WikiAnesthesia - User contributions [en]

Surgery for pleural mesothelioma

2021-11-08T01:52:09Z

Nkamdar:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Double-lumen tube; CPAP and PEEP control equipment
| lines_access = Arterial line +/- flow monitoring equipment (i.e. Flotrac); Large bore peripheral access
| monitors = Standard; blood gas monitoring
| considerations_preoperative = Cardiac testing and prehabilitation
| considerations_intraoperative = vasoplegia; colloid infusion requirements
| considerations_postoperative = Extended post-op hypotension and fluid shifts; large post-operative air leaks from chest tubes
}}Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal|last=Janes|first=Sam M.|last2=Alrifai|first2=Doraid|last3=Fennell|first3=Dean A.|date=2021-09-23|editor-last=Longo|editor-first=Dan L.|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma|url=http://www.nejm.org/doi/10.1056/NEJMra1912719|journal=New England Journal of Medicine|language=en|volume=385|issue=13|pages=1207–1218|doi=10.1056/NEJMra1912719|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal|last=Neragi-Miandoab|first=Siyamek|last2=Richards|first2=William G.|last3=Sugarbaker|first3=David J.|date=2008-08-01|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605|journal=International Journal of Surgery|language=en|volume=6|issue=4|pages=293–297|doi=10.1016/j.ijsu.2008.04.004|issn=1743-9191}}</ref><ref>{{Cite journal|last=Vigneswaran|first=Wickii T.|last2=Kircheva|first2=Diana Y.|last3=Ananthanarayanan|first3=Vijayalakshimi|last4=Watson|first4=Sydeaka|last5=Arif|first5=Qudsia|last6=Celauro|first6=Amy Durkin|last7=Kindler|first7=Hedy L.|last8=Husain|first8=Aliya N.|date=March 1, 2017|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316|journal=The Annals of Thoracic Surgery|language=en|volume=103|issue=3|pages=962–966|doi=10.1016/j.athoracsur.2016.08.063|via=}}</ref>

One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphram, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal|last=Wolf|first=Andrea S.|last2=Daniel|first2=Jonathan|last3=Sugarbaker|first3=David J.|date=2009-06-01|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract|journal=Seminars in Thoracic and Cardiovascular Surgery|language=English|volume=21|issue=2|pages=132–148|doi=10.1053/j.semtcvs.2009.07.007|issn=1043-0679|pmid=19822285}}</ref><ref>{{Cite journal|last=Ng|first=Ju-Mei|last2=Hartigan|first2=Philip M.|date=February 1, 2008|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx|journal=Current Opinion in Anesthesiology|language=en-US|volume=21|issue=1|pages=21–27|doi=10.1097/ACO.0b013e3282f2a9c3|issn=0952-7907|via=}}</ref><ref>{{Cite journal|last=Vlahu|first=Tedi|last2=Vigneswaran|first2=Wicki T.|date=June 1, 2017|title=Pleurectomy and decortication|url=http://atm.amegroups.com/article/view/14825/15364|journal=Annals of Translational Medicine|volume=5|issue=11|pages=246–246|doi=10.21037/atm.2017.04.03|pmc=PMC5497109|pmid=28706914|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal|last=Infante|first=Maurizio|last2=Morenghi|first2=Emanuela|last3=Bottoni|first3=Edoardo|last4=Zucali|first4=Paolo|last5=Rahal|first5=Daoud|last6=Morlacchi|first6=Andrea|last7=Ascolese|first7=Anna Maria|last8=De Rose|first8=Fiorenza|last9=Navarria|first9=Pierina|last10=Crepaldi|first10=Alessandro|last11=Testori|first11=Alberto|date=December 1, 2016|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215|journal=European Journal of Cardio-Thoracic Surgery|language=en|volume=50|issue=6|pages=1077–1082|doi=10.1093/ejcts/ezw215|issn=1010-7940|via=}}</ref><ref>{{Cite journal|last=Sugarbaker|first=David J|last2=Wolf|first2=Andrea S|date=June 1, 2010|title=Surgery for malignant pleural mesothelioma|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35|journal=Expert Review of Respiratory Medicine|language=en|volume=4|issue=3|pages=363–372|doi=10.1586/ers.10.35|issn=1747-6348|via=}}</ref><ref>{{Cite journal|last=Neragi-Miandoab|first=S.|last2=Weiner|first2=S.|last3=Sugarbaker|first3=D. J.|date=2008-12-01|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099|journal=Interactive CardioVascular and Thoracic Surgery|language=en|volume=7|issue=6|pages=1039–1042|doi=10.1510/icvts.2008.181099|issn=1569-9293}}</ref>

