WikiAnesthesia - User contributions [en]

General OR

2024-01-17T01:23:45Z

Jchen900: Replaced content with "*"

General OR

2024-01-17T01:23:12Z

Jchen900: Created page with "OR Setup: MS MAIDES M: Machine check (Check leaks, vaporizers filled) S: Suction (On and within reach) M: Monitors (EKG, pulse ox, BP cuff, EtCO2, temp) A: Airway (Laryngoscope, ETT, oral airway) I: IV equipment (Manifold tubing with stop cocks, start kit) # D: Drugs # E: Emergency (Ambu bag, O2 tank, code drugs) S: Special (Central line, arterial line, etc.) Emergency Trauma Room Setup: ● As per MS MAIDES, but also: * ○ A-line set up/wet and zeroed *..."

OR Setup:

MS MAIDES

M: Machine check (Check leaks, vaporizers filled) S: Suction (On and within reach)

M: Monitors (EKG, pulse ox, BP cuff, EtCO2, temp) A: Airway (Laryngoscope, ETT, oral airway)

I: IV equipment (Manifold tubing with stop cocks, start kit)

# D: Drugs
# E: Emergency (Ambu bag, O2 tank, code drugs)

S: Special (Central line, arterial line, etc.)

Emergency Trauma Room Setup:

● As per MS MAIDES, but also:

* ○ A-line set up/wet and zeroed
* ○ IVF warmer set up and wet
* ○ Level 1 (rapid transfuser) checked and ready (dry)
* ○ Drugs (must be ready): ■ 10 mL Phenylephrine (100 mcg/mL) x 1-2 ■ 10 mL Epinephrine (10 mcg/mL) x1 ■ 10 (9) mL Epinephrine (100 mcg/mL) x1 ■ 10 mL Rocuronium (10 mg/mL) x1 ■ 10 mL Succinylcholine (20 mg/mL) x1 ■ 2.5 mL Atropine (0.4mg/mL) x1

Off-pump and minimally invasive coronary artery bypass grafting

2023-12-20T01:41:17Z

Jchen900:

{{Infobox surgical procedure
| anesthesia_type = General +/- epidural
| airway = DLT, L sided
| lines_access = Large bore PIVs, central line, arterial line
| monitors = Standard, 5-Lead ECG, arterial line, +/- TEE
| considerations_preoperative = Known coronary artery disease
| considerations_intraoperative = DLT, ischemic preconditioning, temporary occlusion
| considerations_postoperative = Pain control
}}

Off pump coronary artery bypass grafting is a term that applies to all cases of coronary revascularization without the need of cardiopulmonary bypass. Minimally invasive coronary artery bypass grafting is a sub-type of off pump coronary artery bypass that is performed through a small thoracotomy incision. The ideal candidate for this technique is hemodynamically stable, normal ejection fraction, no previous cardiac surgery, no history of severe pulmonary conditions, and non-obese<ref>{{Cite journal|last=Patel|first=Amit N.|last2=Benetti|first2=Federico|last3=Hamman|first3=Baron|date=2003-07|title=Patient Selection and Technical Considerations for Off-Pump Coronary Surgery|url=https://www.tandfonline.com/doi/full/10.1080/08998280.2003.11927916|journal=Baylor University Medical Center Proceedings|language=en|volume=16|issue=3|pages=291–293|doi=10.1080/08998280.2003.11927916|issn=0899-8280}}</ref><ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2014|isbn=978-1-4511-7660-5}}</ref>. In the mid-1990s, this technique gained interest as a way to avoid the postoperative complications associated with cardiopulmonary bypass including systemic inflammatory response, cerebral dysfunction, renal dysfunction, bleeding, myocardial depression, and hemodynamic instability<ref>{{Cite journal|last=Shroyer|first=A. Laurie|last2=Grover|first2=Frederick L.|last3=Hattler|first3=Brack|last4=Collins|first4=Joseph F.|last5=McDonald|first5=Gerald O.|last6=Kozora|first6=Elizabeth|last7=Lucke|first7=John C.|last8=Baltz|first8=Janet H.|last9=Novitzky|first9=Dimitri|date=2009-11-05|title=On-Pump versus Off-Pump Coronary-Artery Bypass Surgery|url=http://www.nejm.org/doi/abs/10.1056/NEJMoa0902905|journal=New England Journal of Medicine|language=en|volume=361|issue=19|pages=1827–1837|doi=10.1056/NEJMoa0902905|issn=0028-4793}}</ref><ref>{{Cite journal|last=Hemmerling|first=ThomasM|last2=Romano|first2=Gianmarco|last3=Terrasini|first3=Nora|last4=Noiseux|first4=Nicolas|date=2013|title=Anesthesia for off-pump coronary artery bypass surgery|url=https://journals.lww.com/10.4103/0971-9784.105367|journal=Annals of Cardiac Anaesthesia|language=en|volume=16|issue=1|pages=28|doi=10.4103/0971-9784.105367|issn=0971-9784}}</ref>.

==Preoperative management==

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

===Labs and studies===

=== Operating room setup===

===Patient preparation and premedication===

===Regional and neuraxial techniques===

==Intraoperative management==

===Monitoring and access===

===Induction and airway management===

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management ==

===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

Lung transplant

2023-10-01T16:49:08Z

Jchen900:

{{Infobox surgical procedure
| anesthesia_type = GA +/- epidural
| airway = DLT, left sided
| lines_access = large bore IVs, central access (volume and infusion lines)
| monitors = Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath
| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
| considerations_postoperative = ICU, generally remain intubated
}}

