WikiAnesthesia - User contributions [en]

Union Memorial (Regional)

2026-01-06T23:24:57Z

Kathylee:

=== About ===
Union Memorial (MedStar Health) is a regional anesthesia elective available to CA-3s who have completed their initial regional rotation downtown. You will work directly with attendings (some remote Hopkins grads) and interact with experienced CRNAs.

=== Getting Started ===

==== Site Coordinators ====

* Joshua Dishon (Chair of Anesthesiology Department at Union Memorial)
* Nicole Mitchell (Administrator)

==== The Experience ====

* 2 week call-free rotation at major orthopedic surgery center
* Expect to get significant experience with both upper and lower extremity blocks. Arguably, the rotation rounds out blocks we do not perform as often at other sites. Most commonly:
** Total Shoulders: Interscalene (single-shot)
** General Hand: Infraclavicular, often with catheter placement (preferred over supraclavicular per general institutional preference)
** Total Knees: Post-op adductor catheters
** Miscellaneous Knee Procedures: Adductor/IPACK
** AKA/BKA: Fem/Sciatic catheters
**Other (less frequent): PECS catheters, TAP catheters

==== First Day ====

* Union Memorial Hospital is located at the Hopkins Homewood campus (201 E University Parkway)
* You'll park in Garage A first day and park in Garage B once you have your parking associated with your employee badge.
** If there is a parking attendant outside the garage that asks if you are a patient, just say yes otherwise they won't let you into the garage
* You'll confirm your Powerchart access, get scrubs/meal card, and meet with Dr. Dishon (Josh) who will take you around, expect to jump into a block as soon as opportunity arises
*There are three floors of ORs: Ground floor (hand +/- shoulders), 3rd floor (newer, knee/hip +/- shoulders), 4th floor (cardiothoracic and vascular [AKA's, BKA's, AVF's])
*Codes: Block cart (0531), 3rd floor staff lounge (2019)[[File:UMH Campus Map.png|thumb|Union Memorial Hospital Campus - Parking located off Calvert Street (turn onto 34th street).]]

==== Contact Info (please do not distribute) ====

* Nicole Mitchell (Admin Assistant) 410-554-6559
* Josh Dishon MD 443-904-2026
* Mark Jensen MD 585-953-9797
* Kerry Blaha MD 410-258-5758
* Tandi Mohammed MD 443-4447-5946
* Jane Radov MD 443-691-3000
* Rahul Guha MD 734-223-3061
* Marcelo Quezado MD 443-801-8889
* Sumanth Kuppalli MD 443-224-3500
*Bob Andrews MD 410-375-5442
*Nadya Averbach MD 703-728-8346
*Rani Emad MD 410-258-8198
*Denisa Pavlickova MD 917-530-5354
*Alyssa Salisbury MD 713-419-2621
*Jane Anh MD 718-962-5774
*Ming Fang MD 443-928-1604
*Kathryn Simms MD 607-280-2081<br />

==== Block Recipes ====

* By and large, you will be using 0.5% ropivicaine for everything
** General volumes (more than you'll be used to):
*** Interscalene: 20 cc
*** Supraclavicular: 20-40 cc (I'm serious)
*** Infraclavicular: 30 cc
*** Adductor/Saphenous: 20 cc
*** Popliteal/Sciatic: 20 cc
**21G 100 mm block needle (exception: shorter needle for interscalene)
**Fent/Versed sedation universally
* For catheters, supplies include:
** PNC kit
** Vial(s) of 0.5% Ropivicaine
** Chloraprep, large/poptart Tegaderm, CHG Tegaderm dressing, sterile ultrasound probe cover (standard for all blocks, whether sterile or not), ultrasound gel, sterile gloves
*If two catheter sites, each pump is run with '''0.2%''' ropivicaine at 10 cc/hour intermittent bolus (PIB) without demand. Otherwise patients with single PNC (e.g. single adductor PNC) have PIB pumps programmed as 8/4/20/3 --> cc per hr / cc demand bolus / lockout interval in minutes / number of demands per hr.

==== Subsequent Days ====

* Arrive by 7:00 AM to catch attendings for any first start blocks (in room by 7:30 AM)
*Anticipate bouncing between floors for 1st case starts -> PACU catheters -> preop blocks
*'''Expect to feel like a medical student''' until you get to know attendings better
*Josh will often help connect you with attendings doing regional cases in the morning, but you will need to hover frequently
*Some attendings will get better about texting you when there is a block
* APS is a good opportunity for blocks/catheters on the floor. Dr. Jensen (Mark) runs APS service and is very good about keeping you in the loop, and proactive with creating block opportunities
*Fridays start with administrative meeting, thus case starts are at 8:30 AM
*Before going home, peek at the list of cases for the following day to figure out the best OR to show up to and when
**The anesthesia schedule is published separately and around 3 pm, so you'll likely have to ask someone if you want to know where specific attendings will be