Currently a multi-center trial, MARS 2, is ongoing in the UK to test the hypothesis that P/D and chemotherapy is superior to chemotherapy alone with respect to overall survival for patients with pleural mesothelioma. The trial will also examine a range of secondary outcomes including adverse health events and cost-effectiveness. If the results of this trial are negative, there will be reason to question if radical surgery, as opposed to palliative procedures such as PleurX catheter insertion, should continue to have a role in the treatment of mesothelioma.<ref>{{Cite journal|last=Lim|first=Eric|last2=Darlison|first2=Liz|last3=Edwards|first3=John|last4=Elliott|first4=Daisy|last5=Fennell|first5=D A|last6=Popat|first6=Sanjay|last7=Rintoul|first7=Robert C|last8=Waller|first8=David|last9=Ali|first9=Clinton|last10=Bille|first10=Andrea|last11=Fuller|first11=Liz|date=September 1, 2020|title=Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma|url=https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2020-038892|journal=BMJ Open|language=en|volume=10|issue=9|pages=e038892|doi=10.1136/bmjopen-2020-038892|issn=2044-6055|pmc=PMC7467531|pmid=32873681|via=}}</ref>

This article will focus on the anesthetic management of radical pleurectomy/decortication, which is done via open thoracotomy with one-lung ventilation by double-lumen endotracheal tube. These procedures may last for eight hours or more, and typically involve substantial blood and fluid loss. Most centers send patients directly to ICU whether or not extubation is possible at the conclusion of surgery.

== Preoperative management ==
Patients may present for P/D with substantial disease burden including decreased lung function on the affected side, pleural or pericardial effusion, anemia, poor nutritional status, and effects of neoadjuvant chemotherapy. Whenever possible, prehabilitation in preparation for surgery should be considered to correct anemia, improve nutritional status, and improve functional capacity.

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Cardiovascular
|Consider stress testing, echocardiography; look for evidence of ventricular dysfunction, pulmonary hypertension, right heart strain from tumor involvement of pericardium
|-
|Hematologic
|Hypercoagulability due to underlying malignancy
|-
|Respiratory
|Pulmonary function testing; CT scan to evaluate extent of lung compression on the operative side, extent of pleural effusion
|-
|Neurologic
|Peripheral neuropathy due to chemotherapy; assess appropriateness for epidural analgesia
|-
|Renal
|Preexisting renal disease may worsen under stress of fluid shifts, blood loss, potential hypotension
|}
=== Operating room setup ===
The operating room setup will be for open thoracotomy with an operating room table that can be flexed. A checklist for equipment and supplies typically will include:

# Double-lumen endotracheal tube
# Fiberoptic bronchoscope
# Video laryngoscope
# Arterial line setup and transducer
# Consider flow parameter monitoring (e.g. FloTrac system, Edwards Lifesciences)
# IV fluid warming device
# Infusion pumps for vasoactive infusion
# Availability of cross-matched blood, albumin
# CPAP equipment with airflow and PEEP control

=== Patient preparation and premedication ===
Patients should fast per institutional guidelines. Premedication is at the choice of the anesthesiologist depending on the patient's age and other relevant factors.

=== Regional and neuraxial techniques ===
Thoracic epidural analgesia is highly recommended as it will benefit the patient's ability to breathe comfortably and resume mobility after the extensive thoracotomy required for radical mesothelioma resection.

The epidural catheter should be inserted at a high enough level that the patient will not have any lumbar motor block and can safely ambulate. Insertion prior to surgery offers the advantage of beginning epidural infusion before the patient emerges from anesthesia.

As there will be continuous blood and fluid loss throughout surgery, it may be preferred not to give any bolus dose or epidural infusion until near the end of surgery to avoid the hypotensive effect of sympathectomy. This decision must be weighed against the potential analgesic value of preemptive dosing.

