WikiAnesthesia - User contributions [en]

Endoscopic retrograde cholangiopancreatography

2022-08-19T20:13:43Z

Chuckcampana: Added positioning

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 1 PIV
| monitors = Standard ASA monitors
| considerations_preoperative = Aspiration Precautions
| considerations_intraoperative = Most patients should be considered for RSI
| considerations_postoperative =
}}

Endoscopic approach to access the bile duct utilized to diagnose and treat liver, gallbladder, biliary, and pancreatic problems. Endoscope is inserted from the mouth to duodenum. Then the papilla of vater (Common bile duct outlet) is identified, catheterized, and injected with contrast to identify obstructions.

== Overview ==

=== Indications ===
liver, gallbladder, biliary, and pancreatic pathology

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|ETT required, bite block
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|Check cervical ROM
|}

=== Labs and studies ===

* CBC

=== Operating room setup ===

* Make sure you have a lead apron available
* Have a prone pillow available and staff to help turn
* Have bite block to facilitate scope passage available.

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

* N/A

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors

=== Induction and airway management ===

* RSI

=== Positioning ===

* Most patients will be prone for this procedure to aid in manipulation of scope into proper placement. If patient cannot tolerate position, lateral or supine positioning can be done (increases difficulty for proceduralist).

=== Maintenance and surgical considerations ===
General anesthesia with ETT. TIVA or volatile

=== Emergence ===

* If obstruction in bile duct is removed, there is a high risk of bile aspiration. Have suction readily available.

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===
Pancreatitis

Cholangitis

Perforation

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Upper GI endoscopy

2022-08-19T20:15:22Z

Chuckcampana: Added bite block

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

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

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

== Preoperative management ==

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

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

=== Operating room setup ===

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

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

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

==Intraoperative management==

===Monitoring and access===

* Standard ASA monitors
*1 PIV

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

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

===Positioning===
Generally left lateral decubitus

===Maintenance and surgical considerations===

*Propofol drip
*Intermittent boluses of propofol may be used in shorter duration cases
*A fentanyl push prior to scope insertion (25 mcg) can help minimize coughing
*The patient being able to tolerate a jaw thrust prior to scope insertion can help determine if patient is deep enough if procedure done under MAC

===Emergence===

==Postoperative management==

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

===Pain management===
Minimal pain

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

Hypoxemia

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

Colonoscopy

2022-08-19T19:54:54Z

Chuckcampana: Added emergence consideration.

{{Infobox surgical procedure
| anesthesia_type = MAC
| airway = Natural airway
| lines_access = 1 PIV (22 gauge)
| monitors = Standard ASA monitors
| considerations_preoperative = Watch for symptomatic anemia from GI bleed
| considerations_intraoperative =
| considerations_postoperative =
}}

A colonoscopy is a flexible scope that is inserted through the rectum to diagnose and treat problems with the lower GI tract (rectum, colon). It is commonly used to further work up patients with:

* Bright red blood per rectum (BRBPR)
* Melena
* Unexplained constipation/diarrhea
* Routine follow-up for patients with known polyps, IBD, other chronic bowel disease
* Colon cancer screening (in US, every 10 years after age 45)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Anemia is common with lower GI bleed
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|Most patients are "dry" from bowel prep and tolerate a fluid bolus well during the procedure.
|}

=== Labs and studies ===

* CBC w/ Hgb

=== Operating room setup ===

* Nasal cannula for oxygenation
*Have oral/nasal airway available

=== Patient preparation and premedication ===

* Bowel prep based on GI physicians

=== Regional and neuraxial techniques ===

* N/A

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* 1 PIV

=== Induction and airway management ===

* Small amount of propofol and lidocaine (for MAC)

=== Positioning ===

* Left lateral decubitus

=== Maintenance and surgical considerations ===

* Propofol drip (TIVA)

=== Emergence ===

* The Cecum is the turning point that determines the insertion and withdrawal phase of the colonoscope. When proceduralist states they have reached the cecum, the propofol drip can slowly be weaned down to time emergence.

== Postoperative management ==

=== Disposition ===

* PACU and home unless unstable anemia

=== Pain management ===

* This procedure is well tolerated and requires minimal/no pain management.

