WikiAnesthesia - User contributions [en]

Cataract surgery

2024-09-12T02:22:09Z

Jashvin:

{{Infobox surgical case reference
| anesthesia_type = MAC
| airway = Noninvasive O2
| lines_access = Peripheral IV
| monitors = Standard
5-lead ECG
| considerations_preoperative =
| considerations_intraoperative = Dysrhythmias
Oculocardiac reflex
| considerations_postoperative =
}}
'''Cataract surgery''' is an elective procedure 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.

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Uncontrolled movement disorders, significant anxiety, or agitation may warrant general anesthesia.
|-
|Cardiovascular
|
|-
|Pulmonary
|
* Patients with chronic cough may warrant general anesthesia.
|-
|Gastrointestinal
|
* Assess for GERD. Patient will need to lay flat and therefore at increased risk for aspiration
|-
|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===

* N/A

===Operating room setup===

* Nasal cannula
* Drape retractor for comfort (optional)

===Patient preparation and premedication===

* N/A

===Regional and neuraxial techniques===

* Retrobulbar or sub-tenon block can be used in procedure room and OR environments

==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
* Lidocaine-propofol-alfentanil mixtures<ref>{{Cite journal|last=Fang|first=Zhuang T.|last2=Keyes|first2=Mary A.|date=2006|title=A novel mixture of propofol, alfentanil, and lidocaine for regional block with monitored anesthesia care in ophthalmic surgery|url=https://linkinghub.elsevier.com/retrieve/pii/S0952818005003508|journal=Journal of Clinical Anesthesia|language=en|volume=18|issue=2|pages=114–117|doi=10.1016/j.jclinane.2005.08.007|via=}}</ref> can be used for induction during application of retrobulbar or sub-tenon blocks by proceduralist
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
* Placement of retrobulbulbar or peribulbar blocks can be briefly very painful - consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg)
** Be prepared to treat sudden decrease in blood pressure or apnea

===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
* Coughing or valsalva should be avoided as much as possible
* If any cautery is used, the delivered FiO2 < 30%
* Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure.
** Stop surgical manipulation, give [[atropine]]/[[glycopyrrolate]]

=== Second Eye Effect ===
* Patients report more unpleasant experience with their second eye surgery.
*Before the surgery on their second eye, patients report less anxiety and have higher expectations. However, almost 50% of patients say that their second eye was less pleasant compared to their first. <ref>{{Cite web|date=2015-02-25|title=Study confirms “second eye” effect in cataract surgery|url=https://www.aao.org/education/editors-choice/study-confirms-differences-in-patients-subjective-|access-date=2024-09-12|website=American Academy of Ophthalmology|language=en}}</ref>
*This may be due to an "expectation gap"

===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)
* PO or IV acetaminophen
*

===Potential complications===

==Procedure variants==

{| class="wikitable"
|+
!
!Femptosecond Laser
!Astigmatism Correcting
Lens insertion
!Combined Case
|-
|Unique considerations
|Two rooms required
|Surgeon must have eye

marked prior to sedation
|
|-
|Position
|
|
|
|-
|Surgical time
|
|
|
|-
|EBL
|
|
|
|-
|Postoperative disposition
|
|
|
|-
|Pain management
|
|
|
|-
|Potential complications
|
|
|
|}

==References==

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

Cataract surgery

2024-09-12T02:21:13Z

Jashvin: second eye effect

{{Infobox surgical case reference
| anesthesia_type = MAC
| airway = Noninvasive O2
| lines_access = Peripheral IV
| monitors = Standard
5-lead ECG
| considerations_preoperative =
| considerations_intraoperative = Dysrhythmias
Oculocardiac reflex
| considerations_postoperative =
}}
'''Cataract surgery''' is an elective procedure 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.

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Uncontrolled movement disorders, significant anxiety, or agitation may warrant general anesthesia.
|-
|Cardiovascular
|
|-
|Pulmonary
|
* Patients with chronic cough may warrant general anesthesia.
|-
|Gastrointestinal
|
* Assess for GERD. Patient will need to lay flat and therefore at increased risk for aspiration
|-
|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===

* N/A

===Operating room setup===

* Nasal cannula
* Drape retractor for comfort (optional)

===Patient preparation and premedication===

* N/A

===Regional and neuraxial techniques===

* Retrobulbar or sub-tenon block can be used in procedure room and OR environments

==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
* Lidocaine-propofol-alfentanil mixtures<ref>{{Cite journal|last=Fang|first=Zhuang T.|last2=Keyes|first2=Mary A.|date=2006|title=A novel mixture of propofol, alfentanil, and lidocaine for regional block with monitored anesthesia care in ophthalmic surgery|url=https://linkinghub.elsevier.com/retrieve/pii/S0952818005003508|journal=Journal of Clinical Anesthesia|language=en|volume=18|issue=2|pages=114–117|doi=10.1016/j.jclinane.2005.08.007|via=}}</ref> can be used for induction during application of retrobulbar or sub-tenon blocks by proceduralist
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
* Placement of retrobulbulbar or peribulbar blocks can be briefly very painful - consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg)
** Be prepared to treat sudden decrease in blood pressure or apnea