If the patient has a contraindication to epidural catheter placement, other regional techniques may be considered: lumbar spinal opioid analgesia, erector spinae plane block <ref>{{Cite journal|last=Adhikary|first=SanjibDas|last2=Pruett|first2=Ashlee|last3=Forero|first3=Mauricio|last4=Thiruvenkatarajan|first4=Venkatesan|date=2018|title=Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane|url=http://www.ijaweb.org/text.asp?2018/62/1/75/223077|journal=Indian Journal of Anaesthesia|language=en|volume=62|issue=1|pages=75|doi=10.4103/ija.IJA_693_17|issn=0019-5049|pmc=PMC5787896|pmid=29416155}}</ref>, intercostal or paravertebral blocks.

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

# Arterial monitoring is highly recommended for continuous blood pressure monitoring and blood gas measurement. Consider use of a flow parameter monitoring transducer (e.g. FloTrac, Edwards Lifesciences).
# Large-bore IV access is indicated; central venous access is not mandatory unless peripheral veins are inadequate.

=== Induction and airway management ===

# Induction medications and muscle relaxant choice per anesthesiologist preference. Ketamine may be a useful adjunct, especially for patients with chronic pain or a history of preoperative opioid use.
# A double-lumen endotracheal tube (typically 37-39 Fr) is inserted and position confirmed with fiberoptic bronchoscopy

=== Positioning ===
The patient is placed in the lateral decubitus position with the table flexed. No position changes are usually necessary during the operation.

=== Maintenance and surgical considerations ===
The choice of maintenance anesthetic is per anesthesiologist preference; inhaled agents offer the advantage of bronchodilation. Muscle relaxation is continued throughout the procedure.

Lung protective ventilation strategies are recommended:

* Tidal volume 4-6 ml/kg on one-lung ventilation

* Permissive hypercapnia if necessary
* PEEP to the nonoperative lung
Regular blood gas measurement helps in the assessment of blood loss, volume status, and electrolyte balance. The development of metabolic acidosis may be a valuable indicator of volume deficit. For diabetic patients, insulin infusion may be helpful. The surgeon may use intermittent irrigation of the plane of dissection with sterile water to aid in lysis of adhesions, so careful attention must be paid to distinguish irrigation fluid from accumulated blood loss.

During dissection and decortication of the visceral pleura from the lung surface, the surgeon may request reinflation of the lung and maintenance of partial inflation with continuous CPAP at a range of 5-20 cm H20. A CPAP/PEEP valve connected to an auxiliary oxygen source is used at the flow rate requested by the surgeon. Avoid attaching oxygen tubing directly to a double-lumen tube without a CPAP valve as this can lead to over-inflation and barotrauma to the lung.

During dissection, venous return may be impeded by compression from retractors and by blunt dissection pressure. It may be tempting to correct preload with crystalloid volume expansion. However, albumin, vasopressors, and blood products may be more helpful in optimizing volume status until the specimen is removed.

Blood loss may not be obvious as it pools in the chest cavity.

Coagulation parameters (PT/PTT/INR), platelet count, and fibrinogen should be assessed as surgery progresses, typically after transfusion of 2-4 units of PRBC. The use of FFP and platelets may be necessary. Cryoprecipitate, recombinant clotting factors, and Factor VII have been required in some cases.

It is not uncommon to see vasoplegia or the apparent development of a systemic inflammatory response during mesothelioma resection, resulting in refractory hypotension despite adequate volume replacement. Blood pressure support with phenylephrine or norepinephrine frequently is needed.

=== Emergence ===
If the operative lung has a large air leak, it may be necessary to maintain positive pressure ventilation on the dependent lung until the patient begins to breathe spontaneously.

Bronchoscopy and bronchial lavage may be helpful near the end of surgery to clear blood or secretions from the upper airways.

As air leaks are common, it is preferable to extubate at the conclusion of surgery in order to avoid worsening the air leaks in the operative lung.

As the level of general anesthesia is lightened, the epidural catheter may be activated either by bolus or continuous infusion, per clinician preference.

If the pericardium was involved with tumor and pericardiectomy was performed, herniation of the heart with torsion of the great vessels and circulatory arrest may abruptly occur upon turning the patient to the supine position at the end of surgery. This is more common in right-sided cases. The immediate return to the lateral position is the appropriate response.

== Postoperative management ==
=== Disposition ===
At most centers, patients are transferred to intensive care after surgery for mesothelioma resection unless the procedure was a minimal palliative intervention. A step-down unit may be appropriate in some cases. Many patients continue to require vasopressor support in the initial period of post-extubation recovery.