A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

== Preoperative management ==

=== Patient evaluation<ref>{{Cite journal|last=Murray|first=Andrew W.|last2=Boisen|first2=Michael L.|last3=Fritz|first3=Ashley|last4=Renew|first4=J. Ross|last5=Martin|first5=Archer Kilbourne|date=2021-11|title=Anesthetic considerations in lung transplantation: past, present and future|url=https://pubmed.ncbi.nlm.nih.gov/34992834|journal=Journal of Thoracic Disease|volume=13|issue=11|pages=6550–6563|doi=10.21037/jtd-2021-10|issn=2072-1439|pmc=8662503|pmid=34992834}}</ref><ref name=":0" />===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Right to left intracardiac shunting can cause strokes.
|-
|Cardiovascular
|
* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref name=":0">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2009|isbn=978-1-4511-7660-5}}</ref>
* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
|-
|Pulmonary
|
* May be on high oxygen/ventilatory requirement prior to procedure.
*6 minute walk test can be another useful tool to assess disease severity
|-
|Gastrointestinal
|
* Obesity is a contraindication for transplantation (Class II-III obesity is considered to be absolute contraindication).
* Many patients are underweight and present with sarcopenia.
|-
|Hematologic
|
* Polycythemia in setting of chronic hypoxia.
|-
|Renal
|
* Renal dysfunction is prevalent. Preoperative etiologies include hypotension, decreased cardiac output, hypoxemia, and nephrotoxic medications (antibiotics, calcinurin inhibitors).
* Presence of renal dysfunction is a determinant of post-transplant survival.
|-
| colspan="2" |
|}

=== Labs and studies ===

* Cardiac studies: ECG, ECHO, RHC, LHC
* Pulmonary studies: PFTs, CT Chest, V/Q scan
* Labs: Type and screen, complete blood count, chemistry panel, coagulation panel, thromboelastography

=== Operating room setup ===

* Vasopressors/Inotropes Infusions: epinephrine, vasopressin, phenylephrine, norepinephrine
* Additional infusions: insulin, +/- mannitol
* Antibiotics (institutional specific): vancomycin (1gm, 1.5gm for >90kg), posaconazole 300mg, ceftazidime 1-2gm
* Inhaled vasodilators: epoprostenol vs nitric oxide
* ICU ventilator (may be required prior to transplant if concerns for high ventilator pressures)
* TIVA setup after transition to ICU ventilator
* Crossmatched blood products
*Heparin, TXA, and protamine (if going on pump)

=== Patient preparation and premedication ===

* Immunosuppressants (institutional specific): myophenolate 1000mg IV, azathioprine 2mg/kg IV, basilixamab 20mg IV, tacrolimus 1mg sublingual
** Methylprednisolone 500mg IV usually given prior to reperfusion

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Cardiac monitoring: TEE, +/- continuous cardiac output monitoring
* Neuromonitoring: +/- sedline, cerebral ox
* Lines: large bore IVs, central lines x 1-2 (consider MAC or Cordis), +/- PA catheter, arterial line x 1-2, foley
* Fiberoptic scope
* Temperature probe: peripheral and central (both required if going on bypass)

=== Induction and airway management ===

* ETT: left sided double lumen if off bypass, single lumen if on bypass

=== Positioning ===

* For single lung: supine, lateral decubitus
* For double lung: supine

=== Maintenance and surgical considerations ===

* Before reperfusion:
** PA clamping: may increase PAP leading to RV dysfunction
** May need to give methylprednisolone 500mg IV prior to reperfusion of each lung
* Reperfusion:
** Watch for hemodynamic instability. If off bypass, have low dose (10-16mcg/ml) and high dose (100mcg/ml) epinephrine ready.
** Give mannitol 25mg
** In line suction for new lung
** Inflate lungs with Ambu during direct visualization

=== Emergence ===
Transported to ICU intubated.

== Postoperative management ==

=== Disposition ===
Transported to ICU intubated.

=== Pain management ===

* Thoracic epidural catheter
* Parenteral narcotics

== Potential complications ==

=== Primary Graft Dysfunction (PGD)<ref>{{Cite journal|last=Potestio|first=Christopher|last2=Jordan|first2=Desmond|last3=Kachulis|first3=Bessie|date=2017-06|title=Acute postoperative management after lung transplantation|url=http://dx.doi.org/10.1016/j.bpa.2017.07.004|journal=Best Practice & Research Clinical Anaesthesiology|volume=31|issue=2|pages=273–284|doi=10.1016/j.bpa.2017.07.004|issn=1521-6896}}</ref> ===
Primary graft dysfunction (PGD) is a form of acute lung injury that occurs in the immediate postoperative period. It is associated with 30% of all deaths in the immediate postoperative period. The characteristics of PGD are similar to ARDS and as follows:

* Hypoxemia with pulmonary infiltrates in absence of left heart failure
* New diagnosis of pulmonary hypertension in immediate postoperative period
* Otherwise unexplained respiratory failure

There are many independent risk factors for PGD including (many of these are modifiable risk factors):

* Overweight and obesity
* Preoperative pulmonary hypertension or sarcoidosis
* Use of cardiopulmonary bypass
* Single lung transplantation
* Increased FiO2 during allograft reperfusion
* Blood products administered during surgery
* Donor age less than 21 or greater than 45 years old, female gender, smoker, and African American in origin

Treatment for PGD consists of lung protective ventilation, similar to ARDS. Pulmonary vasodilators such as iNO and Iloprost have been used. Severe cases may require ECMO support.

=== Atrial Arrhythmias ===

=== Gastroesophageal Reflux ===

=== Acute Renal Insufficiency ===

=== Infection ===

=== Thromboembolic Events ===

=== Surgical Nerve Injury ===

=== Acute Allograft Rejection ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!On Pump BOLT
!Off Pump BOLT
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Transphenoidal resection of pituitary tumor

2023-09-08T00:53:21Z

Jchen900:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 2
Arterial line
| monitors = Standard ASA
5-lead EKG
Core temp
UOP
± EEG
| considerations_preoperative = Characterize baseline neurologic deficits (i.e., visual field defects)
Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted
| considerations_intraoperative = Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding
Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation
| considerations_postoperative = PONV prophylaxis
Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)
}}

A '''transphenoidal resection of pituitary tumor''' is a neurosurgical procedure performed through an intranasal exposure to remove tissue from the sella turica.