===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
* Coughing or valsalva should be avoided as much as possible
* If any cautery is used, the delivered FiO2 < 30%
* Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure.
** Stop surgical manipulation, give [[atropine]]/[[glycopyrrolate]]

=== Second Eye Effect ===
* Patients report more unpleasant experience with their second eye surgery.
*Before the surgery on their second eye, patients report less anxiety and have higher expectations. However, almost 50% of patients say that their second eye was less pleasant compared to their first.
*This may be due to an "expectation gap"

===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)
* PO or IV acetaminophen
*

===Potential complications===

==Procedure variants==

{| class="wikitable"
|+
!
!Femptosecond Laser
!Astigmatism Correcting
Lens insertion
!Combined Case
|-
|Unique considerations
|Two rooms required
|Surgeon must have eye

marked prior to sedation
|
|-
|Position
|
|
|
|-
|Surgical time
|
|
|
|-
|EBL
|
|
|
|-
|Postoperative disposition
|
|
|
|-
|Pain management
|
|
|
|-
|Potential complications
|
|
|
|}

==References==

[[Category:Surgical procedures]]
<references />''2. Study confirms ‘Second eye’ effect in cataract surgery'' (2015) ''American Academy of Ophthalmology''. Available at: <nowiki>https://www.aao.org/education/editors-choice/study-confirms-differences-in-patients-subjective-</nowiki> (Accessed: 11 September 2024).
[[Category:Ophthalmology]]

Lumbar Laminectomy

2023-03-30T18:54:09Z

Jashvin:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, +/- A-line
| monitors = Standard, +/- A-line, +/- BIS/Massimo if TIVA
| considerations_preoperative =
| considerations_intraoperative = Intraoperative electrophysiological monitoring if at level of spinal cord, Prone positioning
| considerations_postoperative = Pain control
}}

Lunar laminectomy is a complete removal of lamina, which is use for to decompress the neural elements of the lumbar spine, usually via a posterior approach in the prone position.

== Overview ==

=== Indications ===
Lumbar radiculopathy 2° degenerative disc disease from herniated disks, congenital stenosis, neoplasm, and, occasionally, trauma. Lumbar laminectomy is also used to gain access to the spinal canal for dealing with intradural tumors, arteriovenous malformations (AVMs), and other spinal cord lesions.

=== Surgical procedure ===

== Preoperative management ==

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

=== Labs and studies ===
CBC, Coags

=== Operating room setup ===
TIVA if neurophysiological monitoring

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Large bore IV access. Potential for large volume blood loss during exposure

=== Induction and airway management ===
Standard induction

Avoid long acting paralytic if neurophysiological monitoring. Consider succinylcholine or remifentanil bolus (1.5mg/kg)

=== Positioning ===
Prone positioning

=== Maintenance and surgical considerations ===
1-2 hour for single level

+0.5-1hr per additional level

TIVA if neurophysiological monitoring (Propofol, Remi, phenylephrine to support BP)

BIS or Massimo to monitor depth of anesthesia if using TIVA

Avoid large volume resuscitation given prone positioning

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===
Prone positioning

* Minimize large volume of crystalloid
** Ischemic neuropathy
** Airway edema
** Consider blood or albumin for intravascular expansion
* Pad pressure points
** Check eyes and ears
** Foam pillow with cutouts for eyes, nose mouth,
** Typically arms abducted & limit flexion to <90*
** Pad elbows knees, feet, arms

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Lumbar Laminectomy

2023-03-30T18:47:54Z

Jashvin: New page for Lumbar lami

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, +/0 A-line
| monitors = Standard, +/- A-line
| considerations_preoperative =
| considerations_intraoperative = Intraoperative electrophysiological monitoring if at level of spinal cord, Prone positioning
| considerations_postoperative = Pain control
}}

Lunar laminectomy is a complete removal of lamina, which is use for to decompress the neural elements of the lumbar spine, usually via a posterior approach in the prone position.

== Overview ==

=== Indications ===
Lumbar radiculopathy 2° degenerative disc disease from herniated disks, congenital stenosis, neoplasm, and, occasionally, trauma. Lumbar laminectomy is also used to gain access to the spinal canal for dealing with intradural tumors, arteriovenous malformations (AVMs), and other spinal cord lesions.

=== 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 ===
Large bore IV access. Potential for large volume blood loss.