=== Pain management ===
Continuous epidural thoracic analgesia is the most common method used, with a combination of low-dose local anesthetic (e.g. bupivacaine, ropivacaine) and narcotic (e.g. fentanyl, hydromorphone). A low-dose ketamine infusion may be helpful in the management of opioid-tolerant patients. If hypotension is problematic, local anesthetic can be eliminated from the epidural infusion.

=== Potential complications ===
The most frequent major complications of pleurectomy/decortication are respiratory failure (2.3–7.1%), bleeding (0.0–16.7%), and prolonged air leak (7.1–23.5%). However, as with other thoracic surgeries, atrial fibrillation (2.3–21.4%, higher risk in age > 65), myocardial infarction, DVT/PE, pneumonia, acute renal failure, empyema, pleural sepsis, prolonged intubation, UTI, and wound infections may also be seen.

Immediate postoperative bleeding may occur due to extensive raw surface oozing. It is best managed by correcting any coagulopathy and with increased PEEP on the ventilator if the patient is intubated.

Delayed hemorrhage 8-10 hours postoperatively is often due to unopposed regional hyperfibrinolysis and consumptive coagulopathy after removal of the hypercoagulable tumor. Treatment with aminocaproic acid has been utilized in this setting. ROTEM monitoring can aid in the diagnosis of fibrinolysis.

The pleural space is monitored with serial chest X-rays. Prolonged air leak is common and is managed by maintaining chest tubes on mild suction, then weaning to water seal, and finally using pneumostats for portability if needed.

== References ==

[[Category:Surgical procedures]]
<references responsive="0" />

Surgery for pleural mesothelioma

2021-11-05T21:20:35Z

Nkamdar:

Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal|last=Janes|first=Sam M.|last2=Alrifai|first2=Doraid|last3=Fennell|first3=Dean A.|date=2021-09-23|editor-last=Longo|editor-first=Dan L.|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma|url=http://www.nejm.org/doi/10.1056/NEJMra1912719|journal=New England Journal of Medicine|language=en|volume=385|issue=13|pages=1207–1218|doi=10.1056/NEJMra1912719|issn=0028-4793}}</ref> The most important risk factor for its development

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Double-lumen tube; CPAP and PEEP control equipment
| lines_access = Arterial line +/- flow monitoring equipment (i.e. Flotrac); Large bore peripheral access
| monitors = Standard; blood gas monitoring
| considerations_preoperative = Cardiac testing and prehabilitation
| considerations_intraoperative = vasoplegia; colloid infusion requirements
| considerations_postoperative = Extended post-op hypotension and fluid shifts; large post-operative air leaks from chest tubes
}}

is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal|last=Neragi-Miandoab|first=Siyamek|last2=Richards|first2=William G.|last3=Sugarbaker|first3=David J.|date=2008-08-01|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605|journal=International Journal of Surgery|language=en|volume=6|issue=4|pages=293–297|doi=10.1016/j.ijsu.2008.04.004|issn=1743-9191}}</ref><ref>{{Cite journal|last=Vigneswaran|first=Wickii T.|last2=Kircheva|first2=Diana Y.|last3=Ananthanarayanan|first3=Vijayalakshimi|last4=Watson|first4=Sydeaka|last5=Arif|first5=Qudsia|last6=Celauro|first6=Amy Durkin|last7=Kindler|first7=Hedy L.|last8=Husain|first8=Aliya N.|date=March 1, 2017|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316|journal=The Annals of Thoracic Surgery|language=en|volume=103|issue=3|pages=962–966|doi=10.1016/j.athoracsur.2016.08.063|via=}}</ref>