==Overview==

* Most pituitary tumors are benign adenomas<ref>{{Cite web|date=2022-05-23|title=Pituitary Tumors Treatment (PDQ®)–Health Professional Version - NCI|url=https://www.cancer.gov/types/pituitary/hp/pituitary-treatment-pdq|access-date=2022-09-19|website=www.cancer.gov|language=en}}</ref>
** Only 0.1-0.2% malignant carcinomas
* Approximately 35% are invasive into adjacent bony and/or vascular structures
* Approximately 75% of tumors are functional (hormone-secreting)<ref name=":0">{{Cite book|last=Reddy|first=SS|url=https://www.worldcat.org/oclc/234428919|title=The Cleveland Clinic Foundation intensive review of internal medicine|last2=Hamrahian|first2=AH|date=2009|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|others=James K. Stoller, Franklin A. Michota, Brian F. Mandell, Cleveland Clinic Foundation|isbn=978-0-7817-9079-6|edition=5|location=Philadelphia|chapter=Pituitary Disorders and Multiple Endocrine Neoplasia Syndromes|oclc=234428919}}</ref>
* Mass effect of tumor can lead to decreased secretion of one or more pituitary hormones and other neurologic deficiencies

===Indications===
*Resection of pituitary tumor
===Surgical procedure===

* Performed via a transphenoidal approach through the nares

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
*ACTH or GH secreting tumors may lead to airway abnormalities
*GH: macroglossia, enlarged epiglottis, RLN palsy, subglottic stenosis, enlarged nasal turbinates
|-
|Neurologic
|
*Baseline neuro exam
*GH prone to peripheral neuropathies.
|-
|Cardiovascular
|
*Hyperthyroid patients may have ECG abnormalities
*GH pts may have HTN, LVH, diastolic dysfunction, arrhythmias, CAD
|-
|Renal
|
*Preoperative diabetes insipidus
|-
|Endocrine
|
*Identify and treat (if needed) pituitary hormone abnormalities (see below)
|}

====Tumor anatomy====

*Classified based upon size/structural invasion<ref>{{Cite journal|last=Asa|first=S. L.|last2=Ezzat|first2=S.|date=1998|title=The cytogenesis and pathogenesis of pituitary adenomas|url=https://pubmed.ncbi.nlm.nih.gov/9861546|journal=Endocrine Reviews|volume=19|issue=6|pages=798–827|doi=10.1210/edrv.19.6.0350|issn=0163-769X|pmid=9861546}}</ref>
**Stage I: Microadenoma (<1 cm)
**Stage II: Macroadenoma (≥1 cm)
**Stage III: Macroadenoma with invasion
**Stage IV: Destruction of the sella
*Mass effect can directly compress neurologic structures
**Visual field defects (classically bitemporal hemianopsia)
**Eye movement deficits (CN III more common than CN VI)
**Elevated ICP rare (secondary to obstructive hydrocephalus)
*Invasion into adjacent structures
**Bone
***Skull base
***Sphenoid
**Vascular
***Cavernous sinus
***Carotid artery
*Tumor can be hemorrhagic and/or necrotic

====Endocrine abnormalities====

*Pituitary tumors can be classified as functional (hormone-secreting) or nonfunctional (not hormone-secreting)
**Prolactin > GH > ACTH > LH/FSH > TSH<ref name=":0" />
*Endocrine deficiencies from mass effect
**GH > LH/FSH > TSH > ACTH > Prolactin
**Panhypopituitarism possible
**Posterior pituitary deficiencies less common (ADH, oxytocin)

=== Labs and studies===

* Brain MRI
** Review imaging to evaluate structural invasion
*** Invasion into cavernous sinus and/or enveloping carotid artery higher risk for bleeding

===Operating room setup===

===Patient preparation and premedication===

*Versed
*Consider aprepitant 40 mg PO for PONV prophylaxis

==Intraoperative management==

===Monitoring and access===

*PIV x 2 (20g for drips, 18g+ for bolus)
*Arterial line

*If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.

=== Induction and airway management===

* Standard induction
**Propofol
**Short acting opioid vs beta blocker
***Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
**Rocuronium
***Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
*ETT with straight connector
**Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.
**GH: glottic opening may be very distal, traditional ETT may not be long enough, consider MLT 6.0mm

===Positioning===

*180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
*Supine
*Arms tucked
** Additional IV access site options: saphenous veins

===Maintenance and surgical considerations===

*Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)
* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
*± Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
*No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
*Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.
* ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension
*Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection
*As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested remifentanil gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
*Consider short-to-intermediate acting BB (i.e, esmolol, labetalol) for HTN/stimulation not controlled by remifentanil bolus/gtt. HTN will worsen bleeding during ENT portion.
*Surgeons will ask for Valsalva during the case.
*Note down when throat pack is placed in and taken out during case.
*Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection

=== Emergence===

*Pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
* Paralytic reversal (if used).
*Spin back to neutral (particularly, if solo).
*Smooth awake extubation (i.e., remifentanil wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.
*Avoid positive pressure masking after extubation.

=== Potential Modalities of Neuromonitoring<ref>{{Cite journal|last=Singh|first=Harminder|last2=Vogel|first2=Richard W.|last3=Lober|first3=Robert M.|last4=Doan|first4=Adam T.|last5=Matsumoto|first5=Craig I.|last6=Kenning|first6=Tyler J.|last7=Evans|first7=James J.|date=2016|title=Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide|url=https://pubmed.ncbi.nlm.nih.gov/27293965|journal=Scientifica|volume=2016|pages=1751245|doi=10.1155/2016/1751245|issn=2090-908X|pmc=4886091|pmid=27293965}}</ref> ===
{| class="wikitable"
|+
!Surgical Approach
!Potential IONM Modalities
!Common Pathologies
|-
|Transsphenoidal to sella
|None
|Adenoma, Rathke's cleft cyst
|-
|Transsphenoidal, transplanum, transtuberculum to suprasellar region
|EEG, SSEPs, MEPs
|Meningioma, craniopharyngioma, giant piutitary adenomas
|-
|Transsphenoidal to orbital apex
|EEG, SSEPs, MEPs, EMG (CN III, IV, VI)
|Hemangioma, meningioma, neoplasm
|}

==Postoperative management ==

===Disposition===

*PACU

===Pain management===

* Tylenol IV
*Fentanyl (be judicious) as surgeons will likely want a good neuro exam post-op.

