WikiAnesthesia - User contributions [en]

Open reduction and interal fixation of the tibial plateau fracture

2022-07-18T02:45:57Z

Eeshwar.Chandrasekar: Created page with "{{Infobox surgical procedure | anesthesia_type = General | airway = ETT | lines_access = PIV | monitors = Standard ASA Monitors | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Provide a brief summary here. == Overview == === Indications === === Surgical procedure === == Preoperative management == === Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove row..."

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV
| monitors = Standard ASA Monitors
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Provide a brief summary here.

== 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 ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Liver transplant

2022-07-18T02:40:37Z

Eeshwar.Chandrasekar:

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

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

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

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

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

===Labs and studies===

* Full workup prior to transplant.
* CBC
* CMP
* Coagulation panel
* CXR
* EKG
* Cardiac evaluation possibly including stress test or TTE

===Operating room setup===

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

===Patient preparation and premedication===

===Regional and neuraxial techniques===

* Avoided due to coagulopathy.

== Intraoperative management==

===Monitoring and access===

* Large bore PIVs
* Arterial line
* Central access (often large-bore volume line and an infusion line).
** Common practice can include introducer catheter for volume and a triple lumen catheter for infusions.
** CVP monitoring.
* In patients with underlying cardiac disease can consider intraoperative TEE and/or pulmonary artery catheter

===Induction and airway management===

===Positioning===

* Supine

===Maintenance and surgical considerations===

* Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
* Mental status may be further depressed by coexisting metabolic derangements, including hyponatremia and hypoglycemia.
* Limited hepatic clearance of various toxins, such as ammonia, can lead to alterations in endogenous neurotransmitters and neuro-signaling pathways, largely involving y-aminobutyric acid (GABA), glutamate and nitric oxide.

===Emergence===

==Postoperative management==

===Disposition===

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

=== Pain management===

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

===Potential complications===

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

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

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

Coronary artery bypass graft

2022-07-18T02:35:15Z

Eeshwar.Chandrasekar:

{{Infobox surgical case reference
| anesthesia_type = GA
| airway = ETT
| lines_access = PIV x2
Arterial line
Central line [often 2]
Introducer
± PA catheter
| monitors = Standard
5-lead ECG
Temperature
ABP
CVP
TEE
NIRS
± PAP
| considerations_preoperative = beta-blocker
discussion with surgeon regarding any regional anesthesia adjuncts
| considerations_intraoperative = Heparinization for graft harvest
Full heparinization prior to coming on CPB
Hemodyamics and cardiac function coming off CPB
Reversal of heparin with protamine
Discussion with surgeon regarding extubation in OR
| considerations_postoperative = transfusion and vasopressor requirements
inotropic support
}}
'''Coronary Artery Bypass Graft''', also known as '''CABG''', is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|cognitive function
Identify any atherosclerotic lesions along carotid vessels
|-
|Cardiovascular
|Identify diseased vessels & any associated collaterals
Evaluate LVEF, wall thickness and valve functionality

All antianginal medications should be given day of surgery
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Confirm T+S and at least 4 units pRBCs are on hold, as well as FFP
Anticoagulation is common in these patients
|-
|Renal
|Evaluate for any pre-operative renal insufficiency
|-
|Endocrine
|Evaluate HgbA1c and if Insulin-dependent diabetic, note current insulin regimen
|-
|Other
|Redo sternotomies have a greater risk of significant bleeding and complication
|}

=== Labs and studies ===

* CBC, CMP
* PT, PTT
* CXR: to evaluate for abnormalities (cardiomegaly, pleural effusions)
* EKG: check for LBBB. If a PA catheter is planned, occasionally patients with LBBB may develop a third degree block as a consequence of PA catheter placement

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider ketamine, precedex, ancef
* Drugs:
** Heparin, protamine, calcium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* All cardiac medications should be continued on day of surgery except ACE inhibitors which should be stopped 24h prior to surgery

=== Regional and neuraxial techniques ===

*Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology

== Intraoperative management ==

=== Monitoring and access ===

* 2 large bore PIVs
* Arterial line
* CVP
* Cordis
* +/- Pulmonary artery catheter

=== Induction and airway management ===

*Cardio-protective induction with etomidate vs standard induction with propofol depending on patient's cardiac function and pathology