One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphram, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal|last=Wolf|first=Andrea S.|last2=Daniel|first2=Jonathan|last3=Sugarbaker|first3=David J.|date=2009-06-01|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract|journal=Seminars in Thoracic and Cardiovascular Surgery|language=English|volume=21|issue=2|pages=132–148|doi=10.1053/j.semtcvs.2009.07.007|issn=1043-0679|pmid=19822285}}</ref><ref>{{Cite journal|last=Ng|first=Ju-Mei|last2=Hartigan|first2=Philip M.|date=February 1, 2008|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx|journal=Current Opinion in Anesthesiology|language=en-US|volume=21|issue=1|pages=21–27|doi=10.1097/ACO.0b013e3282f2a9c3|issn=0952-7907|via=}}</ref><ref>{{Cite journal|last=Vlahu|first=Tedi|last2=Vigneswaran|first2=Wicki T.|date=June 1, 2017|title=Pleurectomy and decortication|url=http://atm.amegroups.com/article/view/14825/15364|journal=Annals of Translational Medicine|volume=5|issue=11|pages=246–246|doi=10.21037/atm.2017.04.03|pmc=PMC5497109|pmid=28706914|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal|last=Infante|first=Maurizio|last2=Morenghi|first2=Emanuela|last3=Bottoni|first3=Edoardo|last4=Zucali|first4=Paolo|last5=Rahal|first5=Daoud|last6=Morlacchi|first6=Andrea|last7=Ascolese|first7=Anna Maria|last8=De Rose|first8=Fiorenza|last9=Navarria|first9=Pierina|last10=Crepaldi|first10=Alessandro|last11=Testori|first11=Alberto|date=December 1, 2016|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215|journal=European Journal of Cardio-Thoracic Surgery|language=en|volume=50|issue=6|pages=1077–1082|doi=10.1093/ejcts/ezw215|issn=1010-7940|via=}}</ref><ref>{{Cite journal|last=Sugarbaker|first=David J|last2=Wolf|first2=Andrea S|date=June 1, 2010|title=Surgery for malignant pleural mesothelioma|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35|journal=Expert Review of Respiratory Medicine|language=en|volume=4|issue=3|pages=363–372|doi=10.1586/ers.10.35|issn=1747-6348|via=}}</ref><ref>{{Cite journal|last=Neragi-Miandoab|first=S.|last2=Weiner|first2=S.|last3=Sugarbaker|first3=D. J.|date=2008-12-01|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099|journal=Interactive CardioVascular and Thoracic Surgery|language=en|volume=7|issue=6|pages=1039–1042|doi=10.1510/icvts.2008.181099|issn=1569-9293}}</ref>

Currently a multi-center trial, MARS 2, is ongoing in the UK to test the hypothesis that P/D and chemotherapy is superior to chemotherapy alone with respect to overall survival for patients with pleural mesothelioma. The trial will also examine a range of secondary outcomes including adverse health events and cost-effectiveness. If the results of this trial are negative, there will be reason to question if radical surgery, as opposed to palliative procedures such as PleurX catheter insertion, should continue to have a role in the treatment of mesothelioma.<ref>{{Cite journal|last=Lim|first=Eric|last2=Darlison|first2=Liz|last3=Edwards|first3=John|last4=Elliott|first4=Daisy|last5=Fennell|first5=D A|last6=Popat|first6=Sanjay|last7=Rintoul|first7=Robert C|last8=Waller|first8=David|last9=Ali|first9=Clinton|last10=Bille|first10=Andrea|last11=Fuller|first11=Liz|date=September 1, 2020|title=Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma|url=https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2020-038892|journal=BMJ Open|language=en|volume=10|issue=9|pages=e038892|doi=10.1136/bmjopen-2020-038892|issn=2044-6055|pmc=PMC7467531|pmid=32873681|via=}}</ref>

This article will focus on the anesthetic management of radical pleurectomy/decortication, which is done via open thoracotomy with one-lung ventilation by double-lumen endotracheal tube. These procedures may last for eight hours or more, and typically involve substantial blood and fluid loss. Most centers send patients directly to ICU whether or not extubation is possible at the conclusion of surgery.

== Preoperative management ==
Patients may present for P/D with substantial disease burden including decreased lung function on the affected side, pleural or pericardial effusion, anemia, poor nutritional status, and effects of neoadjuvant chemotherapy. Whenever possible, prehabilitation in preparation for surgery should be considered to correct anemia, improve nutritional status, and improve functional capacity.

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Cardiovascular
|Consider stress testing, echocardiography; look for evidence of ventricular dysfunction, pulmonary hypertension, right heart strain from tumor involvement of pericardium
|-
|Hematologic
|Hypercoagulability due to underlying malignancy
|-
|Respiratory
|Pulmonary function testing; CT scan to evaluate extent of lung compression on the operative side, extent of pleural effusion
|-
|Neurologic
|Peripheral neuropathy due to chemotherapy; assess appropriateness for epidural analgesia
|-
|Renal
|Preexisting renal disease may worsen under stress of fluid shifts, blood loss, potential hypotension
|}
=== Operating room setup ===
The operating room setup will be for open thoracotomy with an operating room table that can be flexed. A checklist for equipment and supplies typically will include:

# Double-lumen endotracheal tube
# Fiberoptic bronchoscope
# Video laryngoscope
# Arterial line setup and transducer
# Consider flow parameter monitoring (e.g. FloTrac system, Edwards Lifesciences)
# IV fluid warming device
# Infusion pumps for vasoactive infusion
# Availability of cross-matched blood, albumin
# CPAP equipment with airflow and PEEP control

=== Patient preparation and premedication ===
Patients should fast per institutional guidelines. Premedication is at the choice of the anesthesiologist depending on the patient's age and other relevant factors.

