lab draws
*IVs and arterial lines should avoid the side of AV fistula if present

=== Induction and airway management ===

* If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used

=== Positioning ===

* Supine
* Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.

=== Maintenance and surgical considerations ===

* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
*Anticipate prolonged drug effects for renally metabolized/excreted medications
** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)
* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
*Will be instructed to clamp Foley by surgeons
*May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection

=== Emergence ===

* Patients are usually extubated in the OR
* Ensure adequate NMB reversal

== Postoperative management ==

=== Disposition ===

* Usually to PACU
* Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU

=== Pain management ===

* PCA
* Epidural

=== Potential complications ===

* Fistula thrombosis if improperly padded
* Hemorrhage
* Delayed urine output, dialysis may be needed until renal function returns
* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Hypospadias repair

2022-07-31T18:32:56Z

CFitzgerald:

{{DISPLAYTITLE:Hypospadias Repair}}
{{Infobox surgical procedure
| anesthesia_type = General
| airway = [[ETT]] or [[LMA]]
| lines_access = [[PIV]]
| monitors = Standard
| considerations_preoperative = None
| considerations_intraoperative = ± [[caudal block]] or penile block
| considerations_postoperative = Pain control
}}

== Overview ==

=== Indications ===

* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus)
* Very common congenital defect seen in approximately 1:200 births<ref>{{Cite journal|last=Mai|first=Cara T.|last2=Isenburg|first2=Jennifer|last3=Langlois|first3=Peter H.|last4=Alverson|first4=CJ|last5=Gilboa|first5=Suzanne M.|last6=Rickard|first6=Russel|last7=Canfield|first7=Mark A.|last8=Anjohrin|first8=Suzanne B.|last9=Lupo|first9=Philip J.|last10=Jackson|first10=Deanna R.|last11=Stallings|first11=Erin B.|date=2015|title=Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence|url=http://dx.doi.org/10.1002/bdra.23461|journal=Birth Defects Research Part A: Clinical and Molecular Teratology|volume=103|issue=11|pages=972–993|doi=10.1002/bdra.23461|issn=1542-0752}}</ref><ref>{{Cite journal|last=Paulozzi|first=Leonard J.|last2=Erickson|first2=J. David|last3=Jackson|first3=Richard J.|date=1997-11-01|title=Hypospadias Trends in Two US Surveillance Systems|url=http://dx.doi.org/10.1542/peds.100.5.831|journal=Pediatrics|volume=100|issue=5|pages=831–834|doi=10.1542/peds.100.5.831|issn=1098-4275}}</ref>
* Subdivided by severity/location of developmental abnormality
** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected
** Standard hypospadias associated with normal foreskin, penile length, and glans size. There may be normal variable penile curvature; typically a distal meatus defect.
** Severe hypospadias associated with proximal defects including the scrotum or perineum and/or an abnormally small glans size with severe curvature abnormalities

* Elective procedure in most cases

* Most often considered and recommended in cases with severe cosmetic abnormalities, defects leading to limitations in voiding positions, severe curvature abnormalities that may inhibit intercourse, and concern for future fertility issues

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Typically normal, but review available labs and imaging if other abnormalities are present
|-
|Endocrine
|
|-
|Other
|Patients are typically healthy children
|}

=== Patient preparation and premedication ===

* Anxiolysis, if needed, with midazolam (PO)
* Acetaminophen PO (or PR prior to procedure)

=== Regional and neuraxial techniques ===

* [[Caudal block|Caudal block (caudal epidural)]]
** Placed after induction of anesthesia, intravenous access, and airway management
** Additives to local can include clonidine, ketamine, and opiates
*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic
**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal|last=Hansen|first=T.G.|last2=Henneberg|first2=S.W.|last3=Walther-Larsen|first3=S|last4=Lund|first4=J|last5=Hansen|first5=M|date=2004|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study|url=http://dx.doi.org/10.1093/bja/aeh028|journal=British Journal of Anaesthesia|volume=92|issue=2|pages=223–227|doi=10.1093/bja/aeh028|issn=0007-0912}}</ref>
** Associated with better operating conditions and slightly less blood loss during the surgery<ref>{{Cite journal|last=Gunter|first=Joel B.|last2=Forestner|first2=John E.|last3=Manley|first3=Charles B.|date=1990|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5|journal=Journal of Urology|volume=144|issue=2 Part 2|pages=517–519|doi=10.1016/s0022-5347(17)39509-5|issn=0022-5347}}</ref>
** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal|last=Kim|first=M. H.|last2=Im|first2=Y. J.|last3=Kil|first3=H. K.|last4=Han|first4=S. W.|last5=Joe|first5=Y. E.|last6=Lee|first6=J. H.|date=2016|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463|journal=Anaesthesia|language=en|volume=71|issue=7|pages=773–778|doi=10.1111/anae.13463}}</ref>, a known common complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal|last=Zaidi|first=Raza H.|last2=Casanova|first2=Nina F.|last3=Haydar|first3=Bishr|last4=Voepel-Lewis|first4=Terri|last5=Wan|first5=Julian H.|date=2015|editor-last=Bosenberg|editor-first=Adrian|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719|journal=Pediatric Anesthesia|language=en|volume=25|issue=11|pages=1144–1150|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal|last=Zhu|first=Change|last2=Wei|first2=Rong|last3=Tong|first3=Yiru|last4=Liu|first4=Junjun|last5=Song|first5=Zhaomeng|last6=Zhang|first6=Saiji|date=2019|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis|url=https://rapm.bmj.com/content/44/2/259|journal=Regional Anesthesia & Pain Medicine|language=en|volume=44|issue=2|pages=259–267|doi=10.1136/rapm-2018-000022|issn=1098-7339|pmid=30700621}}</ref>
* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal|last=Chhibber|first=Ashwani K.|last2=Perkins|first2=Fredrick M.|last3=Rabinowitz|first3=Ronald|last4=Vogt|first4=Alison W.|last5=Hulbert|first5=William C.|date=1997|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children|url=http://dx.doi.org/10.1097/00005392-199709000-00118|journal=The Journal of Urology|pages=1156–1159|doi=10.1097/00005392-199709000-00118|issn=0022-5347}}</ref>

== Intraoperative management ==

=== Monitoring and access ===

* Standard monitors
* PIV x1

=== Induction and airway management ===

* Inhalational induction followed by PIV placement
* Airway
** ETT vs LMA (most common)
** Complex repair with buccal graft may require an oral RAE ETT

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Volatile agents (most common)
* TIVA with propofol ± fentanyl boluses or remifentanil gtt
** the need for intraoperative narcotics should be significantly lowered or eliminated with a working caudal block

=== Emergence ===

* Deep vs awake extubation
*Emergence delirium risk age-dependent
**Dexmedetomidine 0.3 mcg/kg IV PRN

== Postoperative management ==

=== Disposition ===

* PACU then Home

=== Pain management ===

* Pain control requirements depend on the extent of the repair, scheduled dosing of non-opiate analgesics should likely be started before the termination of caudal effects (if one was performed)
* Morphine IV (0.025-0.05 mg/kg) with possible transition to PO opiate prior to discharge at surgical team's discretion; but not typically required
* Additional acetaminophen (10-15 mg/kg with a q6hr dosing interval) and/or ibuprofen is generally adequate for pain control

=== Potential complications ===

* Urethrocutaneous fistula
* Urethral stricture
* Urethral diverticulum
* Urinary extravasation

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
{{DEFAULTSORT:Hypospadias Repair}}
<references />
[[Category:Urology]]
[[Category:Pediatric urology]]
[[Category:Urologic]]
[[Category:Pediatric urologic surgery]]

Hypospadias repair

2022-07-31T18:31:10Z

CFitzgerald: emergence delirium

{{DISPLAYTITLE:Hypospadias Repair}}
{{Infobox surgical procedure
| anesthesia_type = General
| airway = [[ETT]] or [[LMA]]
| lines_access = [[PIV]]
| monitors = Standard
| considerations_preoperative = None
| considerations_intraoperative = ± [[caudal block]] or penile block
| considerations_postoperative = Pain control
}}

== Overview ==

=== Indications ===

* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus)
* Very common congenital defect seen in approximately 1:200 births<ref>{{Cite journal|last=Mai|first=Cara T.|last2=Isenburg|first2=Jennifer|last3=Langlois|first3=Peter H.|last4=Alverson|first4=CJ|last5=Gilboa|first5=Suzanne M.|last6=Rickard|first6=Russel|last7=Canfield|first7=Mark A.|last8=Anjohrin|first8=Suzanne B.|last9=Lupo|first9=Philip J.|last10=Jackson|first10=Deanna R.|last11=Stallings|first11=Erin B.|date=2015|title=Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence|url=http://dx.doi.org/10.1002/bdra.23461|journal=Birth Defects Research Part A: Clinical and Molecular Teratology|volume=103|issue=11|pages=972–993|doi=10.1002/bdra.23461|issn=1542-0752}}</ref><ref>{{Cite journal|last=Paulozzi|first=Leonard J.|last2=Erickson|first2=J. David|last3=Jackson|first3=Richard J.|date=1997-11-01|title=Hypospadias Trends in Two US Surveillance Systems|url=http://dx.doi.org/10.1542/peds.100.5.831|journal=Pediatrics|volume=100|issue=5|pages=831–834|doi=10.1542/peds.100.5.831|issn=1098-4275}}</ref>
* Subdivided by severity/location of developmental abnormality
** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected
** Standard hypospadias associated with normal foreskin, penile length, and glans size. There may be normal variable penile curvature; typically a distal meatus defect.
** Severe hypospadias associated with proximal defects including the scrotum or perineum and/or an abnormally small glans size with severe curvature abnormalities