==== '''PowerChart''' ====

* To get to OR board
** View (Toolbar on very top) > Perioperative Tracking > UMH Main OR Whiteboard
* To get to APS list
** Hit the drop down to the right of 'Amb Huddle MPage' > CORES Handoff > Select the following:
*** UMH
*** Acute Pain Service
*** Active List
*** None

=== Miscellaneous ===

* There is a full gym (free weights, machines, cardio) adjacent to the anesthesia offices in the 33rd Street Professional Building
*Good hiding spots - Resident Lounge (fully stocked with yogurt, fruit, snacks) directly across from the main cafeteria, free lunches in the Physician Lounge located next to the Resident Lounge
* Nearby cafes for studying if preparing for ITE/Advanced:
** Bird in Hand (free wifi, outlets for laptop/phone, good food/beverage selection)

Intraoperative neuromonitoring

2025-09-14T00:25:52Z

Kathylee:

'''Intraoperative neuromonitoring''' ('''IONM''') is a monitoring technique which is used to assess the integrity of the brain, brainstem, spinal cord, cranial, or peripheral nerves.

=== Types of IONM ===
{| class="wikitable"
!Type
!Stimulate
!Signal
!Measures
|-
|Electromyography (EMG)
|Nerves
|Muscle response (twitches)
|Functional integrity of nerve root and peripheral nerves
|-
|Motor Evoked Potentials (MEP)
|Cerebral cortex
|Muscle response (twitches)
|Descending motor pathways (e.g. corticospinal tract)
|-
|Somatosensory Evoked Potentials (SSEP)
|Peripheral nerve (e.g. median nerve, ulnar nerve, posterior tibial nerve)
|Cerebral cortex
|Sensory pathways (e.g. dorsal columns)
|-
|Electroencephalography (EEG)
|Cortex
|Cortex
|Cortical electrical activity to detect cerebral ischemia
|-
|Visual Evoked Potentials (VEP)
|Light under eyelid
|Visual cortex
|Optic pathway integrity
|-
|Brainstem Auditory Evoked Response (BAER)
|Sound emission in ear
|Auditory cortex
|Auditory pathway integrity
|-
|Direct Stimulation of Specific Nerve
|Specific nerve (e.g. facial nerve)
|Muscle response (e.g. orbicularis oculi, orbicularis oris, frontalis, mentalis)
|Specific nerve function
|}

=== Anesthetic Considerations ===

* Most to least affected by anesthetics
** VEP (Very)
** MEP (Mostly)
** SSEP (Somewhat)
** BAER (Barely)
* Effects of anesthetic medications on neuromonitoring
** Volatile ↓↓
** Propofol ↓
** Benzodiazepines ↓
** Nitrous ↓
** Opioids minimal effect
** Etomidate ↑
** Ketamine ↑
* Effect of patient factors on neuromonitoring
** Anemia, ischemia, hypoxia ↓

=== Types of Neuromonitoring Used in Specific Surgeries ===
{| class="wikitable"
|+
!Surgery
!IONM
|-
|Intracranial tumor removal, aneurysm clipping
|SSEP, EEG
|-
|Acoustic neuroma
|SSEP, EMG, BAER, CNVII direct stimulation
|-
|Chiari malformation
|MEP, BAER, CNVII direct stimulation
|-
|ACDF
|SSEP, +/- MEP, +/- EMG
|-
|Thoracic spine surgery
|SSEP, MEP
|-
|Lumbar spine surgery
|EMG
|}

Insertion of percutaneous ventricular assist device

2025-09-13T23:48:45Z

Kathylee:

{{Infobox surgical case reference
| anesthesia_type = GA vs. Regional vs. Local
| airway =
| lines_access = Large-bored PIV, arterial line
| monitors = Intraoperative transesophageal echocardiography (TEE) if GA
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Percutaneous ventricular assist device (pVADs) are temporary mechanical circulatory support devices that provide acute hemodynamic support.

=== Types of pVAD ===

# Impella Devices
## Left-sided
### Examples: Impella 2.5 (femoral), CP 5.0 (femoral), Impella 5.0 or 5.5 (axillary)
####Femoral access may be done under local anesthesia
####Axillary access often requires surgical cutdown and general anesthesia
### Catheter-based pumps inserted via femoral artery and pump blood from left ventricle into ascending aorta, providing up to 5 L/min of flow
## Right-sided
### Example: RP
### Catheter-based pumps inserted via femoral vein and pump blood from right atrium to the pulmonary artery
# Tandem Heart
## Continuous-flow centrifugal pump system that pumps blood from left atrium via a transseptal puncture to femoral artery, providing up to 5 L/min of flow
## May include ProtekDuo cannula for right ventricular support

=== Indications ===

* Cardiogenic shock (SCAI C-D stages)
* ECMO patients with left ventricular distention (ECPELLA)
* High risk PCI

=== Contraindications ===

* Biventricular failure
* High bleeding risk (inability to tolerate systemic anticoagulation)
* Left ventricular thrombus
* Aortic valve disease (moderate-severe aortic regurgitation, aortic stenosis, mechanical AVR)
* Aortic dissection
* Tamponade
* Severe peripheral artery disease