===Potential complications===

*Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
**Important to monitor intraop and post-op urinary output.

==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:Neurosurgery]]

<references />

Lung transplant

2023-09-04T20:03:45Z

Jchen900:

{{Infobox surgical procedure
| anesthesia_type = GA +/- epidural
| airway = DLT, left sided
| lines_access = large bore IVs, central access (volume and infusion lines)
| monitors = Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath
| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
| considerations_postoperative = ICU, generally remain intubated
}}

A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

== Preoperative management ==

=== Patient evaluation<ref>{{Cite journal|last=Murray|first=Andrew W.|last2=Boisen|first2=Michael L.|last3=Fritz|first3=Ashley|last4=Renew|first4=J. Ross|last5=Martin|first5=Archer Kilbourne|date=2021-11|title=Anesthetic considerations in lung transplantation: past, present and future|url=https://pubmed.ncbi.nlm.nih.gov/34992834|journal=Journal of Thoracic Disease|volume=13|issue=11|pages=6550–6563|doi=10.21037/jtd-2021-10|issn=2072-1439|pmc=8662503|pmid=34992834}}</ref><ref name=":0" />===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Right to left intracardiac shunting can cause strokes.
|-
|Cardiovascular
|
* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref name=":0">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2009|isbn=978-1-4511-7660-5}}</ref>
* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
|-
|Pulmonary
|
* May be on high oxygen/ventilatory requirement prior to procedure.
*6 minute walk test can be another useful tool to assess disease severity
|-
|Gastrointestinal
|
* Obesity is a contraindication for transplantation (Class II-III obesity is considered to be absolute contraindication).
* Many patients are underweight and present with sarcopenia.
|-
|Hematologic
|
* Polycythemia in setting of chronic hypoxia.
|-
|Renal
|
* Renal dysfunction is prevalent. Preoperative etiologies include hypotension, decreased cardiac output, hypoxemia, and nephrotoxic medications (antibiotics, calcinurin inhibitors).
* Presence of renal dysfunction is a determinant of post-transplant survival.
|-
| colspan="2" |
|}

=== Labs and studies ===

* Cardiac studies: ECG, ECHO, RHC, LHC
* Pulmonary studies: PFTs, CT Chest, V/Q scan
* Labs: Type and screen, complete blood count, chemistry panel, coagulation panel, thromboelastography

=== Operating room setup ===

* Vasopressors/Inotropes Infusions: epinephrine, vasopressin, phenylephrine, norepinephrine
* Additional infusions: insulin, +/- mannitol
* Antibiotics (institutional specific): vancomycin (1gm, 1.5gm for >90kg), posaconazole 300mg, ceftazidime 1-2gm
* Inhaled vasodilators: epoprostenol vs nitric oxide
* ICU ventilator (may be required prior to transplant if concerns for high ventilator pressures)
* TIVA setup after transition to ICU ventilator
* Crossmatched blood products
*Heparin, TXA, and protamine (if going on pump)

=== Patient preparation and premedication ===

* Immunosuppressants (institutional specific): myophenolate 1000mg IV, azathioprine 2mg/kg IV, basilixamab 20mg IV, tacrolimus 1mg sublingual
** Methylprednisolone 500mg IV usually given prior to reperfusion

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Cardiac monitoring: TEE, +/- continuous cardiac output monitoring
* Neuromonitoring: +/- sedline, cerebral ox
* Lines: large bore IVs, central lines x 1-2 (consider MAC or Cordis), +/- PA catheter, arterial line x 1-2, foley
* Fiberoptic scope
* Temperature probe: peripheral and central (both required if going on bypass)

=== Induction and airway management ===

* ETT: left sided double lumen if off bypass, single lumen if on bypass

=== Positioning ===

* For single lung: supine, lateral decubitus
* For double lung: supine

=== Maintenance and surgical considerations ===

* Before reperfusion:
** PA clamping: may increase PAP leading to RV dysfunction
** May need to give methylprednisolone 500mg IV prior to reperfusion of each lung
* Reperfusion:
** Watch for hemodynamic instability. If off bypass, have low dose (10-16mcg/ml) and high dose (100mcg/ml) epinephrine ready.
** Give mannitol 25mg
** In line suction for new lung
** Inflate lungs with Ambu during direct visualization

=== Emergence ===
Transported to ICU intubated.

== Postoperative management ==

=== Disposition ===
Transported to ICU intubated.

=== Pain management ===

* Thoracic epidural catheter
* Parenteral narcotics

=== Potential complications ===

* RV dysfunction/failure
* Rejection
* Infection
* Pulmonary edema

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!On Pump BOLT
!Off Pump BOLT
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Lung transplant

2023-08-31T01:21:48Z

Jchen900:

{{Infobox surgical procedure
| anesthesia_type = GA +/- epidural
| airway = DLT, left sided
| lines_access = large bore IVs, central access (volume and infusion lines)
| monitors = Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath
| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
| considerations_postoperative = ICU, generally remain intubated
}}

A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

== Preoperative management ==

=== Patient evaluation<ref>{{Cite journal|last=Murray|first=Andrew W.|last2=Boisen|first2=Michael L.|last3=Fritz|first3=Ashley|last4=Renew|first4=J. Ross|last5=Martin|first5=Archer Kilbourne|date=2021-11|title=Anesthetic considerations in lung transplantation: past, present and future|url=https://pubmed.ncbi.nlm.nih.gov/34992834|journal=Journal of Thoracic Disease|volume=13|issue=11|pages=6550–6563|doi=10.21037/jtd-2021-10|issn=2072-1439|pmc=8662503|pmid=34992834}}</ref><ref name=":0" />===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Right to left intracardiac shunting can cause strokes.
|-
|Cardiovascular
|
* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref name=":0">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2009|isbn=978-1-4511-7660-5}}</ref>
* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
|-
|Pulmonary
|
* May be on high oxygen/ventilatory requirement prior to procedure.
|-
|Gastrointestinal
|
* Obesity is a contraindication for transplantation (Class II-III obesity is considered to be absolute contraindication).
* Many patients are underweight and present with sarcopenia.
|-
|Hematologic
|
* Polycythemia in setting of chronic hypoxia.
|-
|Renal
|
* Renal dysfunction is prevalent. Preoperative etiologies include hypotension, decreased cardiac output, hypoxemia, and nephrotoxic medications (antibiotics, calcinurin inhibitors).
* Presence of renal dysfunction is a determinant of post-transplant survival.
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Cardiac studies: ECG, ECHO, RHC, LHC
* Pulmonary studies: PFTs, CT Chest, V/Q scan
* Labs: Type and screen, complete blood count, chemistry panel, coagulation panel, thromboelastography