=== Induction and airway management ===
Standard induction

Avoid long acting paralytic if neurophysiological monitoring. Consider succinylcholine or remifentanil bolus (1.5mg/kg)

=== Positioning ===
Prone positioning

=== Maintenance and surgical considerations ===
1-2 hour for single level

+0.5-1hr per additional level

TIVA if neurophysiological monitoring (Propofol, Remi, phenylephrine to support BP)

BIS or Massimo to monitor depth of anesthesia if using TIVA

Avoid large volume resuscitation given prone positioning

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Circumcision

2023-02-02T14:40:36Z

Jashvin: Caudal dose

{{Infobox surgical procedure
| anesthesia_type = General, Caudal Epidural
| airway = ETT vs LMA
| lines_access = PIV x 1
| monitors = Standard, Temperature
| considerations_preoperative = OR and table pre-warmed
| considerations_intraoperative = Temperature
| considerations_postoperative = Emergence delirium
}}

'''Circumcision''' is a procedure involving the foreskin removal of the penis exposing the glans penis. Indication includes family reasons, phimosis or recurrent balanitis <ref name=":0">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref><ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117280100|title=A guide to pediatric anesthesia|date=2020|others=Craig Sims, Dana Weber, Chris Johnson|isbn=978-3-030-19246-4|edition=2nd ed|location=Cham|oclc=1117280100}}</ref>. Most circumcisions occur in the newborn nursery performed by pediatrician or obstetrician with different clamps when patients are neonates<ref name=":0" /><ref name=":2">{{Cite book|url=https://www.worldcat.org/oclc/1137179895|title=Gregory's pediatric anesthesia|date=2020|others=Dean B. Andropoulos, George A. Gregory|isbn=978-1-119-37151-9|edition=Sixth edition|location=Hoboken, NJ|oclc=1137179895}}</ref>. However, if circumcision is performed in the operating room, the procedure begins with two incisions to remove the penile skin surrounding and covering the glans penis which is the most common method in the operating room<ref name=":2" />.

== Preoperative management ==

=== Operating room setup ===

* Set OR temperature to 70o to 75o
* Underbody bair hugger preheated

=== Patient preparation and premedication ===

* PO midazolam for anxiety in children experiencing separation anxiety
* PO acetaminophen for pain

=== Regional and neuraxial techniques ===

* Caudal epidural, penile block, or dorsal ring block for analgesia supplemented with general <ref name=":0" /><ref name=":1" />'
*Caudal: 0.25% Bupivacaine 1cc/kg

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* Temperature
* PIV x 1

=== Induction and airway management ===

* Mask induction with sevoflurane +/- N2O
** ETT vs LMA
* IV induction for patients > 10 years old

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Maintenance with volatile anesthetics, IV anesthetic or a combination
* Monitor temperature and ensure large surface areas are covered with warm blankets

=== Emergence ===

* Emergence delirium

== Postoperative management ==

=== Disposition ===

* PACU
* Usually discharged home

=== Pain management ===

* Pain is mild
** Multimodal
*** PO/PR/IV acetaminophen
*** IV/PO NSAIDs
*** IV/PO opioids
*** Topical local anesthetic
*** Regional block
*** Caudal epidural

=== Potential complications ===

* Infection
* Hematoma

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Circumcision
|-
|Position
|Supine
|-
|Surgical time
|30 minutes
|-
|EBL
|Minimal
|-
|Postoperative disposition
|Home
|-
|Pain management
|Mild , multimodal
|-
|Potential complications
|Infection, hematoma
|}

== References ==

[[Category:Surgical procedures]]

Fentanyl

2023-02-02T02:31:26Z

Jashvin:

{{Infobox drug reference
| trade_names = Actiq, Duragesic, Sublimaze
| drug_class = Opioid
| drug_class_color = opioid
| uses = Analgesia
| contraindications =
| routes = Buccal, Epidural, Intrathecal, Intravenous, Transdermal
| dosage =
| halflife_elimination = 16 hours
| formula = 5 minutes
| image_file = Fentanyl.svg
| protein_binding = 80-85%
| clearance =
| time_onset = 5 minutes
| halflife_redistribution = 6 minutes (initial)
1 hour (slow)
| metabolism = Hepatic (CYP3A4)
| duration = 30-60 minutes
| adverse_effects =
| dosage_calculation = fentanyl
| mechanism = μ-opioid agonism
| molar_mass = 336.479 g/mol
}}

'''Fentanyl''' is a synthetic, lipophilic phenylpiperidine opioid agonist used for analgesia. It is highly lipophilic leading to fast passage across the blood-brain barrier with a 6.8 minute onset time. Fentanyl will also rapidly redistribute to adipose and fatty tissue leading to a short duration of action.

==Uses==

* Administration
** IV, IM, transdermal, intranasal, intrathecal, epidural, buccal.

==Contraindications==

===Absolute contraindications===

===Precautions===

*

==Pharmacology==

===Pharmacodynamics===

====Mechanism of action====

* µ-selective opioid receptor
* Low affinity: delta & kappa opioid receptors

====Adverse effects====

===Pharmacokinetics===

* Context Sensitive Half Time
** Infusion or repeated doses lead to prolong duration of action as drug redistributes back from tissue to plasma.

==Chemistry and formulation==

==History==

==References==

# Comer SD, Cahill CM. Fentanyl: Receptor pharmacology, abuse potential, and implications for treatment. Neurosci Biobehav Rev. 2019 Nov;106:49-57.