== Preoperative management ==

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

=== Labs and studies ===

* Pre-operative echocardiography to ensure no clots in left ventricle, adequate right ventricular function to receive post-pVAD insertion increased cardiac output
* Type and screen

=== Operating room setup ===

* Arterial line set up
* Intraoperative transesopheageal echocardiography
* Near-infrared spectroscopy system (NIRs)

=== Patient preparation and premedication ===

* Patients often have pacemakers or ICDs
** May need to contact electrophysiology to disable tachyarrhythmia therapy and place defibrillator pads on patient prior to procedure
** If pacer dependent, will need to be placed in DOO at set rate

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Large peripheral IVs
* Arterial line on opposite side as axillary artery that will be used for Impella insertion
* Pulmonary artery catheter
* Intraoperative transesophageal echocardiography

=== Induction and airway management ===

=== Positioning ===
Supine, arms out

=== Maintenance and surgical considerations ===

* Hemodynamic management
* Adequate anticoagulation
** Heparin to achieve goal ACT of 250-300 seconds
* Intraoperative TEE to exclude contraindications (e.g. LV thrombus, aortic valve pathology) and guide device positioning

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

* Limb ischemia
* Vascular injury
* Bleeding
* Hemolysis
* Acute kidney injury
* Thromboembolism, air embolism
* Cardiac perforation
* Valve injury
* Device malposition
* Cardiac tamponade

== Procedure variants ==

{| class="wikitable"
|+
!
!Impella 5.0, 5.5
!Impella 2.5, CP
|-
|Unique considerations
|Axillary access
Often GA, but may be done under regional
|Femoral access
Often local or regional anesthesia
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

# Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. ''J Am Coll Cardiol''. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036
# Bernhardt AM, Copeland H, Deswal A, et al. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. ''J Card Fail''. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003

[[Category:Surgical procedures]]

Insertion of percutaneous ventricular assist device

2025-09-13T23:44:49Z

Kathylee:

{{Infobox surgical case reference
| anesthesia_type = GA vs. Local
| airway =
| lines_access = Large-bored PIV, arterial line, pulmonary artery catheter
| monitors = Intraoperative transesophageal echocardiography (TEE)
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Percutaneous ventricular assist device (pVADs) are temporary mechanical circulatory support devices that provide acute hemodynamic support.

=== Types of pVAD ===

# Impella Devices
## Left-sided
### Examples: Impella 2.5, Impella 5.5, CP 5.0
### Catheter-based pumps inserted via femoral artery and pump blood from left ventricle into ascending aorta, providing up to 5 L/min of flow
## Right-sided
### Example: RP
### Catheter-based pumps inserted via femoral vein and pump blood from right atrium to the pulmonary artery
# Tandem Heart
## Continuous-flow centrifugal pump system that pumps blood from left atrium via a transseptal puncture to femoral artery, providing up to 5 L/min of flow
## May include ProtekDuo cannula for right ventricular support

=== Indications ===

* Cardiogenic shock (SCAI C-D stages)
* ECMO patients with left ventricular distention (ECPELLA)
* High risk PCI

=== Contraindications ===

* Biventricular failure
* High bleeding risk (inability to tolerate systemic anticoagulation)
* Left ventricular thrombus
* Aortic valve disease (moderate-severe aortic regurgitation, aortic stenosis, mechanical AVR)
* Aortic dissection
* Tamponade
* Severe peripheral artery disease

== Preoperative management ==

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

=== Labs and studies ===

* Pre-operative echocardiography to ensure no clots in left ventricle, adequate right ventricular function to receive post-pVAD insertion increased cardiac output
* Type and screen

=== Operating room setup ===

* Arterial line set up
* Intraoperative transesopheageal echocardiography
* Near-infrared spectroscopy system (NIRs)

=== Patient preparation and premedication ===

* Patients often have pacemakers or ICDs
** May need to contact electrophysiology to disable tachyarrhythmia therapy and place defibrillator pads on patient prior to procedure
** If pacer dependent, will need to be placed in DOO at set rate

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Large peripheral IVs
* Arterial line on opposite side as axillary artery that will be used for Impella insertion
* Pulmonary artery catheter
* Intraoperative transesophageal echocardiography

=== Induction and airway management ===

=== Positioning ===
Supine, arms out

=== Maintenance and surgical considerations ===

* Hemodynamic management
* Adequate anticoagulation
** Heparin to achieve goal ACT of 250-300 seconds
* Intraoperative TEE to exclude contraindications (e.g. LV thrombus, aortic valve pathology) and guide device positioning

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

* Limb ischemia
* Vascular injury
* Bleeding
* Hemolysis
* Acute kidney injury
* Thromboembolism, air embolism
* Cardiac perforation
* Valve injury
* Device malposition
* Cardiac tamponade