* Elective procedure in most cases

* Most often considered and recommended in cases with severe cosmetic abnormalities, defects leading to limitations in voiding positions, severe curvature abnormalities that may inhibit intercourse, and concern for future fertility issues

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Typically normal, but review available labs and imaging if other abnormalities are present
|-
|Endocrine
|
|-
|Other
|Patients are typically healthy children
|}

=== Patient preparation and premedication ===

* Anxiolysis, if needed, with midazolam (PO)
* Acetaminophen PO (or PR prior to procedure)

=== Regional and neuraxial techniques ===

* [[Caudal block|Caudal block (caudal epidural)]]
** Placed after induction of anesthesia, intravenous access, and airway management
** Additives to local can include clonidine, ketamine, and opiates
*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic
**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal|last=Hansen|first=T.G.|last2=Henneberg|first2=S.W.|last3=Walther-Larsen|first3=S|last4=Lund|first4=J|last5=Hansen|first5=M|date=2004|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study|url=http://dx.doi.org/10.1093/bja/aeh028|journal=British Journal of Anaesthesia|volume=92|issue=2|pages=223–227|doi=10.1093/bja/aeh028|issn=0007-0912}}</ref>
** Associated with better operating conditions and less blood loss during the surgery<ref>{{Cite journal|last=Gunter|first=Joel B.|last2=Forestner|first2=John E.|last3=Manley|first3=Charles B.|date=1990|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5|journal=Journal of Urology|volume=144|issue=2 Part 2|pages=517–519|doi=10.1016/s0022-5347(17)39509-5|issn=0022-5347}}</ref>
** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal|last=Kim|first=M. H.|last2=Im|first2=Y. J.|last3=Kil|first3=H. K.|last4=Han|first4=S. W.|last5=Joe|first5=Y. E.|last6=Lee|first6=J. H.|date=2016|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463|journal=Anaesthesia|language=en|volume=71|issue=7|pages=773–778|doi=10.1111/anae.13463}}</ref>, a known complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal|last=Zaidi|first=Raza H.|last2=Casanova|first2=Nina F.|last3=Haydar|first3=Bishr|last4=Voepel-Lewis|first4=Terri|last5=Wan|first5=Julian H.|date=2015|editor-last=Bosenberg|editor-first=Adrian|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719|journal=Pediatric Anesthesia|language=en|volume=25|issue=11|pages=1144–1150|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal|last=Zhu|first=Change|last2=Wei|first2=Rong|last3=Tong|first3=Yiru|last4=Liu|first4=Junjun|last5=Song|first5=Zhaomeng|last6=Zhang|first6=Saiji|date=2019|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis|url=https://rapm.bmj.com/content/44/2/259|journal=Regional Anesthesia & Pain Medicine|language=en|volume=44|issue=2|pages=259–267|doi=10.1136/rapm-2018-000022|issn=1098-7339|pmid=30700621}}</ref>
* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal|last=Chhibber|first=Ashwani K.|last2=Perkins|first2=Fredrick M.|last3=Rabinowitz|first3=Ronald|last4=Vogt|first4=Alison W.|last5=Hulbert|first5=William C.|date=1997|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children|url=http://dx.doi.org/10.1097/00005392-199709000-00118|journal=The Journal of Urology|pages=1156–1159|doi=10.1097/00005392-199709000-00118|issn=0022-5347}}</ref>

== Intraoperative management ==

=== Monitoring and access ===

* Standard monitors
* PIV x1

=== Induction and airway management ===

* Inhalational induction followed by PIV placement
* Airway
** ETT vs LMA (most common)
** Complex repair with buccal graft may require an oral RAE ETT

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Volatile agents (most common)
* TIVA with propofol ± fentanyl boluses or remifentanil gtt
** the need for intraoperative narcotics should be significantly lowered or eliminated with a working caudal block

=== Emergence ===

* Deep vs awake extubation
*Emergence delirium risk age-dependent
**Dexmedetomidine 0.3 mcg/kg IV PRN

== Postoperative management ==

=== Disposition ===

* PACU then Home

=== Pain management ===

* Pain control requirements depend on the extent of the repair, scheduled dosing of non-opiate analgesics should likely be started before the termination of caudal effects (if one was performed)
* Morphine IV (0.025-0.05 mg/kg) with possible transition to PO opiate prior to discharge at surgical team's discretion; but not typically required
* Additional acetaminophen (10-15 mg/kg with a q6hr dosing interval) and/or ibuprofen is generally adequate for pain control

=== Potential complications ===

* Urethrocutaneous fistula
* Urethral stricture
* Urethral diverticulum
* Urinary extravasation

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
{{DEFAULTSORT:Hypospadias Repair}}
<references />
[[Category:Urology]]
[[Category:Pediatric urology]]
[[Category:Urologic]]
[[Category:Pediatric urologic surgery]]

Hypospadias repair

2022-07-31T18:24:48Z

CFitzgerald: minor edits for consistancy

{{DISPLAYTITLE:Hypospadias Repair}}
{{Infobox surgical procedure
| anesthesia_type = General
| airway = [[ETT]] or [[LMA]]
| lines_access = [[PIV]]
| monitors = Standard
| considerations_preoperative = None
| considerations_intraoperative = ± [[caudal block]] or penile block
| considerations_postoperative = Pain control
}}

== Overview ==

=== Indications ===

* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus)
* Very common congenital defect seen in approximately 1:200 births<ref>{{Cite journal|last=Mai|first=Cara T.|last2=Isenburg|first2=Jennifer|last3=Langlois|first3=Peter H.|last4=Alverson|first4=CJ|last5=Gilboa|first5=Suzanne M.|last6=Rickard|first6=Russel|last7=Canfield|first7=Mark A.|last8=Anjohrin|first8=Suzanne B.|last9=Lupo|first9=Philip J.|last10=Jackson|first10=Deanna R.|last11=Stallings|first11=Erin B.|date=2015|title=Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence|url=http://dx.doi.org/10.1002/bdra.23461|journal=Birth Defects Research Part A: Clinical and Molecular Teratology|volume=103|issue=11|pages=972–993|doi=10.1002/bdra.23461|issn=1542-0752}}</ref><ref>{{Cite journal|last=Paulozzi|first=Leonard J.|last2=Erickson|first2=J. David|last3=Jackson|first3=Richard J.|date=1997-11-01|title=Hypospadias Trends in Two US Surveillance Systems|url=http://dx.doi.org/10.1542/peds.100.5.831|journal=Pediatrics|volume=100|issue=5|pages=831–834|doi=10.1542/peds.100.5.831|issn=1098-4275}}</ref>
* Subdivided by severity/location of developmental abnormality
** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected
** Standard hypospadias associated with normal foreskin, penile length, and glans size. There may be normal variable penile curvature; typically a distal meatus defect.
** Severe hypospadias associated with proximal defects including the scrotum or perineum and/or an abnormally small glans size with severe curvature abnormalities

* Elective procedure in most cases

* Most often considered and recommended in cases with severe cosmetic abnormalities, defects leading to limitations in voiding positions, severe curvature abnormalities that may inhibit intercourse, and concern for future fertility issues

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Typically normal, but review available labs and imaging if other abnormalities are present
|-
|Endocrine
|
|-
|Other
|Patients are typically healthy children
|}

=== Patient preparation and premedication ===

* Anxiolysis, if needed, with midazolam (PO)
* Acetaminophen PO (or PR prior to procedure)

=== Regional and neuraxial techniques ===

* [[Caudal block|Caudal block (caudal epidural)]]
** Placed after induction of anesthesia, intravenous access, and airway management
** Additives to local can include clonidine, ketamine, and opiates
*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic
**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal|last=Hansen|first=T.G.|last2=Henneberg|first2=S.W.|last3=Walther-Larsen|first3=S|last4=Lund|first4=J|last5=Hansen|first5=M|date=2004|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study|url=http://dx.doi.org/10.1093/bja/aeh028|journal=British Journal of Anaesthesia|volume=92|issue=2|pages=223–227|doi=10.1093/bja/aeh028|issn=0007-0912}}</ref>
** Associated with better operating conditions and less blood loss during the surgery<ref>{{Cite journal|last=Gunter|first=Joel B.|last2=Forestner|first2=John E.|last3=Manley|first3=Charles B.|date=1990|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5|journal=Journal of Urology|volume=144|issue=2 Part 2|pages=517–519|doi=10.1016/s0022-5347(17)39509-5|issn=0022-5347}}</ref>
** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal|last=Kim|first=M. H.|last2=Im|first2=Y. J.|last3=Kil|first3=H. K.|last4=Han|first4=S. W.|last5=Joe|first5=Y. E.|last6=Lee|first6=J. H.|date=2016|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463|journal=Anaesthesia|language=en|volume=71|issue=7|pages=773–778|doi=10.1111/anae.13463}}</ref>, a known complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal|last=Zaidi|first=Raza H.|last2=Casanova|first2=Nina F.|last3=Haydar|first3=Bishr|last4=Voepel-Lewis|first4=Terri|last5=Wan|first5=Julian H.|date=2015|editor-last=Bosenberg|editor-first=Adrian|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719|journal=Pediatric Anesthesia|language=en|volume=25|issue=11|pages=1144–1150|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal|last=Zhu|first=Change|last2=Wei|first2=Rong|last3=Tong|first3=Yiru|last4=Liu|first4=Junjun|last5=Song|first5=Zhaomeng|last6=Zhang|first6=Saiji|date=2019|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis|url=https://rapm.bmj.com/content/44/2/259|journal=Regional Anesthesia & Pain Medicine|language=en|volume=44|issue=2|pages=259–267|doi=10.1136/rapm-2018-000022|issn=1098-7339|pmid=30700621}}</ref>
* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal|last=Chhibber|first=Ashwani K.|last2=Perkins|first2=Fredrick M.|last3=Rabinowitz|first3=Ronald|last4=Vogt|first4=Alison W.|last5=Hulbert|first5=William C.|date=1997|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children|url=http://dx.doi.org/10.1097/00005392-199709000-00118|journal=The Journal of Urology|pages=1156–1159|doi=10.1097/00005392-199709000-00118|issn=0022-5347}}</ref>