=== Operating room setup ===

* Vasopressors/Inotropes Infusions: epinephrine, vasopressin, phenylephrine, norepinephrine
* Additional infusions: insulin, +/- mannitol
* Antibiotics (institutional specific): vancomycin (1gm, 1.5gm for >90kg), posaconazole 300mg, ceftazidime 1-2gm
* Inhaled vasodilators: epoprostenol vs nitric oxide
* ICU ventilator (may be required prior to transplant if concerns for high ventilator pressures)
* TIVA setup after transition to ICU ventilator
* Crossmatched blood products
*Heparin, TXA, and protamine (if going on pump)

=== Patient preparation and premedication ===

* Immunosuppressants (institutional specific): myophenolate 1000mg IV, azathioprine 2mg/kg IV, basilixamab 20mg IV, tacrolimus 1mg sublingual
** Methylprednisolone 500mg IV usually given prior to reperfusion

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Cardiac monitoring: TEE, +/- continuous cardiac output monitoring
* Neuromonitoring: +/- sedline, cerebral ox
* Lines: large bore IVs, central lines x 1-2 (consider MAC or Cordis), +/- PA catheter, arterial line x 1-2, foley
* Fiberoptic scope
* Temperature probe: peripheral and central (both required if going on bypass)

=== Induction and airway management ===

* ETT: left sided double lumen if off bypass, single lumen if on bypass

=== Positioning ===

* For single lung: supine, lateral decubitus
* For double lung: supine

=== Maintenance and surgical considerations ===

* Before reperfusion:
** PA clamping: may increase PAP leading to RV dysfunction
** May need to give methylprednisolone 500mg IV prior to reperfusion of each lung
* Reperfusion:
** Watch for hemodynamic instability. If off bypass, have low dose (10-16mcg/ml) and high dose (100mcg/ml) epinephrine ready.
** Give mannitol 25mg
** In line suction for new lung
** Inflate lungs with Ambu during direct visualization

=== Emergence ===
Transported to ICU intubated.

== Postoperative management ==

=== Disposition ===
Transported to ICU intubated.

=== Pain management ===

* Thoracic epidural catheter
* Parenteral narcotics

=== Potential complications ===

* RV dysfunction/failure
* Rejection
* Infection
* Pulmonary edema

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!On Pump BOLT
!Off Pump BOLT
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Double-lumen endotracheal tube

2023-08-20T15:23:23Z

Jchen900:

{{Infobox surgical case reference
| anesthesia_type = Thoracic surgery
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative = Hypoxemia
Misplacement
Inadvertent airway suturing
Airway perforation
| considerations_postoperative = Traumatic Laryngitis
Vocal cord palsy
Tracheal irritation
}}

A double-lumen endotracheal tube (DLT) is an airway device that is commonly used to facilitate one-lung ventilation strategy in [[thoracic surgery]], lung transplantation, or infection and trauma management of a single lung.

== Indications<ref name=":0">{{Cite journal|last=Hao|first=David|last2=Saddawi-Konefka|first2=Daniel|last3=Low|first3=Sarah|last4=Alfille|first4=Paul|last5=Baker|first5=Keith|date=2021-10-14|editor-last=Ingelfinger|editor-first=Julie R.|title=Placement of a Double-Lumen Endotracheal Tube|url=http://www.nejm.org/doi/10.1056/NEJMvcm2026684|journal=New England Journal of Medicine|language=en|volume=385|issue=16|pages=e52|doi=10.1056/NEJMvcm2026684|issn=0028-4793}}</ref> ==

* Hemorrhage and infected abscess/spillage in a single lung requiring isolation
* Controlled distributed ventilation for surgery
* Bronchopleural fistula, large lung bulla and or cysts
* Tracheobronchial disruption
* Single-lung lavage for pulmonary alveolar proteinosis

== Contraindications ==

* Known difficult airway
* Tracheal stenosis
* Airway distortion, lesions, masses that would preclude safe placement (e.g. tumors, airway strictures)
*Presence of right upper bronchus takeoff above the carina (colloquially known as "pig bronchus") is an absolute contraindication for use of right sided DLTs

== Setup ==

=== Operating room setup ===

* DLT with appropriately chosen size
* Laryngoscope (video or direct laryngoscope)
* Syringes 3mL (bronchial cuff) and 10mL (tracheal cuff)
* Fiberoptic bronchoscope for confirming post-placement position
* Consider tooth guard to prevent shearing tracheal balloon during placement
*Water based lubricant applied to outside of ETT to facilitate placement (optional)

=== Tube Selection Selection ===

* Most single-lung ventilation procedures can be accomplished with a left-sided DLT
* Right DLT indications
** Left pneumonectomy
** Left lung transplant
** Trauma to the left mainstem bronchus<ref name=":1">{{Cite journal|last=Pedoto|first=Alessia|date=2012-12|title=How to choose the double-lumen tube size and side: the eternal debate|url=https://pubmed.ncbi.nlm.nih.gov/23089502|journal=Anesthesiology Clinics|volume=30|issue=4|pages=671–681|doi=10.1016/j.anclin.2012.08.001|issn=1932-2275|pmid=23089502}}</ref>
** Left tracheobronchial repair
** Consider for left thoracoscopic lung procedures (can be accomplished with L-DLT as well)

==== Tube Size Selection ====
Several sources of literature help anesthesiologists choose the correct size DLT:

# Pedoto (2012)<ref name=":1" />
# Brodsky et al. (1999)<ref>{{Cite journal|last=Brodsky|first=J. B.|last2=Fitzmaurice|first2=B. G.|last3=Macario|first3=A.|date=1999-02|title=Selecting double-lumen tubes for small patients|url=https://pubmed.ncbi.nlm.nih.gov/9972778|journal=Anesthesia and Analgesia|volume=88|issue=2|pages=466–467|doi=10.1097/00000539-199902000-00049|issn=0003-2999|pmid=9972778}}</ref>
# Hao etl al. (2021)<ref name=":0" />

== Complications ==

* Laryngitis
* Tracheal irritation
* Vocal cord palsy
* Airway rupture or perforation (<1% total incidence<ref>{{Cite journal|last=Fitzmaurice|first=B. G.|last2=Brodsky|first2=J. B.|date=1999-06|title=Airway rupture from double-lumen tubes|url=https://pubmed.ncbi.nlm.nih.gov/10392687|journal=Journal of Cardiothoracic and Vascular Anesthesia|volume=13|issue=3|pages=322–329|doi=10.1016/s1053-0770(99)90273-2|issn=1053-0770|pmid=10392687}}</ref>): trachea (52.4%) and left main bronchus (37.4%) are the most common sites<ref>{{Cite journal|last=Liu|first=Shiqing|last2=Mao|first2=Yuqiang|last3=Qiu|first3=Peng|last4=Faridovich|first4=Khasanov Anvar|last5=Dong|first5=Youjing|date=2020-11|title=Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases|url=https://pubmed.ncbi.nlm.nih.gov/33079871|journal=Anesthesia and Analgesia|volume=131|issue=5|pages=1485–1490|doi=10.1213/ANE.0000000000004669|issn=1526-7598|pmid=33079871}}</ref>

== Technical Specifications ==

== References ==

[[Category:Surgical procedures]]

Nasal intubation

2023-08-16T22:11:39Z

Jchen900:

'''Nasal intubation''' is an approach to [[endotracheal intubation]] often used to increase intraoral exposure during head & neck surgery.

== Indications==
*Transoral robotic surgery
*Maxillofacial surgery
*Dental surgery
* Restricted mouth opening
*Cervical spine instability
*Lower facial trauma
*Structural abnormalities that preclude oral intubation

==Contraindications==

* Severe bleeding diathesis
*Anticoagulation
* Basilar skull fractures
**Advancing a nasal tube in a patient with a basilar skull fracture risks penetration into the brain.<ref name=":0">{{Cite journal|last=Hall|first=C. E. J.|last2=Shutt|first2=L. E.|date=2003|title=Nasotracheal intubation for head and neck surgery|url=https://pubmed.ncbi.nlm.nih.gov/12603455|journal=Anaesthesia|volume=58|issue=3|pages=249–256|doi=10.1046/j.1365-2044.2003.03034.x|issn=0003-2409|pmid=12603455|via=}}</ref>

==Patient evaluation==
A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />

==Preparation of Nasal Mucosa==

===Topical anesthesia and vasoconstriction===
Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%. If topical anesthesia is also desirable, lidocaine 3-4% (with phenylephrine 0.25-1%) or cocaine 4-10% may also be used.<ref name=":0" /> Prepare for any potential hemodynamic effects from systemic absorption of the drugs and/or additives used.

Consider, alternatively mixing small but equal amounts of 0.2mg glycopyrrolate, with 100mcg /cc phenylephrine, which should balance out heart rate perturbations during induction. Spray 2-3 cc of each onto 4X4, and add lubricant.

===Mechanical dilation===
Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal|last=Adamson|first=D. N.|last2=Theisen|first2=F. C.|last3=Barrett|first3=K. C.|date=1988|title=Effect of mechanical dilation on nasotracheal intubation|url=https://pubmed.ncbi.nlm.nih.gov/3163370|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons|volume=46|issue=5|pages=372–375|doi=10.1016/0278-2391(88)90220-0|issn=0278-2391|pmid=3163370|via=}}</ref> <ref>{{Citation|last=Folino|first=Thomas B.|title=Nasotracheal Intubation|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK499967/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29763142|access-date=2022-08-17|last2=Mckean|first2=George|last3=Parks|first3=Lance J.}}</ref> Robertazzi aiways size 28-34 usually sufficient.

Consider preparing a Red Rubber Urethral Catheter. Size 12Fr is ideal in most cases. Above this size, the catheter is too stiff and can cause trauma. Smaller sizes are too soft and cannot be easily directed. Lubricate the nasal airways and catheter, with 2-3 drops of vasoconstricting agent.

==Selection of Endotracheal Tube==

Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation.

*[[Ring-Adair-Elwyn endotracheal tube|Nasal RAE tubes]] have a preformed bend at a set depth depending on the internal diameter of the tube
** Must be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth
**Most patients require a size 7.0 mm internal diameter nasal RAE or larger
*[[Microlaryngeal endotracheal tube|Microlaryngeal tubes]] may be used if a smaller diameter is desirable
**Typically 5.0 mm and 6.0 mm internal diameter are sufficiently long to be used for nasotracheal intubation

Prepare Nasal RAE by leaving in a container of warm saline. Have half a size up and below available and similarly prepared. Traditionally this is necessary with clear plastic RAE's due to their stiffness. Consider using softer tube to minimize pharyngeal trauma (such as Smiths Medical Portex), but and more difficult to direct /manipulate, and require McGill Forceps.

After dilating Nares sequentially with Nasal Airways, insert Red Rubber Urethral catheter into nares, with RAE ET tube attached to trailing end. Under DL, carefully pull out leading edge of red catheter from pharynx, and detach, looking away. Proceed under DL to intubate with or without McGill. May need to rotate ET tube to direct the leading edge through the vocal chords.

Alternatively, if patient has narrow mouth opening, can attempt placement utilizing Glidescope. After placing RAE ETT in nare, perform laryngoscopy using Glidescope. Once vocal cord is in view, minimalize the upward force of the Glidescope blade such that the glottis and vocal cords are sitting in the lowest position on the screen and centered. Advance RAE ETT until visualized on Glidescope screen. Line up the tip of the nasal RAE with glottic opening and advance. If the glottis appears higher than tip of ETT, inflate balloon until tip is aligned with glottis and advance.