== Procedure variants ==

{| class="wikitable"
|+
!
!Impella
!ProtekDuo
!TandemHeart
|-
|Unique considerations
|
|
|
|-
|Position
|
|
|
|-
|Surgical time
|
|
|
|-
|EBL
|
|
|
|-
|Postoperative disposition
|
|
|
|-
|Pain management
|
|
|
|-
|Potential complications
|
|
|
|}

== References ==

# Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. ''J Am Coll Cardiol''. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036
# Bernhardt AM, Copeland H, Deswal A, et al. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. ''J Card Fail''. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003

[[Category:Surgical procedures]]

Extracorporeal membrane oxygenation

2025-09-13T22:21:37Z

Kathylee:

Extracorporeal membrane oxygenation (ECMO) is a technique that provides prolonged cardiac and/or respiratory support to patients with potentially reversible cardiac or pulmonary failure unresponsive to conventional treatments. The goal of ECMO is to serve as a bridge for patients to resolve the cardiopulmonary disease process or to long term device placement or transplant. ECMO consists of a blood pump, membrane oxygenator, and vascular access cannula. It is different from cardiopulmonary bypass (CPB) in that it does not contain an open reservoir for direct volume management. ECMO requires anticoagulation, oftentimes with heparin, to achieve goal ACT of around 200 seconds.

=== Configurations ===

# Veno-venous (VV) ECMO
## Supports only respiratory function by draining and returning oxygenated blood to venous system
## Cannulas
### Single dual-lumen cannula in vein
# Veno-arterial (VA) ECMO
## Supports primarily cardiac but also respiratory function by draining and returning oxygenated blood to arterial system
## Cannulas
### Peripheral VA ECMO
#### Arterial: femoral artery
#### Venous: femoral vein or jugular vein
### Central VA ECMO
#### Arterial: aorta
#### Venous: right atrium or IVC + SVC
# Veno-arterial-veno (VAV) ECMO
## Supports both cardiac and respiratory function by draining and returning oxygenated blood to both venous and arterial system
## Often used in patients who develop differential hypoxemia (Harlequin syndrome) during VA ECMO

=== Settings ===

* Flow rate ~ cardiac output
** Typically 3-6 L/min (around 50ml/kg/min)
** Higher flows are associated with increased risk of hemolysis
** Lower flows are associated with increased risk of thrombosis
* FiO2 ~ oxygenation
* Sweep gas ~ ventilation
** Typically 1-9 L/min
** Adjusted to achieve target partial pressure of carbon dioxide
** Lower flows are desired if baseline hypercapnia (to avoid dropping too fast) or situations where hypocapnia can be dangerous (e.g. high ICP)
** Very low flows, however, can start to affect oxygenation
* Revolutions per minute (RPM)
** Controls speed of ECMO pump, directly affects flow rate
* Other settings
** Pven = venous pressure
*** Pressure before blood enters pump, or suction needed to drain venous blood
** Pint = internal pressure
*** Highest pressure in ECMO circuit
** Part = arterial pressure
*** Pressure inside arterial return tubing after leaving membrane
** Delta P = transmembrane pressure = Pint - Part

=== Harlequin Syndrome (North-South Syndrome, Differential Hypoxemia) ===
Harlequin syndrome is a complication of VA ECMO when there is concomitant severe respiratory failure. In this situation, poorly oxygenated blood from the native lung is ejected by left ventricle into ascending aorta, supplying the upper body (including brain and heart) while well-oxygenated blood from ECMO circuit flows retrograde from the femoral artery, supplying the lower body. Blood can be sampled from a RIGHT radial arterial line to determine the "point" of mixing of well-oxygenated and poorly-oxygenated blood. Treatment includes increasing ECMO flow (to push mixing "point" more proximal to heart) or VAV ECMO (also returning oxygenated blood to right atrium via right internal jugular cannula)

=== Complications ===
{| class="wikitable"
|+
!
!Complications
|-
|Neurologic
|CVA hemorrhage, infarct
Seizures
|-
|Cardiac
|Arrhythmia
Tamponade
|-
|Pulmonary
|Pneumothorax
Pulmonary hemorrhage
|-
|Renal
|Acute kidney injury
|-
|Hematologic
|Hemolysis
Disseminated intravascular coagulation (DIC)

Fibrin or coagulation factor consumption

Acquired Von Willebrand disease

Thrombocytopenia

Heparin-induced thrombocytopenia (HIT)

Venous thromboembolism

Bleeding at cannula site, surgical site, gastrointestinal, pulmonary, retroperitoneal
|-
|Infectious
|Bacteremia
Cannula insertion site infection
|-
|Circuit-related
|Circuit component clots
Oxygenator failure

Hemofilter clots

Air in circuit

Pump failure
|-
|Cannula-related
|Cannula site bleeding
Limb ischemia

Compartment syndrome
|}

Cardiopulmonary bypass

2025-09-13T21:47:27Z

Kathylee:

Cardiopulmonary bypass (CPB) is a technique to temporarily replace the function of the heart and lungs during cardiac surgery using a mechanical pump-oxygenator system. The system takes venous blood from the patient, oxygenates and removes carbon dioxide from the blood, then returns it to the arterial circulation. The use of CPB allows for cardiac decompression and a bloodless surgical field. This technique is often used in open-heart procedures where cardiac arrest is required, including valve repair or replacement, coronary artery bypass grafting. It is different from extracorporeal membrane oxygenation (ECMO) in that it has an open reservoir, allowing for direct volume management.