=== Positioning ===

*Supine position

=== Maintenance and surgical considerations ===

* Redo sternotomies have higher risk of significant bleeding

=== Emergence ===

*Patients are not emerged and instead remain under anesthesia during transit to cardiac ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Can consider regional anesthesia with parasternal intercostal plane blocks

=== Potential complications ===

* MI 6%
* CVA 5%
* Mild neuropsychatric effects 90%
* Death 1-3% (preop-risk dependent)
* Transfusion 40-90%
* Delirium 8%-15%
* Atrial fibrillation Up to 35%
* Renal failure 1%
* Mediastinitis 1-2%

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
[[Category:Cardiac surgery]]
[[Category:Cardiac revascularization procedures]]

Carotid endarterectomy

2022-03-15T01:38:34Z

Eeshwar.Chandrasekar:

{{Infobox surgical case reference
| anesthesia_type = GETA vs. regional anesthesia
| airway = Endotracheal Tube
| lines_access = PIV x 2 18 ga or larger is adequate
| monitors = Standard monitors, arterial line
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}'''Carotid endarterectomy''' ('''CEA''') is a surgical procedure for treating occlusive atherosclerotic disease involving the common and internal carotid arteries. The procedure is more effective than medical management for patients with high grade stenosis (70–99%), symptomatic moderate stenosis (50-69%), or asymptomatic high-grade stenosis (≥ 60%).<ref>{{Cite journal|last=Texakalidis|first=Pavlos|last2=Giannopoulos|first2=Stefanos|last3=Kokkinidis|first3=Damianos G.|last4=Karasavvidis|first4=Theofilos|last5=Rangel-Castilla|first5=Leonardo|last6=Reavey-Cantwell|first6=John|date=2018-12|title=Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis|url=http://dx.doi.org/10.1016/j.wneu.2018.08.183|journal=World Neurosurgery|volume=120|pages=563–571.e3|doi=10.1016/j.wneu.2018.08.183|issn=1878-8750}}</ref> CEA involves making a longitudinal incision along the anterior border of the sternocleidomastoid muscle to expose the common, internal, and external carotid arteries as well as the carotid sinus. The carotid artery is then opened and the atherosclerotic plaque is removed. Opening of the carotid artery requires occlusion of the proximal common carotid and distal internal and external carotid arteries, which requires adequate collateral flow from the contralateral common carotid artery or placement of an internal shunt between the proximal common carotid and the distal internal carotid arteries. On removal of the atherosclerotic plaque, the media and adventitia of the arteries may be re-approximated or a graft may be used. These grafts are typically synthetic, but vein grafts are occasionally used.

== Preoperative management ==
=== Patient evaluation  ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Evaluate plaque location and adequacy of collateral flow with carotid angiograms prior to surgery
|-
|Cardiovascular
|Preoperative ECG is useful as perioperative MI is the most common major postoperative complication. Uncontrolled hypertension or diabetes, as well as recent MI are reasons to delay the case.
|-
|Pulmonary
|ABGs, Spirometry, and CXRs are useful only if otherwise indicated from the H&P
|-
|Hematologic
|Anti-platelet agents (typically aspirin) are typically initiated preoperatively and continued until the day of surgery to prevent perioperative thromboembolic complications.
|}
=== Labs and studies  ===

* No unique laboratory evaluation is necessary

=== Operating room setup  ===
=== Patient preparation and premedication  ===

* Premedication in CEA may complicate the immediate postoperative evaluation for stroke or TIA.
* Use of preoperative benzodiazepines and opioids should be limited.
* If a discussion of the operation and safety steps is inadequate to alleviate the patient's fear, a small dose of midazolam is preferred to opioid premedication.