== Intraoperative management ==

=== Monitoring and access ===

* Standard monitors
* PIV x1

=== Induction and airway management ===

* Inhalational induction followed by PIV placement
* Airway
** ETT vs LMA (most common)
** Complex repair with buccal graft may require an oral RAE ETT

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Volatile agents (most common)
* TIVA with propofol ± fentanyl boluses or remifentanil gtt
** the need for intraoperative narcotics should be significantly lowered or eliminated with a working caudal block

=== Emergence ===

* Deep vs awake extubation

== Postoperative management ==

=== Disposition ===

* PACU then Home

=== Pain management ===

* Pain control requirements depend on the extent of the repair, scheduled dosing of non-opiate analgesics should likely be started before the termination of caudal effects (if one was performed)
* Morphine IV (0.025-0.05 mg/kg) with possible transition to PO opiate prior to discharge at surgical team's discretion; but not typically required
* Additional acetaminophen (10-15 mg/kg with a q6hr dosing interval) and/or ibuprofen is generally adequate for pain control

=== Potential complications ===

* Urethrocutaneous fistula
* Urethral stricture
* Urethral diverticulum
* Urinary extravasation

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
{{DEFAULTSORT:Hypospadias Repair}}
<references />
[[Category:Urology]]
[[Category:Pediatric urology]]
[[Category:Urologic]]
[[Category:Pediatric urologic surgery]]

Hypospadias repair

2022-07-31T18:15:15Z

CFitzgerald: inital page draft

{{DISPLAYTITLE:Hypospadias Repair}}
{{Infobox surgical procedure
| anesthesia_type = General
| airway = [[ETT]] or [[LMA]]
| lines_access = [[PIV]]
| monitors = Standard
| considerations_preoperative = None
| considerations_intraoperative = ± [[caudal block]] or penile block
| considerations_postoperative = Pain control
}}

== Overview ==

=== Indications ===

* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus).
* Relatively common congenital defect seen in approximately 1:350 births
* Subdivided by severity/location of developmental abnormality
** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected
** Standard hypospadias associated with normal foreskin, penile length, and glans size. There may be normal variable penile curvature; typically a distal meatus defect.
** Severe hypospadias associated with proximal defects including the scrotum or perineum and/or an abnormally small glans size with severe curvature abnormalities

* Elective procedure in most cases

* Most often considered and recommended in cases with severe cosmetic abnormalities, defects leading to limitations in voiding positions, severe curvature abnormalities that may inhibit intercourse, and concern for future fertility issues

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Typically normal, but review available labs and imaging if other abnormalities are present
|-
|Endocrine
|
|-
|Other
|Patients are typically healthy children
|}

=== Patient preparation and premedication ===

* Anxiolysis, if needed, with midazolam (PO)
* Acetaminophen PO (or PR prior to procedure)

=== Regional and neuraxial techniques ===

* Caudal Epidural
** Placed after induction of anesthesia, intravenous access, and airway management
** Additives to local can include clonidine, ketamine, and opiates
*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic
**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal|last=Hansen|first=T.G.|last2=Henneberg|first2=S.W.|last3=Walther-Larsen|first3=S|last4=Lund|first4=J|last5=Hansen|first5=M|date=2004|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study|url=http://dx.doi.org/10.1093/bja/aeh028|journal=British Journal of Anaesthesia|volume=92|issue=2|pages=223–227|doi=10.1093/bja/aeh028|issn=0007-0912}}</ref>
** Associated with better operating conditions and less blood loss during the surgery<ref>{{Cite journal|last=Gunter|first=Joel B.|last2=Forestner|first2=John E.|last3=Manley|first3=Charles B.|date=1990|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5|journal=Journal of Urology|volume=144|issue=2 Part 2|pages=517–519|doi=10.1016/s0022-5347(17)39509-5|issn=0022-5347}}</ref>
** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal|last=Kim|first=M. H.|last2=Im|first2=Y. J.|last3=Kil|first3=H. K.|last4=Han|first4=S. W.|last5=Joe|first5=Y. E.|last6=Lee|first6=J. H.|date=2016|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463|journal=Anaesthesia|language=en|volume=71|issue=7|pages=773–778|doi=10.1111/anae.13463}}</ref>, a known complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal|last=Zaidi|first=Raza H.|last2=Casanova|first2=Nina F.|last3=Haydar|first3=Bishr|last4=Voepel-Lewis|first4=Terri|last5=Wan|first5=Julian H.|date=2015|editor-last=Bosenberg|editor-first=Adrian|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719|journal=Pediatric Anesthesia|language=en|volume=25|issue=11|pages=1144–1150|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal|last=Zhu|first=Change|last2=Wei|first2=Rong|last3=Tong|first3=Yiru|last4=Liu|first4=Junjun|last5=Song|first5=Zhaomeng|last6=Zhang|first6=Saiji|date=2019|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis|url=https://rapm.bmj.com/content/44/2/259|journal=Regional Anesthesia & Pain Medicine|language=en|volume=44|issue=2|pages=259–267|doi=10.1136/rapm-2018-000022|issn=1098-7339|pmid=30700621}}</ref>
* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal|last=Chhibber|first=Ashwani K.|last2=Perkins|first2=Fredrick M.|last3=Rabinowitz|first3=Ronald|last4=Vogt|first4=Alison W.|last5=Hulbert|first5=William C.|date=1997|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children|url=http://dx.doi.org/10.1097/00005392-199709000-00118|journal=The Journal of Urology|pages=1156–1159|doi=10.1097/00005392-199709000-00118|issn=0022-5347}}</ref>

== Intraoperative management ==

=== Monitoring and access ===

* Standard monitors
* PIV x1

=== Induction and airway management ===

* Inhalational induction followed by PIV placement
* Airway
** ETT vs LMA (most common)
** Complex repair with buccal graft may require an oral RAE ETT

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Volatile agents (most common)
* TIVA with propofol ± fentanyl boluses or remifentanil gtt
** the need for intraoperative narcotics should be significantly lowered or eliminated with a working caudal block

=== Emergence ===

* Deep vs awake extubation

== Postoperative management ==

=== Disposition ===

* PACU then Home

=== Pain management ===

* Pain control requirements depend on the extent of the repair, scheduled dosing of non-opiate analgesics should likely be started before the termination of caudal effects (if one was performed)
* Morphine IV (0.025-0.05 mg/kg) with possible transition to PO opiate prior to discharge at surgical team's discretion; but not typically required
* Additional acetaminophen (10-15 mg/kg with a q6hr dosing interval) and/or ibuprofen is generally adequate for pain control

=== Potential complications ===

* Urethrocutaneous fistula
* Urethral stricture
* Urethral diverticulum
* Urinary extravasation

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
{{DEFAULTSORT:Hypospadias Repair}}

Maxillary and mandibular osteotomy

2022-07-28T21:35:01Z

CFitzgerald: additional hypotensive strategies

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Nasal ETT
| lines_access = PIV x2 (Large bore IV x1-2)
± Arterial line
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities
| considerations_intraoperative = Highly stimulating, painful surgery
Bed 90-180
| considerations_postoperative = PONV
Pain
Surgical mouth closure with heavy elastic vs wires
}}

== Overview ==

=== Indications ===
Class II-III malocclusion is one of the most common reasons for performing a maxillary and mandibular osteotomies. Severe malocclusion is typically caused by maxillary hypoplasia and is commonly found in patients with orofacial clefts, obstructive sleep apnea (OSA), and maxillary atrophy. Maxillary surgery is required in up to 25% of cleft lip and palate patients.<ref>{{Cite journal|last=Buchanan|first=Edward P.|last2=Hyman|first2=Charles H.|date=2013|title=LeFort I Osteotomy|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805729/|journal=Seminars in Plastic Surgery|volume=27|issue=3|pages=149–154|doi=10.1055/s-0033-1357112|issn=1535-2188|pmc=3805729|pmid=24872761}}</ref><ref>{{Cite journal|last=Scolozzi|first=Paolo|date=2008|title=Distraction Osteogenesis in the Management of Severe Maxillary Hypoplasia in Cleft Lip and Palate Patients|url=http://dx.doi.org/10.1097/scs.0b013e318184365d|journal=Journal of Craniofacial Surgery|volume=19|issue=5|pages=1199–1214|doi=10.1097/scs.0b013e318184365d|issn=1049-2275}}</ref>

=== Surgical Procedure ===
Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal|last=Mercuri|first=L.G.|date=2006|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018|journal=International Journal of Oral and Maxillofacial Surgery|volume=35|issue=3|pages=284–286|doi=10.1016/j.ijom.2005.07.018|issn=0901-5027}}</ref><ref>{{Cite journal|last=Beck|first=James I.|last2=Johnston|first2=Kevin D.|date=2014-02-01|title=Anaesthesia for cosmetic and functional maxillofacial surgery|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X|journal=Continuing Education in Anaesthesia Critical Care & Pain|language=en|volume=14|issue=1|pages=38–42|doi=10.1093/bjaceaccp/mkt027|issn=1743-1816}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* CBC, T&S with blood type verification
* ± PT/PTT
* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)