[[Category:Drug reference]]
[[Category:Opioids]]
[[Category:Opioid analgesics]]
[[Category:Synthetic opioids]]
[[Category:Analgesics]]
[[Category:Local anesthetic adjuvants]]

Infrainguinal arterial bypass

2023-02-02T02:21:07Z

Jashvin:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore IV x2
Arterial line
| monitors = Standard
ABP
| considerations_preoperative = Evaluate for CAD, HTN, DM
| considerations_intraoperative = Ischemia-reperfusion syndrome after cross clamp removal
*Lactic acidosis
*ATN
*Hyperkalemia
| considerations_postoperative =
}}

'''Infrainguinal arterial bypass''' procedures include:

* Aortofemoral bypass or aortobifemoral bypass
* Axillofemoral bypass or axillobifemoral bypass
* Femorofemoral bypass (fem-fem)
*Femoral popliteal bypass (fem-pop)
* Femoral tibial bypass (fem-tib)

== Overview ==

=== Indications ===
Severely PAD causing claudication, ulceration, or infection

=== Surgical procedure ===

* Incision of bypass sites (source and target arteries)
* ± Harvest of vein graft
* Anastomotic tunnel creation
* Clamp of proximal artery
* Distal anastomosis, then proximal anastomosis
* Reperfusion of arteries
* Arteriogram to confirm flow

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|Peripheral neuropathy
|-
|Cardiovascular
|Significant PAD, usually also CAD (prior MIs), HTN
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Possible comorbid CKD
|-
|Endocrine
|Usually DM
|-
|Other
|
|}

=== Labs and studies ===

* BMP to evaluate potassium, creatinine
* Coagulation factors (INR, PTT)

=== Operating room setup ===

* Arterial line setup
* Lead for intraop arteriogram
* Heparin and protamine prepared for clamp/unclamping

=== Patient preparation and premedication ===

* Anxiolysis as indicated

=== Regional and neuraxial techniques ===

* Spinal or epidural can be considered for intraoperative and postoperative pain control
** There is some evidence that regional anesthesia promotes graft survival [citation needed].

== Intraoperative management ==

=== Monitoring and access ===

* 2 large bore IVs for possible fluid/product resuscitation
* Arterial line for ABP

=== Induction and airway management ===
General anesthesia with ETT. Induce with paralysis

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Clamping of large arteries may produce afterload increase, though usually minimal effect
* Unclamping of large arteries may induce ischemia-reperfusion syndrome (lactic acidosis, hyperkalemia, ATN)
* Heparin is needed during anastomosis creation
* Protamine may be needed for reversal at end of case

=== Emergence ===

== Postoperative management ==

=== Disposition ===
IMC vs. ICU

=== Pain management ===
If regional anesthetic used, epidural may be redosed.

Consider lower extremity nerve blocks for acute pain in the PACU (femoral, sciatic, popliteal blocks)

- Take care to check ASRA guidelines prior to any regional anesthesia in the patients.

=== Potential complications ===

* Arterial thrombosis/occlusion
* Acute cardiac event
* Wound hematoma
* Compartment syndrome

== 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:Vascular surgery]]

Transjugular intrahepatic portosystemic shunts

2023-02-02T02:16:05Z

Jashvin: Hepatic encephalopathy

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

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

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

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

==Preoperative management==

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

===Labs and studies===

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

===Operating room setup===

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

===Patient preparation and premedication===

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

==Intraoperative management==

===Monitoring and access===

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

===Induction and airway management===

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

===Positioning===

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

===Maintenance and surgical considerations===

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

===Emergence===

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

==Postoperative management==

===Disposition===

*PACU, ICU or step down ICU as indicated

===Pain management===

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

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

Hepatic encephalopathy: failure of liver to filter toxic metabolites such as ammonia, which leads to CNS toxicity. Most sedative-hypnotics and IV induction agents serve to decrease blood flow to the liver and may result in acute accumulation of toxic metabolites which can precipitate hepatic encephalopathy. Of note, propofol has minimal effect on hepatic blood flow and predictable pharmacokinetic profile even in the setting of severe hepatic dysfunction.

==Procedure variants==

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

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

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

==References==

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

Temporal Artery Biopsy

2023-02-01T18:21:48Z

Jashvin:

{{Infobox surgical procedure
| anesthesia_type = MAC
| airway = Nasal Canual
| lines_access = PIV
| monitors = Standard
| considerations_preoperative = Shared workspace – the surgeon will be prepped and draped at roughly the ear
| considerations_intraoperative = Be careful not to break sterile field when giving jaw thrust. Both arms likely tucked
| considerations_postoperative =
}}

Temporal artery biopsy is the primary modality to diagnose giant cell arteritis / temporal arteritis.

Giant cell arteritis is a chronic vasculitis affecting medium and large diameter arteries. It predominantly affects older individuals and will affect: aortic arch vessels and branches, and external carotid artery. The clinical manifestations result from inflammation of the affected arteries or from their gradual occlusion leading to signs of arterial ischemia.