=== Regional and neuraxial techniques ===
Thoracic epidural analgesia is highly recommended as it will benefit the patient's ability to breathe comfortably and resume mobility after the extensive thoracotomy required for radical mesothelioma resection.

The epidural catheter should be inserted at a high enough level that the patient will not have any lumbar motor block and can safely ambulate. Insertion prior to surgery offers the advantage of beginning epidural infusion before the patient emerges from anesthesia.

As there will be continuous blood and fluid loss throughout surgery, it may be preferred not to give any bolus dose or epidural infusion until near the end of surgery to avoid the hypotensive effect of sympathectomy. This decision must be weighed against the potential analgesic value of preemptive dosing.

If the patient has a contraindication to epidural catheter placement, other regional techniques may be considered: lumbar spinal opioid analgesia, erector spinae plane block <ref>{{Cite journal|last=Adhikary|first=SanjibDas|last2=Pruett|first2=Ashlee|last3=Forero|first3=Mauricio|last4=Thiruvenkatarajan|first4=Venkatesan|date=2018|title=Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane|url=http://www.ijaweb.org/text.asp?2018/62/1/75/223077|journal=Indian Journal of Anaesthesia|language=en|volume=62|issue=1|pages=75|doi=10.4103/ija.IJA_693_17|issn=0019-5049|pmc=PMC5787896|pmid=29416155}}</ref>, intercostal or paravertebral blocks.

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

# Arterial monitoring is highly recommended for continuous blood pressure monitoring and blood gas measurement. Consider use of a flow parameter monitoring transducer (e.g. FloTrac, Edwards Lifesciences).
# Large-bore IV access is indicated; central venous access is not mandatory unless peripheral veins are inadequate.

=== Induction and airway management ===

# Induction medications and muscle relaxant choice per anesthesiologist preference. Ketamine may be a useful adjunct, especially for patients with chronic pain or a history of preoperative opioid use.
# A double-lumen endotracheal tube (typically 37-39 Fr) is inserted and position confirmed with fiberoptic bronchoscopy

=== Positioning ===
The patient is placed in the lateral decubitus position with the table flexed. No position changes are usually necessary during the operation.

=== Maintenance and surgical considerations ===
The choice of maintenance anesthetic is per anesthesiologist preference; inhaled agents offer the advantage of bronchodilation. Muscle relaxation is continued throughout the procedure.

Lung protective ventilation strategies are recommended:

* Tidal volume 4-6 ml/kg on one-lung ventilation

* Permissive hypercapnia if necessary
* PEEP to the nonoperative lung
Regular blood gas measurement helps in the assessment of blood loss, volume status, and electrolyte balance. The development of metabolic acidosis may be a valuable indicator of volume deficit. For diabetic patients, insulin infusion may be helpful. The surgeon may use intermittent irrigation of the plane of dissection with sterile water to aid in lysis of adhesions, so careful attention must be paid to distinguish irrigation fluid from accumulated blood loss.

During dissection and decortication of the visceral pleura from the lung surface, the surgeon may request reinflation of the lung and maintenance of partial inflation with continuous CPAP at a range of 5-20 cm H20. A CPAP/PEEP valve connected to an auxiliary oxygen source is used at the flow rate requested by the surgeon. Avoid attaching oxygen tubing directly to a double-lumen tube without a CPAP valve as this can lead to over-inflation and barotrauma to the lung.

During dissection, venous return may be impeded by compression from retractors and by blunt dissection pressure. It may be tempting to correct preload with crystalloid volume expansion. However, albumin, vasopressors, and blood products may be more helpful in optimizing volume status until the specimen is removed.

Blood loss may not be obvious as it pools in the chest cavity.

Coagulation parameters (PT/PTT/INR), platelet count, and fibrinogen should be assessed as surgery progresses, typically after transfusion of 2-4 units of PRBC. The use of FFP and platelets may be necessary. Cryoprecipitate, recombinant clotting factors, and Factor VII have been required in some cases.