=== Surgical Procedure ===

* Full heparinization
** Typically heparin 400 units/kg to achieve goal ACT of 480 seconds
** For patients with heparin-induced thrombocytopenia (HIT), bivalirudin (direct thrombin inhibitor) can be used
* Aortic cannula placement
** Goal SBP 80-100 during placement to reduce risk of aortic dissection
** After placement, it will be tested by the perfusionist to confirm that it is 1) pulsatile, 2) correlating to arterial line, and 3) responds to test bolus of fluid by increasing pressure
* Venous cannula placement
** Monitor for atrial arrhythmias, which can be common during placement
* Cardioplegia line placement
** Antegrade (via coronary arteries)
** Retrograde (via coronary sinus to feed myocardium)
*** Indications:
**** Aortic insufficiency
**** Severe coronary artery stenosis
**** Prior coronary artery bypass graft
**** Anticipated prolonged pump run
*** AVOID IN:
**** Persistent left superior vena cava (when the left brachiocephalic vein drains into coronary sinus; as retrograde cardioplegia in this context will go into the left ventricle)
* Left ventricle vent placement
** Used to decompress the left ventricle during CPB, which often fills with blood draining from Thesbian veins, bronchial circulation

=== Cannulas ===

# Aortic cannula (ascending aorta, distal to aortic cross-clamp)
# Venous cannula (right atrium appendage)
# Cardioplegia
#* Antegrade (coronary arteries)
#* Retrograde (coronary sinus to feed myocardium)
# Left ventricle vent
# Pump sucker (takes blood from the field and puts it in reservoir bucket, retaining plasma and platelets)

=== Priming ===

* Fluid
* RAP (retrograde autologous priming)
** Use patient's blood to prime aortic cannula
** Need to make sure the patient can tolerate a drop in preload
** Avoids hemodilution and associated with better outcomes, less transfusion
* AAP (anterograde autologous priming)
** Use patient's blood to prime venous cannula

=== Complications ===
Complications of CPB are often due to:

* Low flow, ischemia
* Thromboembolic events
* Anticoagulation
* Systemic inflammatory response syndrome (SIRS)
* Prolonged hypothermia

{| class="wikitable"
|+
!
!Complications
|-
|Neurological
|CVA, watershed infarcts (due to air or circuit related microemboli, sluggish low-flow state following CPB)

Neurocognitive impairment
|-
|Cardiac
|Myocardial stunning (direct effect of cardiotomy, cardioplegia)

Myocardial infarction (coronary ischemia due to air emboli)

Right ventricular dysfunction (pulmonary hypertention related to protamine)

Arrhythmias, heart blood (electrolyte disturbances, hypothermia)
|-
|Pulmonary
|Left lower lobe collapse (phrenic nerve neuropraxia due to cold slush cardioplegia)
Pulmonary hypertension (protamine)

Acute lung injury (complement activation, SIRS)
|-
|Renal
|Post-bypass AKI (thromboembolic events, low-flow state)
Post-operative diuresis (due to intra-op cooling, delayed re-warming)
|-
|Endocrine
|Hyperglycemia (hypothermia-related insulin resistance)
|-
|Gastrointestinal
|Splanchnic ischemia
Hepatic dysfunction

Pancreatitis
|-
|Hematologic
|Coagulopathy (residual AC, dilutional coagulopathy, consumption of clotting factors by bypass circuit)
Platelet dysfunction (SIRS)

Anemia (hemolysis, hemodilution)
|-
|Immunologic
|Coagulation cascade activation (contact of blood with non-biological surfaces)
SIRS

Anaphylaxis (protamine reaction)
|}

Transcatheter mitral valve replacement

2025-09-13T21:12:11Z

Kathylee:

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = 2 PIVs, pre-induction arterial line
| monitors = Standard, intraoperative TEE
| considerations_preoperative = Symptoms of MR, functional capacity, dysphagia/prior gastrointestinal procedures (use of TEE intraoperatively)
| considerations_intraoperative = Hemodynamic management, continuous intraoperative TEE to guide device placement, anticoagulation
| considerations_postoperative =
}}

Transcatheter mitral valve replacement (TMVR) is a minimally invasive approach in which a prosthetic mitral valve is implanted through a transapical or transseptal approach to treat severe mitral valve disease in patients who are not suitable candidates for surgery or transcatheter edge-to-edge repair (TEER).

Transcatheter mitral valve edge-to-edge repair (TEER) is a minimally invasive approach to treat mitral regurgitation (MR) in patients who are at high or prohibitive surgical risk. The procedure involves percutaneous insertion of a clip device via the femoral vein, transseptal puncture, and deployment across the mitral valve leaflets under transesophageal echocardiographic (TEE) and fluoroscopic guidance. The clip approximates the anterior and posterior mitral leaflets at the site of regurgitation, reducing the severity of MR.