== Overview ==

=== Indications ===
Giant cell arteritis conformation

=== Surgical procedure ===
Incision is generally made overlying the superficial temporal artery at the previously chosen side and site (which can be found via doppler)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Shared workspace with surgeon. Caution when giving jaw thrust
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===
Can be done under local only.

MAC with Propofol

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard montioring

=== Induction and airway management ===

=== Positioning ===
Supine

Arms tucked

=== Maintenance and surgical considerations ===
Caution when giving jaw thrust given close proximity to surgery.

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Home (same day procedure)

=== Pain management ===
Fentanyl + local give by surgeon

=== Potential complications ===
Facial nerve injury

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|Giant Cell Arteritis
|
|-
|Position
|Supine
|
|-
|Surgical time
|30-60 minutes
|
|-
|EBL
|Minimal
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|Minimal
|
|-
|Potential complications
|Facial nerve injury
|
|}

== References ==

[[Category:Surgical procedures]]

Temporal Artery Biopsy

2023-02-01T18:19:49Z

Jashvin: Created page with "{{Infobox surgical procedure | anesthesia_type = MAC | airway = Nasal Canual | lines_access = PIV | monitors = Standard | considerations_preoperative = Shared workspace – the surgeon will be prepped and draped at roughly the ear | considerations_intraoperative = Be careful not to break sterile field when giving jaw thrust. Both arms likely tucked | considerations_postoperative = }} Temporal artery biopsy is the primary modality for establishing a diagnosis of giant c..."

{{Infobox surgical procedure
| anesthesia_type = MAC
| airway = Nasal Canual
| lines_access = PIV
| monitors = Standard
| considerations_preoperative = Shared workspace – the surgeon will be prepped and draped at roughly the ear
| considerations_intraoperative = Be careful not to break sterile field when giving jaw thrust. Both arms likely tucked
| considerations_postoperative =
}}

Temporal artery biopsy is the primary modality for establishing a diagnosis of giant cell (temporal) arteritis. Giant cell arteritis is a chronic vasculitis affecting medium and large diameter arteries, predominantly in older individuals. The aortic arch vessels and branches, and particularly branches of the external carotid artery, are most prominently affected. The clinical manifestations result from inflammation of the affected arteries or from their gradual occlusion leading to signs of arterial ischemia

== Overview ==

=== Indications ===
Giant cell arteritis conformation

=== Surgical procedure ===
Incision is generally made overlying the superficial temporal artery at the previously chosen side and site (which can be found via doppler)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Shared workspace with surgeon. Caution when giving jaw thrust
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===
Can be done under local only.

MAC with Propofol

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard montioring

=== Induction and airway management ===

=== Positioning ===
Supine

Arms tucked

=== Maintenance and surgical considerations ===
Caution when giving jaw thrust given close proximity to surgery.

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Home (same day procedure)

=== Pain management ===
Fentanyl + local give by surgeon

=== Potential complications ===
Facial nerve injury

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|30-60 minutes
|
|-
|EBL
|Minimal
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|Minimal
|
|-
|Potential complications
|Facial nerve injury
|
|}

== References ==

[[Category:Surgical procedures]]

Panniculectomy

2022-11-07T20:02:35Z

Jashvin:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 1 (18G)
| monitors = Standard, 5-lead EKG
| considerations_preoperative = Obesity
| considerations_intraoperative = Positioning, fat emboli
| considerations_postoperative = Smooth emergence with minimal bucking to minimize tension on suture line
}}

Panniculectomy is a surgery done to remove stretched out, excess fat and overhanging skin from your abdomen. This can occur after a person undergoes massive weight loss. The skin may hang down and cover your thighs and genitals. Surgery to remove this skin helps improve your health and appearance.

Panniculectomy is different from abdominoplasty. In abdominoplasty, the surgeon will remove extra fat and also tighten your abdominal (belly) muscles. Sometimes, both types of surgery are performed at the same time.

== Overview ==

=== Indications ===
Commonly done after rapid weight loss from (≥ 100lb/45kg) after bariatric surgery.

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Obesity
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|OSA
|-
|Gastrointestinal
|H/o bariatric surgery, full stomach
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard monitoring

=== Induction and airway management ===
Standard induction for healthy patients.

Consider rapid sequence intubation in obese patients, those with GI pathology or repeated abdominal surgeries.

Consider video laryngoscopy.

=== Positioning ===

=== Maintenance and surgical considerations ===
Standard maintenance.

Take care when calculating drug doses (lean body mass vs actual body mass)

=== Emergence ===
Smooth emergence. Avoid bucking to minimize tension on suture lines.

Ensure adequate PONV prophylaxis.

== Postoperative management ==

=== Disposition ===
PACU

=== Pain management ===
IV narcotics

=== Potential complications ===
Fat emboli

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|~100cc
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Panniculectomy

2022-11-07T19:49:52Z

Jashvin: Started new page on panniculectomy

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 1 (18G)
| monitors = Standard, 5-lead EKG
| considerations_preoperative = Obesity
| considerations_intraoperative = Positioning, fat emboli
| considerations_postoperative = Smooth emergence with minimal bucking to minimize tension on suture line
}}

Panniculectomy is a surgery done to remove stretched out, excess fat and overhanging skin from your abdomen. This can occur after a person undergoes massive weight loss. The skin may hang down and cover your thighs and genitals. Surgery to remove this skin helps improve your health and appearance.