=== Operating room setup ===

* Airway
** Nasal ETT
** Accordion and/or straight connector
** ± Nasal trumpet
** ± Fiberscope or VL device
* Bolus line ± fluid warmer connected to largest PIV
* Lower body forced-air warmer
* 2 infusion channels and 2 syringe pumps on a manifold
* Maintenance/Carrier line with flushed octopus connecter

=== Patient preparation and premedication ===

* Pretreatment of both nares with Oxymetazoline (Afrin)
* Tylenol PO 15mg/kg (Max: 1g)
* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
* Scopolamine patch as needed
* Consider antisialagogue dose of glycopyrrolate prior to induction
** Adult
*** PO Dose: 1-2 mg PO; Parenteral Dose: 0.1-0.2 mg SC/IM/IV (Max: 1-2 mg/dose, 8mg/day)
** Pediatric
*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)
=== Regional and neuraxial techniques ===

* Mandibular and maxillary nerve blocks performed by the surgeons can be utilized to aid postoperative pain relief

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
** Core temperature monitoring likely only available via bladder or rectal given oral or nasal probes are likely to interfere with surgical exposure
* PIV x2 , at least 1 large-bore PIV for resuscitation
* ± Arterial line as needed based on patient-specific factors
* ± BIS, PSI, or raw EEG monitoring

=== Induction and airway management ===

* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)

* Nasal Intubation
** Consider fiberscopic placement vs DL or VL ± oral manipulation with MaGill forceps
** Consider dilation with lubricated nasal trumpet (one-size greater than the desired ETT) - this will additionally aid in confirming which nare is most likely to easily accommodate the ETT and allow for change in ETT sizing prior to intubation attempt if there is difficulty
** Airway typically secured by surgical team with suture before wrapping the patient's head

* Dexamethasone 4-10mg, typically at least (0.1mg/kg with Max: 10mg for post operative pain/swelling)
* ± Tranexamic Acid (TXA) bolus, typically 1 gram or 30mg/kg over 10-15 minutes
* Ancef, weight-based dosing

=== Positioning ===

* Supine with neck extended, on foam donut
* Careful eye protection and padding
* One or two arms tucked
* Table is usually turned 90-180 degrees

=== Maintenance and surgical considerations ===

* Maintain anesthetic depth with volatile anesthetic ± IV infusions
** Example setup:
*** Sevoflurane (MAC of ~ 0.5)
*** Dexmedetomidine (0.2-0.4 mcg/kg/min)
*** Short-acting opiate (eg. Sufentanil/Alfentanil) or Ultra-short-acting opiate (Remifentanil)
*** ± Tranexamic Acid (TXA)
*** ± Phenylephrine
*** ± Background propofol for PONV

* Consider higher volume hydration (if tolerated) to prevent PONV
* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal|last=Shepherd|first=Jonathan|date=2004|title=Hypotensive anaesthesia and blood loss in orthognathic surgery|url=http://dx.doi.org/10.1038/sj.ebd.6400238|journal=Evidence-Based Dentistry|volume=5|issue=1|pages=16–16|doi=10.1038/sj.ebd.6400238|issn=1462-0049}}</ref>
**if not controlled with a similar IV anesthetic plan as above you may consider other hypotensive agents for as needed example agent listed below:
***Sodium Nitroprusside or SNP (Infusion), Glyceryl trinitrate or GTN (Infusion), Clonidine (Infusion or bolus), β-blockers (Infusion or bolus), Magnesium (Bolus)
* Redose Acetaminophen as able
* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal|last=Lang|first=Scott|last2=Lanigan|first2=Dennis T.|last3=van der Wal|first3=Mike|date=1991-09-01|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex|url=https://doi.org/10.1007/BF03008454|journal=Canadian Journal of Anaesthesia|language=en|volume=38|issue=6|pages=757|doi=10.1007/BF03008454|issn=1496-8975}}</ref><ref>{{Cite journal|last=Campbell|first=R.|last2=Rodrigo|first2=D.|last3=Cheung|first3=L.|date=1994|title=Asystole and bradycardia during maxillofacial surgery.|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/|journal=Anesthesia Progress|volume=41|issue=1|pages=13–16|issn=0003-3006|pmc=2148710|pmid=8629742}}</ref>

=== Emergence ===

* Toradol 0.5 mg/kg, Max: 30 mg
* Zofran
* Reversal with sugammadex
* Ensure removal of all throat packing
* OGT for gastric decompression/removal of surgical bleeding
* Extubate awake and following commands (swallowing in particular)
* Head up or reverse trendelenburg positioning
* Do not suction in the mouth after OGT has been removed
** Consider instead using a soft suction catheter through contralateral nare

* Expect significant postoperative facial swelling
* Removal of the nasal ETT after Le Fort I osteotomy should be done gently because the sectioned nasal septum may easily be displaced

== Postoperative management ==

=== Disposition ===

* PACU -> observation/overnight admission

=== Pain management ===

* Tylenol q6h (liquid PO), NSAID (liquid PO), and IV narcotics all used in perioperative setting, continued after discharge
** Some patients may be excellent candidates for PCAs post-PACU discharge as nursing ratios change and may be recommended for if their pain is particularly difficult to control

* Maxillofacial surgeons typically advise patients to prepare for a prolonged, painful recovery (~six-weeks off) with additional jaw-healing takings up to 2-3 months

=== Potential complications ===

* The reported incidence of PONV after orthognathic surgery varies from 7<ref>{{Cite journal|last=Ichinohe|first=Tatsuya|last2=Kaneko|first2=Yuzuru|date=2007|title=Nitrous Oxide Does Not Aggravate Postoperative Emesis After Orthognathic Surgery in Female and Nonsmoking Patients|url=http://dx.doi.org/10.1016/j.joms.2006.06.283|journal=Journal of Oral and Maxillofacial Surgery|volume=65|issue=5|pages=936–939|doi=10.1016/j.joms.2006.06.283|issn=0278-2391}}</ref> to 40%<ref>{{Cite journal|last=Silva|first=Alessandro C.|last2=O’Ryan|first2=Felice|last3=Poor|first3=David B.|date=2006|title=Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review|url=http://dx.doi.org/10.1016/j.joms.2006.05.024|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=9|pages=1385–1397|doi=10.1016/j.joms.2006.05.024|issn=0278-2391}}</ref>, with steroid prophylaxis and up to 83%<ref>{{Cite journal|last=Piper|first=Swen N.|last2=Röhm|first2=Kerstin|last3=Boldt|first3=Joachim|last4=Kranke|first4=Peter|last5=Maleck|first5=Wolfgang|last6=Seifert|first6=Rudolf|last7=Suttner|first7=Stefan|date=2008|title=Postoperative nausea and vomiting after surgery for prognathism: Not only a question of patients' comfort. A placebo-controlled comparison of dolasetron and droperidol|url=http://dx.doi.org/10.1016/j.jcms.2007.07.011|journal=Journal of Cranio-Maxillofacial Surgery|volume=36|issue=3|pages=173–179|doi=10.1016/j.jcms.2007.07.011|issn=1010-5182}}</ref> with no antiemetic prophylaxis
* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding
** Have closure removal devices at bedside at all time

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
[[Category:Orthognathic surgery]]
[[Category:Maxillofacial surgery]]

Maxillary and mandibular osteotomy

2022-07-28T21:28:34Z

CFitzgerald: consistency in max dose labeling

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Nasal ETT
| lines_access = PIV x2 (Large bore IV x1-2)
± Arterial line
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities
| considerations_intraoperative = Highly stimulating, painful surgery
Bed 90-180
| considerations_postoperative = PONV
Pain
Surgical mouth closure with heavy elastic vs wires
}}

== Overview ==

=== Indications ===
Class II-III malocclusion is one of the most common reasons for performing a maxillary and mandibular osteotomies. Severe malocclusion is typically caused by maxillary hypoplasia and is commonly found in patients with orofacial clefts, obstructive sleep apnea (OSA), and maxillary atrophy. Maxillary surgery is required in up to 25% of cleft lip and palate patients.<ref>{{Cite journal|last=Buchanan|first=Edward P.|last2=Hyman|first2=Charles H.|date=2013|title=LeFort I Osteotomy|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805729/|journal=Seminars in Plastic Surgery|volume=27|issue=3|pages=149–154|doi=10.1055/s-0033-1357112|issn=1535-2188|pmc=3805729|pmid=24872761}}</ref><ref>{{Cite journal|last=Scolozzi|first=Paolo|date=2008|title=Distraction Osteogenesis in the Management of Severe Maxillary Hypoplasia in Cleft Lip and Palate Patients|url=http://dx.doi.org/10.1097/scs.0b013e318184365d|journal=Journal of Craniofacial Surgery|volume=19|issue=5|pages=1199–1214|doi=10.1097/scs.0b013e318184365d|issn=1049-2275}}</ref>

=== Surgical Procedure ===
Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal|last=Mercuri|first=L.G.|date=2006|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018|journal=International Journal of Oral and Maxillofacial Surgery|volume=35|issue=3|pages=284–286|doi=10.1016/j.ijom.2005.07.018|issn=0901-5027}}</ref><ref>{{Cite journal|last=Beck|first=James I.|last2=Johnston|first2=Kevin D.|date=2014-02-01|title=Anaesthesia for cosmetic and functional maxillofacial surgery|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X|journal=Continuing Education in Anaesthesia Critical Care & Pain|language=en|volume=14|issue=1|pages=38–42|doi=10.1093/bjaceaccp/mkt027|issn=1743-1816}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* CBC, T&S with blood type verification
* ± PT/PTT
* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)