=== Regional and neuraxial techniques  ===

* Superficial cervical plexus blocks + supplemental field blocks by surgeon
* Deep cervical plexus blocks are now avoided due to concomitant Horner's Syndrome, phrenic nerve block, and recurrent laryngeal nerve injuries
* Patients receiving regional anesthesia for CEA have decreased ICU times and may have decreased need for surgical shunts. Regional anesthesia for CEA, however, does not provide cerebral protection afforded by general anesthesia and it makes conversion to GETA more challenging should the need arise.<ref>{{Cite journal|last=Schechter|first=Matthew A.|last2=Shortell|first2=Cynthia K.|last3=Scarborough|first3=John E.|date=2012-09|title=Regional versus general anesthesia for carotid endarterectomy: The American College of Surgeons National Surgical Quality Improvement Program perspective|url=http://dx.doi.org/10.1016/j.surg.2012.05.008|journal=Surgery|volume=152|issue=3|pages=309–314|doi=10.1016/j.surg.2012.05.008|issn=0039-6060}}</ref>

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

* Standard ASA monitors
* Arterial line is required as it allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping.<ref name=":0">{{Citation|last=Norris|first=Edward J.|title=Anesthesia for Vascular Surgery|date=2010|url=http://dx.doi.org/10.1016/b978-0-443-06959-8.00062-5|work=Miller's Anesthesia|pages=1985–2044|publisher=Elsevier|access-date=2021-10-23}}</ref>
** Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.
*Will require second arterial line transducer if surgeon measures stump pressures
* Central access is not typically required.<ref>{{Cite journal|last=Nelson|first=Priscilla|last2=Bustillo|first2=Maria|date=2021-03|title=Anesthesia for Carotid Endarterectomy, Angioplasty, and Stent|url=https://pubmed.ncbi.nlm.nih.gov/33563385/#:~:text=Nelson%20P,%20Bustillo%20M.%20Anesthesia%20for%20Carotid%20Endarterectomy,%20Angioplasty,%20and%20Stent.%20Anesthesiol%20Clin.%202021%20Mar;39(1):37-51.%20doi:%2010.1016/j.anclin.2020.11.006.%20Epub%202021%20Jan%208.%20PMID:%2033563385.|journal=Anesthesiology Clinics|volume=39|issue=1|pages=37–51|doi=10.1016/j.anclin.2020.11.006|issn=1932-2275|pmid=33563385}}</ref>

* [[Electroencephalography|EEG monitoring]], [[Somatosensory evoked potentials|somatosensory evoked potentials]] (SSEPs), and [[Motor evoked potentials|motor evoked potentials]] (MEPs) may be used to assess cerebral perfusion.

=== Induction and airway management  ===

* If general anesthesia is chosen, endotracheal intubation is preferred over placing an LMA.
* Induction medications are dependent on patient comorbidies, but caution should be used with ketamine as it increases CMRO2 at a time when cerebral blood flow is limited.
* For regional anesthesia, light sedation with midazolam, fentanyl, propofol, or dexmedetomidine is reasonable. Avoid heavy sedation as patient cooperation may be required for neurologic exam.

=== Positioning  ===

* Patients are positioned supine with the head turned away from operative site. Beach chair may be used for comfort in awake patients
=== Maintenance and surgical considerations  ===

* Volatile anesthetics supplemented with opioids for analgesia and neuromuscular blockade is adequate for CEA without electrophysiologic monitoring (EP).
* For patients receiving EP monitoring, a total IV anesthetic with propofol and remifentanil provides excellent sedation and operating conditions.
* Heparin is required prior to carotid cross-clamping.
** ACT goal is 200-250 seconds or double the baseline value.
** Typical dose is 100 units/kg
* Carotid cross clamping may induce a severe vagal response with bradycardia and hypotension. Local anesthetic infiltration by the surgeon prior to cross clamping may improve this response.
* Consider induction of burst suppression immediately prior to clamping for neuroprotection
* Induced hypertension is commonly used to promote collateral perfusion during clamping
* Unclamping can produce a reflex bradycardia and vasodilation effect
* Reverse heparin with protamine after unclamping
** Typical dose is 5 mg/1000 units of heparin given
** Limited evidence supports waiting 10 minutes after unclamping to reverse<ref>{{Cite journal|last=Ercius|first=M. S.|last2=Chandler|first2=W. F.|last3=Ford|first3=J. W.|last4=Burkel|first4=W. E.|date=1983-05|title=Early versus delayed heparin reversal after carotid endarterectomy in the dog. A scanning electron microscopy study|url=https://pubmed.ncbi.nlm.nih.gov/6834120|journal=Journal of Neurosurgery|volume=58|issue=5|pages=708–713|doi=10.3171/jns.1983.58.5.0708|issn=0022-3085|pmid=6834120}}</ref>
** Confirm normalization of ACT

=== Blood Pressure Maintenance ===

* MAPs should be kept at or above the patient's awake MAP. A phenylephrine drip is a good choice because it's pure α-1 activity decreases the risk of arrhythmias.
* Wide swings in blood pressure should be expected during CEA.
* Sudden bradycardia may occur with associated hemodynamic instability, so atropine of glycopyrrolate should be available.