Panniculectomy is different from abdominoplasty. In abdominoplasty, the surgeon will remove extra fat and also tighten your abdominal (belly) muscles. Sometimes, both types of surgery are performed at the same time.

== Overview ==

=== Indications ===
Commonly done after rapid weight loss from (≥ 100lb/45kg) after bariatric surgery.

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Obesity
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Obesity
|-
|Gastrointestinal
|H/o bariatric surgery, full stomach
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard monitoring

=== Induction and airway management ===
Standard induction for healthy patients.

Consider rapid sequence intubation in obese patients, those with GI pathology or repeated abdominal surgeries.

Consider video laryngoscopy.

=== Positioning ===

=== Maintenance and surgical considerations ===
Standard maintenance.

Take care when calculating drug doses (lean body mass vs actual body mass)

=== Emergence ===
Smooth emergence. Avoid bucking to minimize tension on suture lines.

Ensure adequate PONV prophylaxis.

== Postoperative management ==

=== Disposition ===
PACU

=== Pain management ===
IV narcotics

=== Potential complications ===
Fat emboli

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|~100cc
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Cochlear implant surgery

2022-10-31T20:14:43Z

Jashvin: Maintenance suggestions

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV
| monitors = Standard; facial nerve monitoring
| considerations_preoperative = Patients' hearing is limited
| considerations_intraoperative = Facial nerve monitoring (avoid paralytics)
| considerations_postoperative =
}}'''Cochlear implant surgery''' is a novel surgical approach to address deafness and sensorineural hearing loss. The surgery consists of implanting a cochlear implant device that resides externally and receives and processes sound, and an internal component that transmits the received sound and stimulates the cochlear nerve<ref>{{Cite journal|last=Naples|first=James G.|last2=Ruckenstein|first2=Michael J.|date=2020|title=Cochlear Implant|url=https://pubmed.ncbi.nlm.nih.gov/31677740|journal=Otolaryngologic Clinics of North America|volume=53|issue=1|pages=87–102|doi=10.1016/j.otc.2019.09.004|issn=1557-8259|pmid=31677740|via=}}</ref><ref>{{Cite journal|last=Mowry|first=Sarah E.|last2=Woodson|first2=Erika|date=2020-01-01|title=Cochlear Implant Surgery|url=https://pubmed.ncbi.nlm.nih.gov/31556929|journal=JAMA otolaryngology-- head & neck surgery|volume=146|issue=1|pages=92|doi=10.1001/jamaoto.2019.2274|issn=2168-619X|pmid=31556929}}</ref>. This surgery has been applied to post-lingual adults and prelingual children with hearing loss. Typically, during surgery, a 2-channel electrode is used to monitor the upper and lower divisions of the facial nerve. The classical approach is a posterior tympanotomy - used both for adults and children. Surgical incision is postauricular and that the cochlear implant device sits internally under the skin behind the incision usually. There is no external mechanical component of the device on the surface of the skin that can be seen immediately post-op. A suprameatal approach is reserved for patients with anatomical variations (16%).

==Preoperative management==

===Patient evaluation===
*Patients' limited hearing may impair preoperative consultation
*Investigate genetic/syndromic sources of hearing loss such as neurofibromatosis it's multi-organ pathology

===Operating room setup===
*Standard GA setup
*Consider straight connector with accordion to ETT
*Circuit extensions for 180-degree supine position

==Intraoperative management==

===Monitoring and access===
*Facial nerve monitoring
*PIV (consider 2nd IV in lower extremity with 180-degree positioning)

===Induction and airway management===
*GETA

===Positioning===
*180-degree turn (head is away from anesthesia team)
*Head positioned away from operating site.
*Surgeons may conduct frequent head position changes intraoperatively
*Surgeons frequently tilt table for adequate visualization under the microscope. Patients must be carefully strapped to table during these extreme table-tilt angles. Consider 3-4 safety straps during initial positioning

===Maintenance and surgical considerations===
* Avoid paralytics to maintain facial nerve monitoring. Consider high-depth of anesthesia or remifentanil infusion
*During microscopy, minimize patient movement
**Consider remifentanil infusion
*Consider TIVA with propofol infusion to aid in preventing PONV
*Volatile anesthetics are appropriate despite facial nerve monitoring