=== Operating room setup ===

* Airway
** Nasal ETT
** Accordion and/or straight connector
** ± Nasal trumpet
** ± Fiberscope or VL device
* Bolus line ± fluid warmer connected to largest PIV
* Lower body forced-air warmer
* 2 infusion channels and 2 syringe pumps on a manifold
* Maintenance/Carrier line with flushed octopus connecter

=== Patient preparation and premedication ===

* Pretreatment of both nares with Oxymetazoline (Afrin)
* Tylenol PO 15mg/kg (Max: 1g)
* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
* Scopolamine patch as needed
* Consider antisialagogue dose of glycopyrrolate prior to induction
** Adult
*** PO Dose: 1-2 mg PO; Parenteral Dose: 0.1-0.2 mg SC/IM/IV (Max: 1-2 mg/dose, 8mg/day)
** Pediatric
*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)

=== Regional and neuraxial techniques ===

* Mandibular and maxillary nerve blocks performed by the surgeons can be utilized to aid postoperative pain relief

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
** Core temperature monitoring likely only available via bladder or rectal given oral or nasal probes are likely to interfere with surgical exposure
* PIV x2 , at least 1 large-bore PIV for resuscitation
* ± Arterial line as needed based on patient-specific factors
* ± BIS, PSI, or raw EEG monitoring

=== Induction and airway management ===

* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)

* Nasal Intubation
** Consider fiberscopic placement vs DL or VL ± oral manipulation with MaGill forceps
** Consider dilation with lubricated nasal trumpet (one-size greater than the desired ETT) - this will additionally aid in confirming which nare is most likely to easily accommodate the ETT and allow for change in ETT sizing prior to intubation attempt if there is difficulty
** Airway typically secured by surgical team with suture before wrapping the patient's head

* Dexamethasone 4-10mg, typically at least (0.1mg/kg with Max: 10mg for post operative pain/swelling)
* ± Tranexamic Acid (TXA) bolus, typically 1 gram or 30mg/kg over 10-15 minutes
* Ancef, weight-based dosing

=== Positioning ===

* Supine with neck extended, on foam donut
* Careful eye protection and padding
* One or two arms tucked
* Table is usually turned 90-180 degrees

=== Maintenance and surgical considerations ===

* Maintain anesthetic depth with volatile anesthetic ± IV infusions
** Example setup:
*** Sevoflurane (MAC of ~ 0.5)
*** Dexmedetomidine (0.2-0.4 mcg/kg/min)
*** Short-acting opiate (eg. Sufentanil/Alfentanil) or Ultra-short-acting opiate (Remifentanil)
*** ± Tranexamic Acid (TXA)
*** ± Phenylephrine
*** ± Background propofol for PONV

* Consider higher volume hydration (if tolerated) to prevent PONV
* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal|last=Shepherd|first=Jonathan|date=2004|title=Hypotensive anaesthesia and blood loss in orthognathic surgery|url=http://dx.doi.org/10.1038/sj.ebd.6400238|journal=Evidence-Based Dentistry|volume=5|issue=1|pages=16–16|doi=10.1038/sj.ebd.6400238|issn=1462-0049}}</ref>
* Redose Acetaminophen as able
* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal|last=Lang|first=Scott|last2=Lanigan|first2=Dennis T.|last3=van der Wal|first3=Mike|date=1991-09-01|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex|url=https://doi.org/10.1007/BF03008454|journal=Canadian Journal of Anaesthesia|language=en|volume=38|issue=6|pages=757|doi=10.1007/BF03008454|issn=1496-8975}}</ref><ref>{{Cite journal|last=Campbell|first=R.|last2=Rodrigo|first2=D.|last3=Cheung|first3=L.|date=1994|title=Asystole and bradycardia during maxillofacial surgery.|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/|journal=Anesthesia Progress|volume=41|issue=1|pages=13–16|issn=0003-3006|pmc=2148710|pmid=8629742}}</ref>

=== Emergence ===

* Toradol 0.5 mg/kg, Max: 30 mg
* Zofran
* Reversal with sugammadex
* Ensure removal of all throat packing
* OGT for gastric decompression/removal of surgical bleeding
* Extubate awake and following commands (swallowing in particular)
* Head up or reverse trendelenburg positioning
* Do not suction in the mouth after OGT has been removed
** Consider instead using a soft suction catheter through contralateral nare

* Expect significant postoperative facial swelling
* Removal of the nasal ETT after Le Fort I osteotomy should be done gently because the sectioned nasal septum may easily be displaced

== Postoperative management ==

=== Disposition ===

* PACU -> observation/overnight admission

=== Pain management ===

* Tylenol q6h (liquid PO), NSAID (liquid PO), and IV narcotics all used in perioperative setting, continued after discharge
** Some patients may be excellent candidates for PCAs post-PACU discharge as nursing ratios change and may be recommended for if their pain is particularly difficult to control

* Maxillofacial surgeons typically advise patients to prepare for a prolonged, painful recovery (~six-weeks off) with additional jaw-healing takings up to 2-3 months

=== Potential complications ===

* The reported incidence of PONV after orthognathic surgery varies from 7<ref>{{Cite journal|last=Ichinohe|first=Tatsuya|last2=Kaneko|first2=Yuzuru|date=2007|title=Nitrous Oxide Does Not Aggravate Postoperative Emesis After Orthognathic Surgery in Female and Nonsmoking Patients|url=http://dx.doi.org/10.1016/j.joms.2006.06.283|journal=Journal of Oral and Maxillofacial Surgery|volume=65|issue=5|pages=936–939|doi=10.1016/j.joms.2006.06.283|issn=0278-2391}}</ref> to 40%<ref>{{Cite journal|last=Silva|first=Alessandro C.|last2=O’Ryan|first2=Felice|last3=Poor|first3=David B.|date=2006|title=Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review|url=http://dx.doi.org/10.1016/j.joms.2006.05.024|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=9|pages=1385–1397|doi=10.1016/j.joms.2006.05.024|issn=0278-2391}}</ref>, with steroid prophylaxis and up to 83%<ref>{{Cite journal|last=Piper|first=Swen N.|last2=Röhm|first2=Kerstin|last3=Boldt|first3=Joachim|last4=Kranke|first4=Peter|last5=Maleck|first5=Wolfgang|last6=Seifert|first6=Rudolf|last7=Suttner|first7=Stefan|date=2008|title=Postoperative nausea and vomiting after surgery for prognathism: Not only a question of patients' comfort. A placebo-controlled comparison of dolasetron and droperidol|url=http://dx.doi.org/10.1016/j.jcms.2007.07.011|journal=Journal of Cranio-Maxillofacial Surgery|volume=36|issue=3|pages=173–179|doi=10.1016/j.jcms.2007.07.011|issn=1010-5182}}</ref> with no antiemetic prophylaxis
* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding
** Have closure removal devices at bedside at all time

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
[[Category:Orthognathic surgery]]
[[Category:Maxillofacial surgery]]

Maxillary and mandibular osteotomy

2022-07-28T21:27:04Z

CFitzgerald: inital page draft

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Nasal ETT
| lines_access = PIV x2 (Large bore IV x1-2)
± Arterial line
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities
| considerations_intraoperative = Highly stimulating, painful surgery
Bed 90-180
| considerations_postoperative = PONV
Pain
Surgical mouth closure with heavy elastic vs wires
}}

== Overview ==

=== Indications ===
Class II-III malocclusion is one of the most common reasons for performing a maxillary and mandibular osteotomies. Severe malocclusion is typically caused by maxillary hypoplasia and is commonly found in patients with orofacial clefts, obstructive sleep apnea (OSA), and maxillary atrophy. Maxillary surgery is required in up to 25% of cleft lip and palate patients.<ref>{{Cite journal|last=Buchanan|first=Edward P.|last2=Hyman|first2=Charles H.|date=2013|title=LeFort I Osteotomy|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805729/|journal=Seminars in Plastic Surgery|volume=27|issue=3|pages=149–154|doi=10.1055/s-0033-1357112|issn=1535-2188|pmc=3805729|pmid=24872761}}</ref><ref>{{Cite journal|last=Scolozzi|first=Paolo|date=2008|title=Distraction Osteogenesis in the Management of Severe Maxillary Hypoplasia in Cleft Lip and Palate Patients|url=http://dx.doi.org/10.1097/scs.0b013e318184365d|journal=Journal of Craniofacial Surgery|volume=19|issue=5|pages=1199–1214|doi=10.1097/scs.0b013e318184365d|issn=1049-2275}}</ref>

=== Surgical Procedure ===
Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal|last=Mercuri|first=L.G.|date=2006|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018|journal=International Journal of Oral and Maxillofacial Surgery|volume=35|issue=3|pages=284–286|doi=10.1016/j.ijom.2005.07.018|issn=0901-5027}}</ref><ref>{{Cite journal|last=Beck|first=James I.|last2=Johnston|first2=Kevin D.|date=2014-02-01|title=Anaesthesia for cosmetic and functional maxillofacial surgery|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X|journal=Continuing Education in Anaesthesia Critical Care & Pain|language=en|volume=14|issue=1|pages=38–42|doi=10.1093/bjaceaccp/mkt027|issn=1743-1816}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* CBC, T&S with blood type verification
* ± PT/PTT
* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)

=== Operating room setup ===

* Airway
** Nasal ETT
** Accordion and/or straight connector
** ± Nasal trumpet
** ± Fiberscope or VL device
* Bolus line ± fluid warmer connected to largest PIV
* Lower body forced-air warmer
* 2 infusion channels and 2 syringe pumps on a manifold
* Maintenance/Carrier line with flushed octopus connecter