=== Emergence  ===

* Many surgeons prefer to verify neurologic status prior to extubation
* Use caution to avoid coughing and bucking which can lead to neck hematoma formation, hypertension, and even hemorrhagic stroke during emergence

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

=== Pain management  ===

* Postoperative pain is typically mild and can be treated with local infiltration by the surgeon.
* Caution is required with opioid use because it may exacerbate respiratory depression from carotid chemoreceptor injury.<ref name=":0" />

=== Potential complications ===

* Neurologic deficits may surface after emboli from plaque or shunts or from hypoperfusion during the procedure
* Plaque removal during surgery may cause baroreceptor changes causing either hypotension or hypertension requiring vasoactive medications in the recovery unit
* Postoperative hypertension may cause neck hematoma or hyperperfusion syndrome.<ref>{{Cite journal|last=Nelson|first=Priscilla|last2=Bustillo|first2=Maria|date=2021-03|title=Anesthesia for Carotid Endarterectomy, Angioplasty, and Stent|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227520301014|journal=Anesthesiology Clinics|language=en|volume=39|issue=1|pages=37–51|doi=10.1016/j.anclin.2020.11.006}}</ref>
* Neck hematoma may result from hypertension, inadequate hemostasis, or coughing. Neck hematoma formation may distort airway anatomy making reintubation challenging.

== Procedure variants  ==

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

== References ==

[[Category:Surgical procedures]]

Cesarean section

2022-03-15T01:34:16Z

Eeshwar.Chandrasekar:

{{Infobox surgical case reference
| anesthesia_type = Neuraxial or general
| airway = ETT if general
| lines_access = 2 large bore PIV
| monitors = Standard ASA 
Fetal heart rate monitor
| considerations_preoperative = Full stomach precautions 
Aspiration prophylaxis 
Left lateral tilt
| considerations_intraoperative = Blood loss: 700-1000mL
| considerations_postoperative =
}}
A '''cesarean section''' (also known as '''C-section''') is a surgical procedure where the baby is delivered through an incision in the uterus. C-sections are typically performed when a vaginal delivery would put the mother or baby at risk. In the USA, about 32% of deliveries are via Cesarean section<ref>{{Cite web|date=2021-03-24|title=FastStats|url=https://www.cdc.gov/nchs/fastats/delivery.htm|access-date=2021-05-27|website=www.cdc.gov|language=en-us}}</ref>, and worldwide the figure is approximately 21%.<ref>{{Cite journal|last=Boerma|first=Ties|last2=Ronsmans|first2=Carine|last3=Melesse|first3=Dessalegn Y.|last4=Barros|first4=Aluisio J. D.|last5=Barros|first5=Fernando C.|last6=Juan|first6=Liang|last7=Moller|first7=Ann-Beth|last8=Say|first8=Lale|last9=Hosseinpoor|first9=Ahmad Reza|last10=Yi|first10=Mu|last11=Neto|first11=Dácio de Lyra Rabello|date=2018-10-13|title=Global epidemiology of use of and disparities in caesarean sections|url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31928-7/abstract|journal=The Lancet|language=English|volume=392|issue=10155|pages=1341–1348|doi=10.1016/S0140-6736(18)31928-7|issn=0140-6736|pmid=30322584}}</ref>

== Preoperative management ==

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

* Risk for aspiration
* Liver enzymes may be mildly elevated
** Check for HELLP
|-
|Hematologic
|
* Increased RBC mass, plasma volume, and blood volume
* Leukocytosis
* Iron deficiency anemia + dilutional anemia of pregnancy
* Excessive blood loss possible with uterine atony, multiple gestation, previous C-section, placental pregnancy, placental abruption, pregnancy induced hypertension, or prolonged labor.
|-
|Renal
|
* Increased renal blood flow, GFR, and creatinine clearance
* Decreased serum creatinine and BUN
* Dependent edema secondary to increased water and sodium retention
|-
|Other
|
|}