Main Types of TEER:

* MitraClip (Abbott)
* Pascal (Edwards)

== Overview ==

=== Indications ===

* Severe symptomatic primary (degenerative) mitral regurgitation
* Moderate-to-severe or severe symptomatic secondary (functional) mitral regurgitation who remain symptomatic despite maximally tolerated guideline-directed medical therapy

=== Surgical procedure ===

* Right femoral venous access
* Transseptal puncture to access left atrium
* Guide catheter and clip delivery system is navigated across mitral valve
* Device positioned perpendicular to mitral leaflet coaptation, targeting area of maximal regurgitant jet, clip arms opened and advanced into left ventricle, then retracted to grasp both the anterior and posterior mitral leaflets
* Confirm leaflet capture by TEE
* Additional clips may be placed to optimize results
* Guide catheter and clip delivery system removed
* Achieve hemostasis at access site

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Symptoms of mitral regurgitation, functional capacity
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Type and screen

=== Operating room setup ===

* Infusion and bolus vasopressors
** Norepinephrine gtt
** Phenylephrine, ephedrine, push dose epinephrine
* Heparin and protamine

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Pre-induction arterial line
* 2 peripheral IVs
** Infusion line
** Bolus line
* Intraoperative transesophageal echocardiography (TEE)

=== Induction and airway management ===
Standard induction, endotracheal intubation

=== Positioning ===
Supine, arms tucked

=== Maintenance and surgical considerations ===

* Maintaining hemodynamic stability
** Avoiding hypotension and tachycardia, which can worsen mitral regurgitation
* Continuous transesophageal echocardiography to guide device placement and assess mitral regurgitation reduction
* Systemic heparinization to prevent thromboembolic events

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Cardiology floor with telemetry

=== Pain management ===
Minimal pain anticipated, often related to positioning or groin access site.

=== Potential complications ===

* Bleeding
* Pericardial tamponade
* Vascular injury
* Device specific complications
** Single leaflet device attachment
** Device embolization
** Loss of leaflet insertion
* Stroke
* Myocardial infarction
* Left ventricular thrombus formation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Transcatheter mitral valve replacement (TMVR)
!Transcatheter edge-to-edge repair (TEER)
|-
|Unique considerations
|
|
|-
|Position
|
|Supine
|-
|Surgical time
|
|2-3 hours
|-
|EBL
|
|Minimal
|-
|Postoperative disposition
|
|Floor with telemetry
|-
|Pain management
|
|Minimal pain anticipated
|-
|Potential complications
|
|
|}

== References ==

# Kampaktsis, P. N., Lebehn, M., & Wu, I. Y. (2021b). Mitral regurgitation in 2020: The 2020 focused update of the 2017 American College of Cardiology Expert Consensus Decision pathway on the management of mitral regurgitation. ''Journal of Cardiothoracic and Vascular Anesthesia'', ''35''(6), 1678–1690. <nowiki>https://doi.org/10.1053/j.jvca.2020.08.056</nowiki>
# Davidson, L. J., & Davidson, C. J. (2021). Transcatheter treatment of valvular heart disease. ''JAMA'', ''325''(24), 2480. <nowiki>https://doi.org/10.1001/jama.2021.2133</nowiki>
# Makkar RR, Chikwe J, Chakravarty T, et al. (2023). Transcatheter Mitral Valve Repair for Degenerative Mitral Regurgitation. ''JAMA 329(20),'' 1778–1788. doi:10.1001/jama.2023.7089

[[Category:Surgical procedures]]

Transcatheter mitral valve replacement

2025-09-13T21:07:05Z

Kathylee:

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = 2 PIVs, pre-induction arterial line
| monitors = Standard, intraoperative TEE
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Transcatheter mitral valve replacement (TMVR) is a minimally invasive approach in which a prosthetic mitral valve is implanted through a transapical or transseptal approach to treat severe mitral valve disease in patients who are not suitable candidates for surgery or transcatheter edge-to-edge repair (TEER).

Transcatheter mitral valve edge-to-edge repair (TEER) is a minimally invasive approach to treat mitral regurgitation (MR) in patients who are at high or prohibitive surgical risk. The procedure involves percutaneous insertion of a clip device via the femoral vein, transseptal puncture, and deployment across the mitral valve leaflets under transesophageal echocardiographic (TEE) and fluoroscopic guidance. The clip approximates the anterior and posterior mitral leaflets at the site of regurgitation, reducing the severity of MR.