=== Patient preparation and premedication ===

* Pretreatment of both nares with Oxymetazoline (Afrin)
* Tylenol PO 15mg/kg (Max of 1g)
* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
* Scopolamine patch as needed
* Consider antisialagogue dose of glycopyrrolate prior to induction
** Adult
*** PO Dose: 1-2 mg PO; Parenteral Dose: 0.1-0.2 mg SC/IM/IV (Max: 1-2 mg/dose, 8mg/day)
** Pediatric
*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)

=== Regional and neuraxial techniques ===

* Mandibular and maxillary nerve blocks performed by the surgeons can be utilized to aid postoperative pain relief

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
** Core temperature monitoring likely only available via bladder or rectal given oral or nasal probes are likely to interfere with surgical exposure
* PIV x2 , at least 1 large-bore PIV for resuscitation
* ± Arterial line as needed based on patient-specific factors
* ± BIS, PSI, or raw EEG monitoring

=== Induction and airway management ===

* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)

* Nasal Intubation
** Consider fiberscopic placement vs DL or VL ± oral manipulation with MaGill forceps
** Consider dilation with lubricated nasal trumpet (one-size greater than the desired ETT) - this will additionally aid in confirming which nare is most likely to easily accommodate the ETT and allow for change in ETT sizing prior to intubation attempt if there is difficulty
** Airway typically secured by surgical team with suture before wrapping the patient's head

* Dexamethasone 4-10mg, typically at least (0.1mg/kg with Max: 10mg for post operative pain/swelling)
* ± Tranexamic Acid (TXA) bolus, typically 1 gram or 30mg/kg over 10-15 minutes
* Ancef, weight-based dosing

=== Positioning ===

* Supine with neck extended, on foam donut
* Careful eye protection and padding
* One or two arms tucked
* Table is usually turned 90-180 degrees

=== Maintenance and surgical considerations ===

* Maintain anesthetic depth with volatile anesthetic ± IV infusions
** Example setup:
*** Sevoflurane (MAC of ~ 0.5)
*** Dexmedetomidine (0.2-0.4 mcg/kg/min)
*** Short-acting opiate (eg. Sufentanil/Alfentanil) or Ultra-short-acting opiate (Remifentanil)
*** ± Tranexamic Acid (TXA)
*** ± Phenylephrine
*** ± Background propofol for PONV

* Consider higher volume hydration (if tolerated) to prevent PONV
* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal|last=Shepherd|first=Jonathan|date=2004|title=Hypotensive anaesthesia and blood loss in orthognathic surgery|url=http://dx.doi.org/10.1038/sj.ebd.6400238|journal=Evidence-Based Dentistry|volume=5|issue=1|pages=16–16|doi=10.1038/sj.ebd.6400238|issn=1462-0049}}</ref>
* Redose Acetaminophen as able
* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal|last=Lang|first=Scott|last2=Lanigan|first2=Dennis T.|last3=van der Wal|first3=Mike|date=1991-09-01|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex|url=https://doi.org/10.1007/BF03008454|journal=Canadian Journal of Anaesthesia|language=en|volume=38|issue=6|pages=757|doi=10.1007/BF03008454|issn=1496-8975}}</ref><ref>{{Cite journal|last=Campbell|first=R.|last2=Rodrigo|first2=D.|last3=Cheung|first3=L.|date=1994|title=Asystole and bradycardia during maxillofacial surgery.|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/|journal=Anesthesia Progress|volume=41|issue=1|pages=13–16|issn=0003-3006|pmc=2148710|pmid=8629742}}</ref>

=== Emergence ===

* Toradol 0.5 mg/kg, max 30 mg
* Zofran
* Reversal with sugammadex
* Ensure removal of all throat packing
* OGT for gastric decompression/removal of surgical bleeding
* Extubate awake and following commands (swallowing in particular)
* Head up or reverse trendelenburg positioning
* Do not suction in the mouth after OGT has been removed
** Consider instead using a soft suction catheter through contralateral nare

* Expect significant postoperative facial swelling
* Removal of the nasal ETT after Le Fort I osteotomy should be done gently because the sectioned nasal septum may easily be displaced

== Postoperative management ==

=== Disposition ===

* PACU -> observation/overnight admission

=== Pain management ===

* Tylenol q6h (liquid PO), NSAID (liquid PO), and IV narcotics all used in perioperative setting, continued after discharge
** Some patients may be excellent candidates for PCAs post-PACU discharge as nursing ratios change and may be recommended for if their pain is particularly difficult to control

* Maxillofacial surgeons typically advise patients to prepare for a prolonged, painful recovery (~six-weeks off) with additional jaw-healing takings up to 2-3 months

=== Potential complications ===

* The reported incidence of PONV after orthognathic surgery varies from 7<ref>{{Cite journal|last=Ichinohe|first=Tatsuya|last2=Kaneko|first2=Yuzuru|date=2007|title=Nitrous Oxide Does Not Aggravate Postoperative Emesis After Orthognathic Surgery in Female and Nonsmoking Patients|url=http://dx.doi.org/10.1016/j.joms.2006.06.283|journal=Journal of Oral and Maxillofacial Surgery|volume=65|issue=5|pages=936–939|doi=10.1016/j.joms.2006.06.283|issn=0278-2391}}</ref> to 40%<ref>{{Cite journal|last=Silva|first=Alessandro C.|last2=O’Ryan|first2=Felice|last3=Poor|first3=David B.|date=2006|title=Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review|url=http://dx.doi.org/10.1016/j.joms.2006.05.024|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=9|pages=1385–1397|doi=10.1016/j.joms.2006.05.024|issn=0278-2391}}</ref>, with steroid prophylaxis and up to 83%<ref>{{Cite journal|last=Piper|first=Swen N.|last2=Röhm|first2=Kerstin|last3=Boldt|first3=Joachim|last4=Kranke|first4=Peter|last5=Maleck|first5=Wolfgang|last6=Seifert|first6=Rudolf|last7=Suttner|first7=Stefan|date=2008|title=Postoperative nausea and vomiting after surgery for prognathism: Not only a question of patients' comfort. A placebo-controlled comparison of dolasetron and droperidol|url=http://dx.doi.org/10.1016/j.jcms.2007.07.011|journal=Journal of Cranio-Maxillofacial Surgery|volume=36|issue=3|pages=173–179|doi=10.1016/j.jcms.2007.07.011|issn=1010-5182}}</ref> with no antiemetic prophylaxis
* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding
** Have closure removal devices at bedside at all time

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
[[Category:Orthognathic surgery]]
[[Category:Maxillofacial surgery]]

Tonsillectomy and/or adenoidectomy

2022-07-20T20:19:52Z

CFitzgerald: post-op complications and planning, otherwise minor edits

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT (consider oral RAE)
| lines_access = PIV
| monitors = Standard
3 or 5-lead ECG
| considerations_preoperative = Assess OSA severity if present
Avoid anxiolytics if severe OSA
| considerations_intraoperative = Mask induction if no PIV
Shared airway with surgeon
Lower FiO2 to reduce risk of airway fire
Emerge after complete hemostasis is achieved
Protect airway from blood/secretions
Increased incidence of laryngospasm
| considerations_postoperative = Smooth, rapid emergence (short case)
High risk of postoperative respiratory complications
OSA precautions
PONV prophylaxis
}}
'''Tonsillectomy and/or adenoidectomy''' (often abbreviated '''T&A''') is a surgical procedure to remove the tonsils with/without adenoids, which are lymphoid tissues encircling the posterior oropharynx. Indications for T&As include 1) recurrent throat infections, 2) obstructive sleep-disordered breathing<ref name=":0">{{Cite journal|last=Mitchell|first=Ron B.|last2=Archer|first2=Sanford M.|last3=Ishman|first3=Stacey L.|last4=Rosenfeld|first4=Richard M.|last5=Coles|first5=Sarah|last6=Finestone|first6=Sandra A.|last7=Friedman|first7=Norman R.|last8=Giordano|first8=Terri|last9=Hildrew|first9=Douglas M.|last10=Kim|first10=Tae W.|last11=Lloyd|first11=Robin M.|date=2019-02-01|title=Clinical Practice Guideline: Tonsillectomy in Children (Update)|url=https://doi.org/10.1177/0194599818801757|journal=Otolaryngology–Head and Neck Surgery|language=en|volume=160|issue=1_suppl|pages=S1–S42|doi=10.1177/0194599818801757|issn=0194-5998}}</ref>. While infections used to be the most common indication in the past, the majority of tonsillectomies are now being performed for obstructive sleep apnea (OSA). Tonsillectomies are the second most common ambulatory surgery performed in children under 15 years old in the United States<ref>{{Cite web|title=Ambulatory surgery in the United States, 2006|url=https://stacks.cdc.gov/view/cdc/5395|access-date=2021-05-16|website=stacks.cdc.gov}}</ref>.

== Preoperative management==

===Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
* OSA is the most common indication for T&As. Polysomnography (sleep study) is useful to assess for severity of OSA. For patients without a polysomnography, access for sleep-disordered breathing with questions about snoring and apnea; other symptoms may include excessive daytime sleepiness, inattention, poor concentration, or hyperactivity.
*Patients often have a history of frequent URIs which may affect the optimal timing of an elective surgery.
|-
|Gastrointestinal
|
* Standard NPO guidelines.
|-
|Hematologic
|
*Assess for history of bleeding tendencies or easy bruising, given the risk of postoperative hemorrhage.
|-
|Renal
|
|-
| Endocrine
|
|-
|Other
|
|}

===Labs and studies===

*The American Academy of Otolaryngology–Head and Neck Surgery recommends referring the following children with obstructive sleep-disordered breathing for polysomnography pre-operatively if:
*#The child is <2 years of age, or
*#The child exhibits any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses<ref name=":0" />.