===Emergence===

==Postoperative management==

===Disposition===
*PACU
*Home discharge

=== Post-op considerations ===

* Patient hearing is still impaired post-op. Patients must wait weeks before external sound sensor is activated and the patient can hear
* Glasscock pressure dressing<ref>{{Cite journal|last=Levy|first=Joshua M.|last2=Johnson|first2=Bradley T.|last3=Molony|first3=Timothy B.|date=2011|title=Effectiveness of the Glasscock dressing compared to the mastoid pressure dressing in cochlear implantation|url=https://onlinelibrary.wiley.com/doi/10.1002/lary.22279|journal=The Laryngoscope|language=en|volume=121|issue=S5|pages=S323–S323|doi=10.1002/lary.22279}}</ref> remains on the patient for 2 days post-op
* Eye and lip sites from facial nerve monitor needles may cause oozing of blood or bruising

===Pain management===
*Oral narcotics
*Multi-modal, non-narcotic medications

===Potential complications===
*PONV

==Procedure variants<ref name=":0">{{Cite journal|last=Xu|first=Bai-Cheng|last2=Wang|first2=Su-Yang|last3=Liu|first3=Xiao-Wen|last4=Yang|first4=Ke-Hu|last5=Zhu|first5=Yi-Ming|last6=Chen|first6=Xing-Jian|last7=Du|first7=Wan|last8=Li|first8=Yong|last9=Chen|first9=Chi|last10=Guo|first10=Yu-Fen|date=2014|title=Comparison of Complications of the Suprameatal Approach and Mastoidectomy with Posterior Tympanotomy Approach in Cochlear Implantation: A Meta-Analysis|url=https://www.karger.com/Article/FullText/358922|journal=ORL|language=en|volume=76|issue=1|pages=25–35|doi=10.1159/000358922|issn=0301-1569}}</ref>==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Posterior
Tympanotomy
!Suprameatal
|-
| Unique considerations
|
|Positioning of the device

via the external auditory canal
|-
|Position
|
|
|-
|Surgical time
|180min
|43min
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|Facial nerve damage (1%)<ref name=":0" />
|
|}

==References==

[[Category:Surgical procedures]]

<references />

Spinal Cord Stimulator Removal

2022-10-02T00:51:25Z

Jashvin:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 1 PIV, +/- A-line
| monitors = Standard, 5-lead EKG
| considerations_preoperative =
| considerations_intraoperative = TIVA for neuromonitoring, prone positioning
| considerations_postoperative =
}}

Neuromodulatory techniques such as spinal cord stimulation (SCS) are playing an increasing role in chronic pain management. The SCS leads are placed in the dorsal epidural space, either surgically or percutaneously, and are connected to a subcutaneously implanted programmable pulse generator.

They are most commonly removed for inadequate pain relief, but can also be removed for lead migration, device damage, infection, etc.

== Overview ==

=== Indications ===

=== Surgical procedure ===
Paddle leads are larger and usually anchored to the spinal column under a small piece of bone.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Prone positioning
|-
|Neurologic
|Careful neurological exam to document preexisting deficits
|-
|Cardiovascular
|Chronic pain can lead to decreased physical activity & decreased cardiovascular reserve.
|-
|Pulmonary
|
|-
|Gastrointestinal
|Chronic opioid use may lead to decrease gastric emptying & decreased GI motility
|-
|Hematologic
|Multilevel laminectomy may be needed. Active type & screen.
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===
CBC

=== Operating room setup ===
TIVA

=== Patient preparation and premedication ===
Chronic opioid use may lead to difficulty with pain control postoperatively. Consider multimodal treatment & acute pain consult.

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
1 good IV

+/- A-line

=== Induction and airway management ===
General endotracheal anesthesia.

=== Positioning ===
Prone

=== Maintenance and surgical considerations ===
TIVA for neuromonitoring

=== Emergence ===

== Postoperative management ==

=== Disposition ===
PACU

=== Pain management ===

=== Potential complications ===
Epidural hematoma

Spinal cord injury

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
[[Category:Neurosurgery]]

Spinal Cord Stimulator Removal

2022-10-02T00:46:04Z

Jashvin: Created page with "{{Infobox surgical procedure | anesthesia_type = General | airway = ETT | lines_access = 1 PIV | monitors = Standard, 5-lead EKG | considerations_preoperative = | considerations_intraoperative = TIVA for neuromonitoring, prone positioning | considerations_postoperative = }} Neuromodulatory techniques such as spinal cord stimulation (SCS) are playing an increasing role in chronic pain management. The SCS leads are placed in the dorsal epidural space, either surgically..."

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 1 PIV
| monitors = Standard, 5-lead EKG
| considerations_preoperative =
| considerations_intraoperative = TIVA for neuromonitoring, prone positioning
| considerations_postoperative =
}}

Neuromodulatory techniques such as spinal cord stimulation (SCS) are playing an increasing role in chronic pain management. The SCS leads are placed in the dorsal epidural space, either surgically or percutaneously, and are connected to a subcutaneously implanted programmable pulse generator.

They are most commonly removed for inadequate pain relief, but can also be removed for lead migration, device damage, infection, etc.

== Overview ==

=== Indications ===

=== Surgical procedure ===
Paddle leads are larger and usually anchored to the spinal column under a small piece of bone.

== 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 ===
1 good IV

=== Induction and airway management ===
General endotracheal anesthesia.