Main Types of TEER:

* MitraClip (Abbott)
* Pascal (Edwards)

== Overview ==

=== Indications ===

* Severe symptomatic primary (degenerative) mitral regurgitation
* Moderate-to-severe or severe symptomatic secondary (functional) mitral regurgitation who remain symptomatic despite maximally tolerated guideline-directed medical therapy

=== Surgical procedure ===

* Right femoral venous access
* Transseptal puncture to access left atrium
* Guide catheter and clip delivery system is navigated across mitral valve
* Device positioned perpendicular to mitral leaflet coaptation, targeting area of maximal regurgitant jet, clip arms opened and advanced into left ventricle, then retracted to grasp both the anterior and posterior mitral leaflets
* Confirm leaflet capture by TEE
* Additional clips may be placed to optimize results
* Guide catheter and clip delivery system removed
* Achieve hemostasis at access site

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Symptoms of mitral regurgitation, functional capacity
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Type and screen

=== Operating room setup ===

* Infusion and bolus vasopressors
** Norepinephrine gtt
** Phenylephrine, ephedrine, push dose epinephrine
* Heparin and protamine

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Pre-induction arterial line
* 2 peripheral IVs
** Infusion line
** Bolus line
* Intraoperative transesophageal echocardiography (TEE)

=== Induction and airway management ===
Standard induction, endotracheal intubation

=== Positioning ===
Supine, arms tucked

=== Maintenance and surgical considerations ===

* Maintaining hemodynamic stability
** Avoiding hypotension and tachycardia, which can worsen mitral regurgitation
* Continuous transesophageal echocardiography to guide device placement and assess mitral regurgitation reduction
* Systemic heparinization to prevent thromboembolic events

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Cardiology floor with telemetry

=== Pain management ===
Minimal pain anticipated, often related to positioning or groin access site.

=== Potential complications ===

* Bleeding
* Pericardial tamponade
* Vascular injury
* Device specific complications
** Single leaflet device attachment
** Device embolization
** Loss of leaflet insertion
* Stroke
* Myocardial infarction
* Left ventricular thrombus formation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Transcatheter mitral valve replacement (TMVR)
!Transcatheter edge-to-edge repair (TEER)
|-
|Unique considerations
|
|
|-
|Position
|
|Supine
|-
|Surgical time
|
|2-3 hours
|-
|EBL
|
|Minimal
|-
|Postoperative disposition
|
|Floor with telemetry
|-
|Pain management
|
|Minimal pain anticipated
|-
|Potential complications
|
|
|}

== References ==

# Kampaktsis, P. N., Lebehn, M., & Wu, I. Y. (2021b). Mitral regurgitation in 2020: The 2020 focused update of the 2017 American College of Cardiology Expert Consensus Decision pathway on the management of mitral regurgitation. ''Journal of Cardiothoracic and Vascular Anesthesia'', ''35''(6), 1678–1690. <nowiki>https://doi.org/10.1053/j.jvca.2020.08.056</nowiki>
# Davidson, L. J., & Davidson, C. J. (2021). Transcatheter treatment of valvular heart disease. ''JAMA'', ''325''(24), 2480. <nowiki>https://doi.org/10.1001/jama.2021.2133</nowiki>
# Makkar RR, Chikwe J, Chakravarty T, et al. (2023). Transcatheter Mitral Valve Repair for Degenerative Mitral Regurgitation. ''JAMA 329(20),'' 1778–1788. doi:10.1001/jama.2023.7089

[[Category:Surgical procedures]]

Transcatheter mitral valve replacement

2025-09-13T21:00:14Z

Kathylee:

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = 2 PIVs, pre-induction arterial line
| monitors = Standard, intraoperative TEE
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Transcatheter mitral valve replacement (TMVR) is a minimally invasive approach in which a prosthetic mitral valve is implanted through a transapical or transseptal approach to treat severe mitral valve disease in patients who are not suitable candidates for surgery or transcatheter edge-to-edge repair (TEER).

Transcatheter mitral valve edge-to-edge repair (TEER) is a minimally invasive approach to treat mitral regurgitation (MR) in patients who are at high or prohibitive surgical risk. The procedure involves percutaneous insertion of a clip device via the femoral vein, transseptal puncture, and deployment across the mitral valve leaflets under transesophageal echocardiographic (TEE) and fluoroscopic guidance. The clip approximates the anterior and posterior mitral leaflets at the site of regurgitation, reducing the severity of MR.

Main Types of TEER:

* MitraClip (Abbott)
* Pascal (Edwards)

== Overview ==

=== Indications ===

* Severe symptomatic primary (degenerative) mitral regurgitation
* Moderate-to-severe or severe symptomatic secondary (functional) mitral regurgitation who remain symptomatic despite maximally tolerated guideline-directed medical therapy

=== Surgical procedure ===

* Right femoral venous access
* Transseptal puncture to access left atrium
* Guide catheter and clip delivery system is navigated across mitral valve
* Device positioned perpendicular to mitral leaflet coaptation, targeting area of maximal regurgitant jet, clip arms opened and advanced into left ventricle, then retracted to grasp both the anterior and posterior mitral leaflets
* Confirm leaflet capture by TEE
* Additional clips may be placed to optimize results
* Guide catheter and clip delivery system removed
* Achieve hemostasis at access site