===Operating room setup===

*Consider a cuffed oral RAE ETT or wire reinforced ETT
*Accordion

===Patient preparation and premedication===

*Consider distraction methods (toys, videos, tablet computers, games, parental presence if deemed appropriate) as opposed to anxiolytics in children with severe OSA
*If giving preoperative anxiolytics, consider continuous pulse oximetry monitoring for children with OSA<ref>{{Cite journal|last=Van Someren|first=V. H.|last2=Hibbert|first2=J.|last3=Stothers|first3=J. K.|last4=Kyme|first4=M. C.|last5=Morrison|first5=G. A.|date=1990-06-01|title=Identification of hypoxaemia in children having tonsillectomy and adenoidectomy|url=https://pubmed.ncbi.nlm.nih.gov/2394027|journal=Clinical Otolaryngology and Allied Sciences|volume=15|issue=3|pages=263–271|doi=10.1111/j.1365-2273.1990.tb00784.x|issn=0307-7772|pmid=2394027|via=}}</ref>
*Consider preoperative albuterol treatment for patients with recent URI <2 weeks ago or moderate-severe OSA

===Regional and neuraxial techniques===

*Local anesthesia is controversial and not preferred (risk of significant complications associated with local infiltration)<ref>{{Cite journal|last=Hollis|first=L. J.|last2=Burton|first2=M. J.|last3=Millar|first3=J. M.|date=2000|title=Perioperative local anaesthesia for reducing pain following tonsillectomy|url=https://pubmed.ncbi.nlm.nih.gov/10796831|journal=The Cochrane Database of Systematic Reviews|issue=2|pages=CD001874|doi=10.1002/14651858.CD001874|issn=1469-493X|pmc=7025437|pmid=10796831}}</ref><ref>{{Cite journal|last=Bean-Lijewski|first=J. D.|date=1997-06-01|title=Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial|url=https://pubmed.ncbi.nlm.nih.gov/9174298|journal=Anesthesia and Analgesia|volume=84|issue=6|pages=1232–1238|doi=10.1097/00000539-199706000-00011|issn=0003-2999|pmid=9174298|via=}}</ref>

==Intraoperative management==

===Monitoring and access===

*Standard ASA monitors
*5-lead EKG if needed
*PIV, often will have to be done post-induction in children

===Induction and airway management===

*Mask induction if no PIV
*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT
**If in-between sizes for oral RAE, consider larger size given the risk of extubating with neck extension during surgery<ref>{{Cite journal|last=Wynne|first=D.M.|last2=Marshall|first2=J.N.|date=2002-10-01|title=Risk of accidental extubation with disposable tonsillectomy instruments|url=https://doi.org/10.1093/bja/aef548|journal=British Journal of Anaesthesia|volume=89|issue=4|pages=659|doi=10.1093/bja/aef548|issn=0007-0912|via=}}</ref>
*Deep intubation vs paralysis
**T&As are generally short procedures (30 min - 1 hour)
**Consider using a low dose of NDMB or succinylcholine if opting to paralyze for intubation to allow for reversal at the end of the case

===Positioning===

*Supine with neck extended
*Table is usually turned 90 degrees

===Maintenance and surgical considerations===

*Maintain anesthetic depth with sevoflurane
*Lower FiO2 to lowest possible to reduce risk of airway fire (preferably below 30%)
*Consider higher volume hydration (if tolerated) to prevent PONV
*Consider dexamethasone 0.5 mg/kg IV to prevent airway edema

===Emergence===

*Administer PONV prophylaxis
**Single-dose IV dexamethasone at the beginning of the case
**Strongly consider a second agent for PONV prophylaxis, such as ondansetron
*Emerge only after the surgeon has achieved hemostasis
*Have surgical team consider placing an OG tube for gastric decompression at case conclusion
*Thoroughly suction the oropharynx prior to emergence to remove blood and secretions, as children who undergo tonsillectomy are at increased risk of laryngospasm and airway reactivity
*Extubate awake for patients with severe OSA

==Postoperative management==

===Disposition===

*Consider arranging for inpatient postoperative monitoring for:
**Age < 3 years
** Severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both)<ref name=":0" /><ref>{{Cite journal|last=Patino|first=M.|last2=Sadhasivam|first2=S.|last3=Mahmoud|first3=M.|date=2013-12-01|title=Obstructive sleep apnoea in children: perioperative considerations|url=https://doi.org/10.1093/bja/aet371|journal=British Journal of Anaesthesia|volume=111|pages=i83–i95|doi=10.1093/bja/aet371|issn=0007-0912|via=}}</ref>)
** Coagulation disorder
** Inability to provide close observation post discharge (eg. families with extended travel time or social issues)
** Comorbid serious systemic disorders
*Consider arranging for PICU postoperative monitoring for:
**Very severe OSA (AHI >30), for associated desaturation events, and for those with comorbidities with a known difficult airway or a syndrome with craniofacial abnormalities (e.g. Down Syndrome, Treacher Collins, Crouzon, Goldenhar, Pierre Robin, CHARGE) potentially predisposing them to postoperative airway obstruction<ref>{{Cite journal|last=Mitchell|first=Ron B.|last2=Archer|first2=Sanford M.|last3=Ishman|first3=Stacey L.|last4=Rosenfeld|first4=Richard M.|last5=Coles|first5=Sarah|last6=Finestone|first6=Sandra A.|last7=Friedman|first7=Norman R.|last8=Giordano|first8=Terri|last9=Hildrew|first9=Douglas M.|last10=Kim|first10=Tae W.|last11=Lloyd|first11=Robin M.|date=2019|title=Clinical Practice Guideline: Tonsillectomy in Children (Update)|url=http://journals.sagepub.com/doi/10.1177/0194599818801757|journal=Otolaryngology–Head and Neck Surgery|language=en|volume=160|issue=1_suppl|pages=S1–S42|doi=10.1177/0194599818801757|issn=0194-5998}}</ref>

===Pain management===

*Procedure itself is quite painful
*Multimodal pain control is strongly preferred, given that children with OSA are more susceptible to the respiratory depressant effects of opioids
**Nonopioids
***IV dexamethasone (usually 0.1 to 0.5 mg/kg IV, usual maximum of 10 mg)
***IV acetaminophen (usually 15mg/kg for patients above age 2, 10mg/kg for children below 2 years old)
***Dexmedetomidine (single loading-dose of 0.3-0.5 mcg/kg)<ref>{{Cite journal|last=Guler|first=Gulen|last2=Akin|first2=Aynur|last3=Tosun|first3=Zeynep|last4=Ors|first4=Sevgi|last5=Esmaoglu|first5=Aliye|last6=Boyaci|first6=Adem|date=2005-09-01|title=Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy|url=https://pubmed.ncbi.nlm.nih.gov/16101707/|journal=Paediatric Anaesthesia|volume=15|issue=9|pages=762–766|doi=10.1111/j.1460-9592.2004.01541.x|issn=1155-5645|pmid=16101707|via=}}</ref>
***Consider low-dose ketamine as an opioid-sparing agent in patients with severe OSA; however, it may also increase postoperative agitation and secretions
***IV NSAIDs are controversial because of the risk of tonsillar bleeding and remain highly surgeon dependent despite emerging evidence that shows similar bleeding rates with ketorolac use in children <ref>{{Cite journal|last=Rabbani|first=Cyrus C.|last2=Pflum|first2=Zachary E.|last3=Ye|first3=Michael J.|last4=Gettelfinger|first4=John D.|last5=Sadhasivam|first5=Senthil|last6=Matt|first6=Bruce H.|last7=Dahl|first7=John P.|date=2020-11-01|title=Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia|url=https://www.sciencedirect.com/science/article/pii/S0165587620304845|journal=International Journal of Pediatric Otorhinolaryngology|language=en|volume=138|pages=110341|doi=10.1016/j.ijporl.2020.110341|issn=0165-5876}}</ref>
**Opioids
***Consider reducing opioid doses by 50% for children with significant OSA, accompanied by continuous monitoring including pulse oximetry and prolonged PACU observation <ref>{{Cite journal|last=Patino|first=M.|last2=Sadhasivam|first2=S.|last3=Mahmoud|first3=M.|date=2013-12-01|title=Obstructive sleep apnoea in children: perioperative considerations|url=https://doi.org/10.1093/bja/aet371|journal=British Journal of Anaesthesia|volume=111|pages=i83–i95|doi=10.1093/bja/aet371|issn=0007-0912|via=}}</ref>

=== PONV prophylaxis ===

* Serotonergic antagonists
** Ondansetron (0.1 mg/kg single dose; maximum 4 mg) with intraoperative dexamethasone<ref>{{Cite journal|last=Bolton|first=C. M.|last2=Myles|first2=P. S.|last3=Nolan|first3=T.|last4=Sterne|first4=J. A.|date=2006-11-01|title=Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/17005507|journal=British Journal of Anaesthesia|volume=97|issue=5|pages=593–604|doi=10.1093/bja/ael256|issn=0007-0912|pmid=17005507|via=}}</ref>
***Cochrane systematic review showed that compared to placebo, children receiving dexamethasone were half as likely to vomit in the first 24 hours<ref>{{Cite journal|last=Steward|first=David L|last2=Grisel|first2=Jedidiah|last3=Meinzen-Derr|first3=Jareen|date=2011-08-10|title=Steroids for improving recovery following tonsillectomy in children|url=http://dx.doi.org/10.1002/14651858.cd003997.pub2|journal=Cochrane Database of Systematic Reviews|doi=10.1002/14651858.cd003997.pub2|issn=1465-1858}}</ref>
* Promethazine is associated with risk of sedation and respiratory depression in the setting of residual anesthesia and opioids <ref>{{Cite journal|last=Starke|first=Peter R.|last2=Weaver|first2=Joyce|last3=Chowdhury|first3=Badrul A.|date=2005-06-23|title=Boxed warning added to promethazine labeling for pediatric use|url=https://pubmed.ncbi.nlm.nih.gov/15972879|journal=The New England Journal of Medicine|volume=352|issue=25|pages=2653|doi=10.1056/NEJM200506233522522|issn=1533-4406|pmid=15972879}}</ref>