=== Positioning ===
Prone

=== Maintenance and surgical considerations ===
TIVA for neuromonitoring

=== Emergence ===

== Postoperative management ==

=== Disposition ===
PACU

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]
[[Category:Neurosurgery]]

Closure of enteric fistula

2022-07-22T11:48:10Z

Jashvin: Added basic info about the case & setup

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = 20G IV+
| monitors = Standard, 5-lead EKG
| considerations_preoperative = Possible SBO, Full stomach considerations
| considerations_intraoperative =
| considerations_postoperative = NG decompression until bowel function returns
}}

Enteric Fistulae can occur between the bowel and adjacent tissue including but not limited to: abdominal wall, loops of intestine (enteroenteric, enterocolic), enterovesical, enterovaginal. Surgical repair involves excision of the fistula and separating the organs.

With optimal nonoperative management a fistula may heal spontaneously, the majority within the first 4 weeks after development. Definitive surgical treatment is best achieved with resection of the bowel containing the fistula and anastomosis of healthy normal bowel. The timing of definitive surgery appears to be optimal months after development, if tolerated. Death rates are low after surgery and patients who experience the recurrence of a fistula after initial attempt at closure can ultimately still be cured. <ref>{{Cite journal|last=Ross|first=Howard|date=2010-09|title=Operative Surgery for Enterocutaneous Fistula|url=http://www.thieme-connect.de/DOI/DOI?10.1055/s-0030-1262987|journal=Clinics in Colon and Rectal Surgery|language=en|volume=23|issue=03|pages=190–194|doi=10.1055/s-0030-1262987|issn=1531-0043|pmc=PMC2967319|pmid=21886469}}</ref>

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|General Endotracheal Anesthesia
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|Malnutrition, dehydration
Consider full stomach.

NG decompression until return of bowel function post op
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|Etiology: can be due to carcinoma
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===
Standard setup with 1 good IV

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard monitoring

1 good IV

=== Induction and airway management ===
Possible SBO and full stomach precautions with Rapid Sequence Intubation to prevent pulmonary aspiration.

Patient may be hypovolemic from lack of nutritional support, consider volume load prior to or after induction.

=== Positioning ===
Supine

Lithotomy access to the anus is helpful

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Inpatient

=== Pain management ===
IV vs Epidural analgesia

=== Potential complications ===
Sepsis

Ileus

PONV

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|50-200cc
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Percutaneous nephrolithotomy or nephrolithotripsy

2022-07-14T19:01:15Z

Jashvin: New page on Percutaneous Nephrolithotomy /Nephrolithotripsy

'''<big>Percutaneous Nephrolithotomy, Nephrolithotriopsy</big>'''

{{Infobox surgical procedure
| anesthesia_type = General
| airway = LMA or ETT
| lines_access = 20G+ IV
| monitors = Standard, 5-lead EKG
| considerations_preoperative =
| considerations_intraoperative = Lateral positioning
| considerations_postoperative =
}}

Provide a brief summary here.

==Overview==

===Indications===
These procedures are treatments for kidney stones that are used in patients with large or irregularly shaped kidney stones, people with infections, stones that have not been broken up enough by SWL (extracorporeal shock wave lithotripsy) or those who are not candidates for another common stone treatment, ureteroscopy. Stones that are bigger than 2 cm (the size of a marble) require this procedure.<ref name=":0">{{Cite web|date=2016-01-07|title=Percutaneous Nephrolithotomy /Nephrolithotripsy|url=https://www.kidney.org/atoz/content/kidneystones_PNN|access-date=2022-07-14|website=National Kidney Foundation|language=en-US}}</ref>

This is what the words mean:

*Percutaneous means through the skin
*Nephrolithotomy is a combination of the word roots nephro- (kidney), litho-(stone), and -tomy (removal)
*Nephrolithotripsy is a combination of the word roots nephro- (kidney), litho (stone), and -tripsy (crushed)<ref name=":0" />

===Surgical procedure===
Both procedures involve entering the kidney through a small incision in the back. Once the surgeon gets to the kidney, a nephroscope (a miniature fiberoptic camera) and other small instruments are threaded in through the hole. lf the stone is removed through the tube, it is called nephrolithotomy. lf the stone is broken up and then removed, it is called nephrolithotripsy. The surgeon can see the stone, use high frequency sound waves to break up the stone, and "vacuum" up the dust using a suction machine.<ref name=":0" />

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|LMA vs ETT. Consider positioning, BMI, pulmonary physiology
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===

===Operating room setup===
Standard setup with 1 IV

===Patient preparation and premedication===

===Regional and neuraxial techniques===

==Intraoperative management==

===Monitoring and access===
Standard monitoring

1 good IV

===Induction and airway management===
Consider ETT > LMA based on patient position and case length

===Positioning===
Sloppy Lateral

===Maintenance and surgical considerations===
Adequate depth to prevent bucking if in lithotomy

===Emergence===

==Postoperative management==

===Disposition===
Outpatient vs inpatient

===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]]
<references />