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Symptoms of mitral regurgitation, functional capacity
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Type and screen

=== Operating room setup ===

* Infusion and bolus vasopressors
** Norepinephrine gtt
** Phenylephrine, ephedrine, push dose epinephrine
* Heparin and protamine

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Pre-induction arterial line
* 2 peripheral IVs
** Infusion line
** Bolus line
* Intraoperative transesophageal echocardiography (TEE)

=== Induction and airway management ===
Standard induction, endotracheal intubation

=== Positioning ===
Supine, arms tucked

=== Maintenance and surgical considerations ===

* Maintaining hemodynamic stability
** Avoiding hypotension and tachycardia, which can worsen mitral regurgitation
* Continuous transesophageal echocardiography to guide device placement and assess mitral regurgitation reduction
* Systemic heparinization to prevent thromboembolic events

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Cardiology floor with telemetry

=== Pain management ===
Minimal pain anticipated, often related to positioning or groin access site.

=== Potential complications ===

* Bleeding
* Pericardial tamponade
* Vascular injury
* Device specific complications
** Single leaflet device attachment
** Device embolization
** Loss of leaflet insertion
* Stroke
* Myocardial infarction
* Left ventricular thrombus formation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Transcatheter mitral valve replacement (TMVR)
!Transcatheter edge-to-edge repair (TEER)
|-
|Unique considerations
|
|
|-
|Position
|
|Supine
|-
|Surgical time
|
|2-3 hours
|-
|EBL
|
|Minimal
|-
|Postoperative disposition
|
|Floor with telemetry
|-
|Pain management
|
|Minimal pain anticipated
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Transcatheter mitral valve replacement

2025-09-13T20:59:48Z

Kathylee:

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = 2 PIVs, pre-induction arterial line
| monitors = Standard, intraoperative TEE
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Transcatheter mitral valve replacement (TMVR) is a minimally invasive approach in which a prosthetic mitral valve is implanted through a transapical or transseptal approach to treat severe mitral valve disease in patients who are not suitable candidates for surgery or transcatheter edge-to-edge repair (TEER).

Transcatheter mitral valve edge-to-edge repair (TEER) is a minimally invasive approach to treat mitral regurgitation (MR) in patients who are at high or prohibitive surgical risk. The procedure involves percutaneous insertion of a clip device via the femoral vein, transseptal puncture, and deployment across the mitral valve leaflets under transesophageal echocardiographic (TEE) and fluoroscopic guidance. The clip approximates the anterior and posterior mitral leaflets at the site of regurgitation, reducing the severity of MR.

Main Types of TEER:

* MitraClip (Abbott)
* Pascal (Edwards)

== Overview ==

=== Indications ===

* Severe symptomatic primary (degenerative) mitral regurgitation
* Moderate-to-severe or severe symptomatic secondary (functional) mitral regurgitation who remain symptomatic despite maximally tolerated guideline-directed medical therapy

=== Surgical procedure ===

* Right femoral venous access
* Transseptal puncture to access left atrium
* Guide catheter and clip delivery system is navigated across mitral valve
* Device positioned perpendicular to mitral leaflet coaptation, targeting area of maximal regurgitant jet, clip arms opened and advanced into left ventricle, then retracted to grasp both the anterior and posterior mitral leaflets
* Confirm leaflet capture by TEE
* Additional clips may be placed to optimize results
* Guide catheter and clip delivery system removed
* Achieve hemostasis at access site

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Symptoms of mitral regurgitation, functional capacity
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* Type and screen

=== Operating room setup ===

* Infusion and bolus vasopressors
** Norepinephrine gtt
** Phenylephrine, ephedrine, push dose epinephrine
* Heparin and protamine

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* Pre-induction arterial line
* 2 peripheral IVs
** Infusion line
** Bolus line
* Intraoperative transesophageal echocardiography (TEE)

=== Induction and airway management ===
Standard induction, endotracheal intubation

=== Positioning ===
Supine, arms tucked

=== Maintenance and surgical considerations ===

* Maintaining hemodynamic stability
** Avoiding hypotension and tachycardia, which can worsen mitral regurgitation
* Continuous transesophageal echocardiography to guide device placement and assess mitral regurgitation reduction
* Systemic heparinization to prevent thromboembolic events

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Cardiology floor with telemetry

=== Pain management ===
Minimal pain anticipated, often related to positioning or groin access site.

=== Potential complications ===

* Bleeding
* Pericardial tamponade
* Vascular injury
* Device specific complications
** Single leaflet device attachment
** Device embolization
** Loss of leaflet insertion
* Stroke
* Myocardial infarction
* Left ventricular thrombus formation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Transcatheter mitral valve replacement (TMVR)
!Transcatheter edge-to-edge repair (TEER)
|-
|Unique considerations
|
|
|-
|Position
|
|Supine
|-
|Surgical time
|
|2-3 hours
|-
|EBL
|
|Minimal
|-
|Postoperative disposition
|
|Floor with telemetry
|-
|Pain management
|
|Minimal pain anticipated
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]