=== Labs and studies ===

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

=== Operating room setup ===

=== Patient preparation and premedication ===

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

=== Regional and neuraxial techniques ===

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

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitors

=== Induction and airway management ===

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

=== Positioning ===

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

=== Maintenance and surgical considerations ===

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

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* L&D PACU
* Operating room PACU

=== Pain management ===

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

=== Potential complications ===

* Ureteral injury
* Post-partum hemorrhage

== Procedure variants ==

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

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

== References ==

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

Mastectomy

2021-05-18T14:48:46Z

Eeshwar.Chandrasekar:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT vs. LMA
| lines_access = PIV
| monitors = Standard monitors
| considerations_preoperative = Place IV in non-operative extremity
| considerations_intraoperative =
| considerations_postoperative =
}}

A total '''mastectomy''' (simple mastectomy) refers to the complete removal of breast tissue. A modified radical mastectomy refers to the removal of the breast and the corresponding axillary lymph nodes.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|Chemotherapy (ex. anthracyclines) can cause cardiomyopathy that is often irreversible. Use of trastuzamab can cause reversible decrease in LV function.
|-
|Respiratory
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Chemotherapy can cause anemia and thrombocytopenia.
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* CBC with diff and platelet count

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

* Consider Paravertebral Blocks

== Intraoperative management ==

=== Monitoring and access ===

* 20g PIV (non-operative extremity)
* Place BP cuff on non-operative extremity

=== Induction and airway management ===

=== Positioning ===

* Supine
* Ipsilateral arm may be prepped into field
* Repositioning may be required
* Avoid brachial plexus stretch

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* PACU

=== Pain management ===

=== Potential complications ===

* PONV
* Lymphedema
* Seroma
* Pneumothorax

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Cataract surgery

2021-03-30T19:36:25Z

Eeshwar.Chandrasekar: Created page with "A cataract surgery is usually an elective surgery in which the opacified lens of the eye is replaced with an artificial intraocular lens. This common surgical procedure is usu..."

A cataract surgery is usually an elective surgery in which the opacified lens of the eye is replaced with an artificial intraocular lens. This common surgical procedure is usually performed among elderly patients as the most common etiology is age-related (90% of cases). Cataract surgery is commonly performed via an extracapsular technique, which involves removing the lens through a small incision in the anterior lens capsule, and phacoemulsification. This is generally preferred to the intracapsular technique, which involves removing the lens and surrounding capsular bag, as the extracapsular approach has improved visual outcomes and fewer adverse reactions. {{Infobox surgical case reference
| anesthesia_type = MAC
| airway = Nasal Canula
| lines_access = Peripheral IV
| monitors = Standard ASA / 5 Lead EKG
| considerations_preoperative =
| considerations_intraoperative = Dysrhythmias, Oculocardiac Reflex
| considerations_postoperative =
}}

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Uncontrolled movement disorders, significant anxiety, or agitation may warrant general anesthesia.
|-
|Cardiovascular
|
|-
|Respiratory
|
* Patients with chronic cough may warrant general anesthesia.
|-
|Gastrointestinal
|Assess patient's risk
|-
|Hematologic
|Antiplatelet or anticoagulant drugs generally do not have to be stopped prior to cataract surgery given the low risk and minimal blood loss
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===

===Operating room setup===

===Patient preparation and premedication===

===Regional and neuraxial techniques===

==Intraoperative management==

===Monitoring and access===

* Standard ASA monitors
* 5 Lead EKG
* 1 Peripheral IV

===Induction and airway management===

* Nasal cannula is commonly used for oxygen supplementation
* Patients are usually awake and alert during procedure, with topical medication commonly administered to operative eye
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort

===Positioning===

* Supine, table usually rotated 90 - 180 degrees
* Protect non-operating eye

===Maintenance and surgical considerations===

* Cataract surgeries are often very short in duration, with case duration ranging on average from 15 mins to 1 hour
* Anesthesiologists should monitor

===Emergence===

==Postoperative management==

===Disposition===

* Patients usually return home same day after short post-operative observation

===Pain management===

* Patients usually have minimal pain after procedure (Pain score 1-2)
*

===Potential complications===

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]