==Complications ==

=== Epistaxis ===

* Most common complication of nasal intubation epistaxis from nasal trauma
* Causes include<ref name=":0" />
** Inadequate vasoconstriction
** Larger diameter endotracheal tubes
** Excessive force
** Repeated insertion attempts.
* Softening the endotracheal tube in hot water may reduce risk<ref>{{Cite journal|last=Lu|first=P. P.|last2=Liu|first2=H. P.|last3=Shyr|first3=M. H.|last4=Ho|first4=A. C.|last5=Wang|first5=Y. L.|last6=Tan|first6=P. P.|last7=Yang|first7=C. H.|date=1998|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation|url=https://pubmed.ncbi.nlm.nih.gov/10399514|journal=Acta Anaesthesiologica Sinica|volume=36|issue=4|pages=193–197|issn=0254-1319|pmid=10399514|via=}}</ref>
* If bleeding occurs, intubation should be completed quickly if possible.
** If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated to tamponade bleeding<ref name=":0" />

=== Alar necrosis ===

* Occurs due to pressure from the nasal tube
* May occur quickly
** Has been reported in nasal intubations of even short duration.<ref name=":0" />
* Prevented by securing the tube such that pressure is avoided on the nasal ala

=== Other complications ===
Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, dissection, and sinusitis.

== References ==
<references />

Lung transplant

2023-08-16T21:36:49Z

Jchen900:

{{Infobox surgical procedure
| anesthesia_type = GA +/- epidural
| airway = DLT, left sided
| lines_access = large bore IVs, central access (volume and infusion lines)
| monitors = Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath
| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
| considerations_postoperative = ICU, generally remain intubated
}}

A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Right to left intracardiac shunting can cause strokes.
|-
|Cardiovascular
|
* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2009|isbn=978-1-4511-7660-5}}</ref>
* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
|-
|Pulmonary
|
* May be on high oxygen/ventilatory requirement prior to procedure.
|-
|Gastrointestinal
|
|-
|Hematologic
|
* Polycythemia in setting of chronic hypoxia.
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Cardiac studies: ECG, ECHO, RHC, LHC
* Pulmonary studies: PFTs, CT Chest, V/Q scan
* Labs: Type and screen, complete blood count, chemistry panel, coagulation panel, thromboelastography

=== Operating room setup ===

* Vasopressors/Inotropes Infusions: epinephrine, vasopressin, phenylephrine, norepinephrine
* Additional infusions: insulin, +/- mannitol
* Antibiotics (institutional specific): vancomycin (1gm, 1.5gm for >90kg), posaconazole 300mg, ceftazidime 1-2gm
* Inhaled vasodilators: epoprostenol vs nitric oxide
* ICU ventilator (may be required prior to transplant if concerns for high ventilator pressures)
* TIVA setup after transition to ICU ventilator
* Crossmatched blood products

=== Patient preparation and premedication ===

* Immunosuppressants (institutional specific): myophenolate 1000mg IV, azathioprine 2mg/kg IV, basilixamab 20mg IV, tacrolimus 1mg sublingual
** Methylprednisolone 500mg IV usually given prior to reperfusion

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Cardiac monitoring: TEE, +/- continuous cardiac output monitoring
* Neuromonitoring: +/- sedline, cerebral ox
* Lines: large bore IVs, central lines x 1-2 (consider MAC or Cordis), +/- PA catheter, arterial line x 1-2, foley
* Fiberoptic scope
* Temperature probe: peripheral and central (both required if going on bypass)

=== Induction and airway management ===

* ETT: left sided double lumen if off bypass, single lumen if on bypass

=== Positioning ===

* For single lung: supine, lateral decubitus
* For double lung: supine

=== Maintenance and surgical considerations ===

* Before reperfusion:
** PA clamping: may increase PAP leading to RV dysfunction
** May need to give methylprednisolone 500mg IV prior to reperfusion of each lung
* Reperfusion:
** Watch for hemodynamic instability. If off bypass, have low dose (10-16mcg/ml) and high dose (100mcg/ml) epinephrine ready.
** Give mannitol 25mg
** In line suction for new lung
** Inflate lungs with Ambu during direct visualization

=== Emergence ===
Transported to ICU intubated.

== Postoperative management ==

=== Disposition ===
Transported to ICU intubated.

=== Pain management ===

* Thoracic epidural catheter
* Parenteral narcotics

=== Potential complications ===

* RV dysfunction/failure
* Rejection
* Infection
* Pulmonary edema

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!On Pump BOLT
!Off Pump BOLT
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Off-pump and minimally invasive coronary artery bypass grafting

2023-08-16T21:47:52Z

Jchen900:

{{Infobox surgical procedure
| anesthesia_type = General +/- epidural
| airway = DLT, L sided
| lines_access = Large bore PIVs, central line, arterial line
| monitors = Standard, 5-Lead ECG, arterial line, +/- TEE
| considerations_preoperative = Known coronary artery disease
| considerations_intraoperative = DLT, ischemic preconditioning, temporary occlusion
| considerations_postoperative = Pain control
}}