===Potential complications===

*High risk of '''postoperative pulmonary complications''', especially in patients with severe OSA<ref>{{Cite web|last=Marrugo Pardo|first=G.|last2=Romero Moreno|first2=L. F.|last3=Beltrán Erazo|first3=P.|last4=Villalobos Aguirre|first4=C.|date=2018-11-01|title=Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population|url=https://www.hindawi.com/journals/sd/2018/1968985/|access-date=2021-09-13|website=Sleep Disorders|language=en}}</ref><ref>{{Cite journal|last=Patino|first=M.|last2=Sadhasivam|first2=S.|last3=Mahmoud|first3=M.|date=2013-12-01|title=Obstructive sleep apnoea in children: perioperative considerations|url=https://doi.org/10.1093/bja/aet371|journal=British Journal of Anaesthesia|volume=111|pages=i83–i95|doi=10.1093/bja/aet371|issn=0007-0912|via=}}</ref>
**Postoperative respiratory complications occur in 5.8% to 26.8% of children with OSA undergoing tonsillectomy<ref>{{Cite journal|last=Saur|first=John S.|last2=Brietzke|first2=Scott E.|date=2017|title=Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy|url=http://dx.doi.org/10.1016/j.ijporl.2017.05.004|journal=International Journal of Pediatric Otorhinolaryngology|volume=98|pages=136–142|doi=10.1016/j.ijporl.2017.05.004|issn=0165-5876}}</ref><ref>{{Cite journal|last=Keamy|first=Donald G.|last2=Chhabra|first2=Karan R.|last3=Hartnick|first3=Christopher J.|date=2015|title=Predictors of complications following adenotonsillectomy in children with severe obstructive sleep apnea|url=http://dx.doi.org/10.1016/j.ijporl.2015.08.021|journal=International Journal of Pediatric Otorhinolaryngology|volume=79|issue=11|pages=1838–1841|doi=10.1016/j.ijporl.2015.08.021|issn=0165-5876}}</ref>
**Common causes include negative pressure pulmonary edema and acute airway obstruction
*Risk of '''postoperative hemorrhage''' and its associated adverse events, including hypoxemia (most common adverse event), bradycardia, hypotension, and difficult intubation<ref>{{Cite journal|last=Fields|first=Ryan G.|last2=Gencorelli|first2=Frank J.|last3=Litman|first3=Ronald S.|date=2010-11-01|title=Anesthetic management of the pediatric bleeding tonsil|url=https://pubmed.ncbi.nlm.nih.gov/20964765|journal=Paediatric Anaesthesia|volume=20|issue=11|pages=982–986|doi=10.1111/j.1460-9592.2010.03426.x|issn=1460-9592|pmid=20964765|via=}}</ref>
**Considerations for control of hemorrhage "take-back" cases
*** Surgical emergency
*** Presume the patient has a full stomach of blood: RSI with careful, yet diligent gastric decompression at the case end
*** May require aggressive resuscitation for hypovolemia
*** Potentially difficult airway due to blood in oropharynx and swollen post-surgical tissue beds
**** Styleted ETT
**** Have additional providers for help
**** Have additional suction ready

==Procedure variants==

{| class="wikitable"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
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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
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|}

==References==

[[Category:Surgical procedures]]

<references />
[[Category:Otolaryngology]]
[[Category:Pharyngeal surgery]]
[[Category:Pediatrics]]

Aortic stenosis

2022-07-08T23:13:44Z

CFitzgerald:

{{Infobox comorbidity
| other_names =
| image_file = Severe_aortic_valve_stenosis_E00264_(CardioNetworks_ECHOpedia).jpg
| image_caption = An echocardiogram showing a valve pressure gradient consistent with severe aortic stenosis
| anesthetic_relevance = Critical
| anesthetic_management = Preserve afterload, maintain normal heart rate
Preinduction art line
Consider PA catheter, TEE
| specialty = Cardiology
| signs_symptoms = Angina, dyspnea, peripheral edema, syncope
| diagnosis = [[Echocardiogram]]
| treatment = Valve replacement surgery
}}
'''Aortic stenosis''' is the narrowing of the outflow tract of the left ventricle due to calcification of the aortic valve.
== Anesthetic implications ==

=== Preoperative optimization ===
Asymptomatic aortic stenosis may be initially detected on physical exam. Peripheral pulses may be weak and late (sometimes called ''pulsus parvus et tardus''). A harsh systolic crescendo-decrescendo murmur may also be present, which is best heard at the right upper sternal border at the 2nd intercostal space. This murmur may also radiate to the carotid arteries.

Patients with suspected aortic stenosis should undergo [[Transthoracic echocardiogram]] to confirm the diagnosis and evaluate the severity of the disease. For severe disease, valve replacement therapy should be considered prior to proceeding with elective surgery.

=== Intraoperative management ===

==== Monitoring ====

* For severe disease, a pre-induction [[arterial line]] should be placed to rapidly detect hemodynamic changes.
* Advanced monitoring such as a [[pulmonary artery catheter]] or [[transesophageal echocardiography]] can be considered.
* Consider placement of defibrillation pads as chest compressions can be ineffective with severe stenosis.

==== Hemodynamics ====

* '''Hypotension''' should be avoided to preserve afterload (i.e. coronary perfusion pressure). Treat with afterload-increasing agents such as [[phenylephrine]].
* '''Bradycardia''' should be avoided as these patients are often heart rate dependent to preserve adequate cardiac output. A heart rate of 60-90 bpm is optimal.
* '''Tachycardia''' and '''hypertension''' should be avoided to preserve left ventricular diastolic filling and reduce myocardial oxygen demand. Treat with increasing anesthetic depth or short-acting beta-blockade with [[esmolol]].

==== Neuraxial anesthesia ====
Neuraxial anesthesia is contraindicated in all but mild disease due to the risk of decreased [[systemic vascular resistance]] leading to decreased [[diastolic blood pressure]] and reduced myocardial perfusion

=== Postoperative management ===
Patients with significant disease may require close postoperative monitoring to quickly identify and manage any hemodynamic instability.

==Related surgical procedures==

*[[Aortic valve repair or replacement]]
*[[Transcatheter aortic valve replacement]]
*[[Balloon valvuloplasty]]

==Pathophysiology==
In aortic stenosis, the opening of the aortic valve is narrowed, typically due to calcification from tissue damage over time. The most common cause is valve degeneration in older patients, though stenosis may develop in younger patients with a [[bicuspid aortic valve]]. It is thought that stenosis results from inflammation due to endothelial cell damage from increased mechanical stress.

As aortic stenosis progresses, higher pressures must be generated by the left ventricle to maintain cardiac output. This initially leads to the development of concentric [[left ventricular hypertrophy]], thereby increasing myocardial oxygen requirement. In later stages of the disease, the left ventricle dilates and the ventricular walls thin, resulting in reduced systolic function.

==Signs and symptoms ==

===Signs===

* Slow/late peripheral pulses (''pulsus parvus et tardus'')
*Harsh systolic crescendo-decrescendo murmur
** Best auscultated at the right upper sternal border at the 2nd intercostal space
** May radiate to both carotids
* Decreased intensity of the second heart sound (A2)

=== Symptoms ===

* Angina
*Decreased exercise tolerance
*Dyspnea
*Syncope
*Symptoms of [[congestive heart failure]]

==Diagnosis==
{| class="wikitable" align="right"
! colspan="3" |'''Severity of aortic stenosis'''
|-
!Degree!! Mean gradient (mmHg)!!Aortic valve area (cm2)
|-
|Mild || <25||>1.5
|-
|Moderate||25 - 40 ||1.0 - 1.5
|-
|Severe||>40||< 1.0
|-
|Very severe||>70||< 0.6
|}Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram|echocardiography]] or [[heart catheterization]].

==Treatment==

===Medication===
In general, medication has poor efficacy in the treatment of aortic stenosis. However, medical therapy is important to manage concomitant cardiac diseases such as [[heart failure]], [[hypertension]] and symptoms such as [[angina]].

=== Surgery ===
Severe symptomatic aortic stenosis is typically treated with [[Aortic valve repair or replacement|aortic valve replacement]]. For patients who are poor candidates for surgical valve replacement, [[transcatheter aortic valve replacement]] is an alternative. [[Balloon valvuloplasty]] is can be effective in infants and children, but has limited efficacy in adults since the valve generally returns to a stenosed state.

=== Prognosis===
Untreated severe symptomatic aortic stenosis has a poor prognosis, with a 2-year survival rate of 50-60%. For patients who undergo valve replacement, life expectancy is about 5 years less than the general population for patients under 65, and similar to patients without aortic stenosis for patients over 65.

==Epidemiology==

[[Category:Comorbidities]]
[[Category:Cardiovascular disorders]]
[[Category:Valvular heart disease]]

== References ==
<references />