=== Potential complications ===

* Colonic Perforation
* Post-polypectomy bleeding

== 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]]

Insertion of pacemaker or ICD

2022-08-08T16:30:53Z

Chuckcampana: Added a maintenance technique

{{Infobox surgical procedure
| anesthesia_type = MAC
| airway = Natural
| lines_access = 1-2 PIV
| monitors = 5 lead EKG
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Pacemaker or ICD placement is a minimally invasive procedure were a small incision below the clavicle is created and a cardiac pacemaker or ICD is placed. Through this pocket the cardiologist will insert a wire into the RV of the heart. Once the device is tested and functional, the pocket is closed and local is typically injected in the field.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|Consider etiology requiring pacemaker/ICD insertion. Symptomatic bradycardia, high degree heart blocks, sick sinus syndrome, syncope, HF are some of the common causes.
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
1-2 PIVs are typically required

Standard ASA monitoring

=== Induction and airway management ===
Natural airway typically utilized. If concerns for obstruction or other considerations, LMA or ETT can be considered.

=== Positioning ===
Supine

=== Maintenance and surgical considerations ===
There is very little stimulation after pocket is made. Due to length of procedure, consider at propofol infusion (25-100 mcg/kg/min) and precedex infusion (0.6-1 mcg/kg/hr). After pocket creation, propofol infusion can slowly be weaned off.

=== Emergence ===

== Postoperative management ==

=== Disposition ===
PACU

=== Pain management ===
Minimally invasive with local injection in field.

=== Potential complications ===
Arrhythmias, pneumothorax, heart perforation, bleeding

Later complications include pericarditis, lead dislodgement, device migration, venous thrombosis, hematoma

== 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]]

Intracardiac catheter ablation for the treatment of arrhythmia

2022-08-08T16:19:24Z

Chuckcampana: Created page with "Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats.<ref>{{Cite web|date=2022-05-17|title=Atrial Fibrillation Ablation|url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation|access-date=2022-08-08|website=www.hopkinsmedicine.org|language=en}}</ref> {{Infobox surgical pro..."

Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats.<ref>{{Cite web|date=2022-05-17|title=Atrial Fibrillation Ablation|url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation|access-date=2022-08-08|website=www.hopkinsmedicine.org|language=en}}</ref>

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 2 PIVs (Usually one larger gauge 16/18). +/- arterial line
| monitors = Standard, Esophageal Temperature Probe
| considerations_preoperative = These patients are usually already on anticoagulants. If they are not, expect a TEE to be performed before the start of the procedure to rule out any thrombus in the LAA.
| considerations_intraoperative = Before ablation, the proceduralist will often ask you to reposition the esophageal temperature probe to ensure that the esophagus is not damaged during ablation. Monitor closely and frequently inform proceduralists of esophageal temperature.

Serial ACTs will be drawn throughout the procedure. Patients will receive IV heparin throughout the case as instructed by proceduralists.

Paralytic is often contraindicated during maintenance as the proceduralist will pace the phrenic nerve during the ablation to ensure it remains intact. An excellent alternative is to run a remifentanil infusion during the case.
| considerations_postoperative =
}}

==Overview==

===Indications===

===Surgical procedure===

==Preoperative management==

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

===Labs and studies===

===Operating room setup===

===Patient preparation and premedication===

==Intraoperative management==

===Monitoring and access===
Standard Monitors. Establish two PIVs (one large bore in case of myocardial perforation). +/- arterial line (consider EF). +/- OG tube.

===Induction and airway management===

===Positioning===
Supine. Arms will be tucked. Ensure all lines are neatly tucked and off of the floor to ensure they are not caught by the swinging C-arm.

===Maintenance and surgical considerations===
Maintenance of anesthesia with inhalation agent at 0.7 - 1 MAC with a remifentanil infusion (0.05 - 0.5 mcg/kg/min). Consider addition of phenylephrine infusion as well. Proceduralists like to know if any vasopressors are added during the case as they monitor for cardiac tamponade/atrial perforation. I have found it helpful to start a low dose phenylephrine infusion at the beginning of case to maintain hemodynamics.

===Emergence===
Standard emergence. Closure of access site in groin often requires pressure to be held for 15- 30 min. Consider timing emergence to include this. Today, a closure device may be used at access site which negates this additional time.

==Postoperative management==

===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

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

==References==

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