Off pump and minimally invasive coronary artery bypass grafting is a surgical technique that allows for coronary revascularization without the use of cardiopulmonary bypass. The ideal candidate for this technique is hemodynamically stable, normal EF, no previous cardiac surgery, no history of severe pulmonary conditions, and non-obese<ref>{{Cite journal|last=Patel|first=Amit N.|last2=Benetti|first2=Federico|last3=Hamman|first3=Baron|date=2003-07|title=Patient Selection and Technical Considerations for Off-Pump Coronary Surgery|url=https://www.tandfonline.com/doi/full/10.1080/08998280.2003.11927916|journal=Baylor University Medical Center Proceedings|language=en|volume=16|issue=3|pages=291–293|doi=10.1080/08998280.2003.11927916|issn=0899-8280}}</ref><ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2014|isbn=978-1-4511-7660-5}}</ref>. In the mid-1990s, this technique gained interest as a way to avoid the postoperative complications associated with cardiopulmonary bypass including systemic inflammatory response, cerebral dysfunction, renal dysfunction, bleeding, myocardial depression, and hemodynamic instability<ref>{{Cite journal|last=Shroyer|first=A. Laurie|last2=Grover|first2=Frederick L.|last3=Hattler|first3=Brack|last4=Collins|first4=Joseph F.|last5=McDonald|first5=Gerald O.|last6=Kozora|first6=Elizabeth|last7=Lucke|first7=John C.|last8=Baltz|first8=Janet H.|last9=Novitzky|first9=Dimitri|date=2009-11-05|title=On-Pump versus Off-Pump Coronary-Artery Bypass Surgery|url=http://www.nejm.org/doi/abs/10.1056/NEJMoa0902905|journal=New England Journal of Medicine|language=en|volume=361|issue=19|pages=1827–1837|doi=10.1056/NEJMoa0902905|issn=0028-4793}}</ref><ref>{{Cite journal|last=Hemmerling|first=ThomasM|last2=Romano|first2=Gianmarco|last3=Terrasini|first3=Nora|last4=Noiseux|first4=Nicolas|date=2013|title=Anesthesia for off-pump coronary artery bypass surgery|url=https://journals.lww.com/10.4103/0971-9784.105367|journal=Annals of Cardiac Anaesthesia|language=en|volume=16|issue=1|pages=28|doi=10.4103/0971-9784.105367|issn=0971-9784}}</ref>.

==Preoperative management==

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

===Labs and studies===

=== Operating room setup===

===Patient preparation and premedication===

===Regional and neuraxial techniques===

==Intraoperative management==

===Monitoring and access===

===Induction and airway management===

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management ==

===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

Circumcision

2023-08-16T20:34:37Z

Jchen900:

{{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, pudendal nerve block, or dorsal ring block for analgesia supplemented with general <ref name=":0" /><ref name=":1" /><ref>{{Cite journal|last=Boisvert-Moreau|first=Frédérique|last2=Turcotte|first2=Bruno|last3=Albert|first3=Natalie|last4=Singbo|first4=Narcisse|last5=Moore|first5=Katherine|last6=Boivin|first6=Ariane|date=2022-11-17|title=Randomized controlled trial (RCT) comparing ultrasound-guided pudendal nerve block with ultrasound-guided penile nerve block for analgesia during pediatric circumcision|url=https://rapm.bmj.com/content/early/2022/11/16/rapm-2022-103785|journal=Regional Anesthesia & Pain Medicine|language=en|doi=10.1136/rapm-2022-103785|issn=1098-7339|pmid=36396298}}</ref>'
*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]]

Lung transplant

2023-08-16T20:30:08Z

Jchen900: Made fairly significant changes to all sections.

{{Infobox surgical procedure
| anesthesia_type = GA +/- epidural
| airway = DLT, left sided
| lines_access = large bore IVs, central access (volume and infusion lines)
| monitors = Standard, arterial line, CVP, +/- PA cath, TEE, neurooximetry
| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
| considerations_postoperative = ICU, generally remain intubated
}}

A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
* Right to left intracardiac shunting can cause strokes.
|-
|Cardiovascular
|
* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2009|isbn=978-1-4511-7660-5}}</ref>
* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
|-
|Pulmonary
|
* May be on high oxygen/ventilatory requirement prior to procedure.
|-
|Gastrointestinal
|
|-
|Hematologic
|
* Polycythemia in setting of chronic hypoxia.
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Cardiac studies: ECG, ECHO, RHC, LHC
* Pulmonary studies: PFTs, CT Chest, V/Q scan
* Labs: Type and screen, complete blood count, chemistry panel, coagulation panel, thromboelastography

=== Operating room setup ===

* Vasopressors/Inotropes Infusions: epinephrine, vasopressin, phenylephrine, norepinephrine
* Additional infusions: insulin, +/- mannitol
* Antibiotics (institutional specific): vancomycin (1gm, 1.5gm for >90kg), posaconazole 300mg, ceftazidime 1-2gm
* Inhaled vasodilators: epoprostenol vs nitric oxide
* ICU ventilator (may be required prior to transplant if concerns for high ventilator pressures)
* TIVA setup after transition to ICU ventilator
* Crossmatched blood products

=== Patient preparation and premedication ===

* Immunosuppressants (institutional specific): myophenolate 1000mg IV, azathioprine 2mg/kg IV, basilixamab 20mg IV, tacrolimus 1mg sublingual
** Methylprednisolone 500mg IV usually given prior to reperfusion

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Cardiac monitoring: TEE, +/- continuous cardiac output monitoring
* Neuromonitoring: +/- sedline, cerebral ox
* Lines: large bore IVs, central lines x 1-2 (consider MAC or Cordis), +/- PA catheter, arterial line x 1-2, foley
* Fiberoptic scope
* Temperature probe: peripheral and central (both required if going on bypass)

=== Induction and airway management ===

* ETT: left sided double lumen if off bypass, single lumen if on bypass

=== Positioning ===

* For single lung: supine, lateral decubitus
* For double lung: supine

=== Maintenance and surgical considerations ===

* Before reperfusion:
** PA clamping: may increase PAP leading to RV dysfunction
** May need to give methylprednisolone 500mg IV prior to reperfusion of each lung
* Reperfusion:
** Watch for hemodynamic instability. If off bypass, have low dose (10-16mcg/ml) and high dose (100mcg/ml) epinephrine ready.
** Give mannitol 25mg
** In line suction for new lung
** Inflate lungs with Ambu during direct visualization

=== Emergence ===
Transported to ICU intubated.

== Postoperative management ==

=== Disposition ===
Transported to ICU intubated.

=== Pain management ===

* Thoracic epidural catheter
* Parenteral narcotics

=== Potential complications ===

* RV dysfunction/failure
* Rejection
* Infection
* Pulmonary edema

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!On Pump BOLT
!Off Pump BOLT
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]