It is not uncommon to see vasoplegia or the apparent development of a systemic inflammatory response during mesothelioma resection, resulting in refractory hypotension despite adequate volume replacement. Blood pressure support with phenylephrine or norepinephrine frequently is needed.

=== Emergence ===
If the operative lung has a large air leak, it may be necessary to maintain positive pressure ventilation on the dependent lung until the patient begins to breathe spontaneously.

Bronchoscopy and bronchial lavage may be helpful near the end of surgery to clear blood or secretions from the upper airways.

As air leaks are common, it is preferable to extubate at the conclusion of surgery in order to avoid worsening the air leaks in the operative lung.

As the level of general anesthesia is lightened, the epidural catheter may be activated either by bolus or continuous infusion, per clinician preference.

If the pericardium was involved with tumor and pericardiectomy was performed, herniation of the heart with torsion of the great vessels and circulatory arrest may abruptly occur upon turning the patient to the supine position at the end of surgery. This is more common in right-sided cases. The immediate return to the lateral position is the appropriate response.

== Postoperative management ==
=== Disposition ===
At most centers, patients are transferred to intensive care after surgery for mesothelioma resection unless the procedure was a minimal palliative intervention. A step-down unit may be appropriate in some cases. Many patients continue to require vasopressor support in the initial period of post-extubation recovery.

=== Pain management ===
Continuous epidural thoracic analgesia is the most common method used, with a combination of low-dose local anesthetic (e.g. bupivacaine, ropivacaine) and narcotic (e.g. fentanyl, hydromorphone). A low-dose ketamine infusion may be helpful in the management of opioid-tolerant patients. If hypotension is problematic, local anesthetic can be eliminated from the epidural infusion.

=== Potential complications ===
The most frequent major complications of pleurectomy/decortication are respiratory failure (2.3–7.1%), bleeding (0.0–16.7%), and prolonged air leak (7.1–23.5%). However, as with other thoracic surgeries, atrial fibrillation (2.3–21.4%, higher risk in age > 65), myocardial infarction, DVT/PE, pneumonia, acute renal failure, empyema, pleural sepsis, prolonged intubation, UTI, and wound infections may also be seen.

Immediate postoperative bleeding may occur due to extensive raw surface oozing. It is best managed by correcting any coagulopathy and with increased PEEP on the ventilator if the patient is intubated.

Delayed hemorrhage 8-10 hours postoperatively is often due to unopposed regional hyperfibrinolysis and consumptive coagulopathy after removal of the hypercoagulable tumor. Treatment with aminocaproic acid has been utilized in this setting. ROTEM monitoring can aid in the diagnosis of fibrinolysis.

The pleural space is monitored with serial chest X-rays. Prolonged air leak is common and is managed by maintaining chest tubes on mild suction, then weaning to water seal, and finally using pneumostats for portability if needed.

== References ==

[[Category:Surgical procedures]]
<references responsive="0" />

2021-10-16T17:36:20Z

Nkamdar: Updated summary table

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

Provide a brief summary of this surgical procedure and its indications here.

== 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 an infected abscess into 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
* Severe airway distortion

== 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

=== 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]]

2021-07-13T14:55:33Z

Nkamdar: pre-operative medication adjustments

{{Infobox comorbidity
| other_names =
| anesthetic_relevance = High
| anesthetic_management = Preoperative HgA1c value
Preoperative glucose value
Preoperative medication adjustment
Insulin administration
Post-operative glucose
| specialty = Endocrine
| signs_symptoms = Excessive thirst
Polyuria
Polydypsia
Glucosuria
Peripheral neuropathy
Ocular degeneration
Cardiovascular disease
| diagnosis = HgA1c
Fasting glucose
| treatment = Oral anti-hyperglycemics
Exogenous insulin administration
| image =
| caption =
}}'''Diabetes''' is an endocrine, metabolic disorder marked by high levels of blood glucose. Three classifications of diabetics exist:

#[[Type 1 Diabetes]], where an immune mediated destruction of pancreatic beta cells occurs causing a total reduction in endogenous insulin and thus causing hyperglycemia
#[[Type II Diabetes]], where patients experience increasing insulin resistance for the level of endogenous insulin thus causing hyperglycemia
# [[Gestational Diabetes]] in which hyperglycemia occurs in the second or third trimester of pregnancy.

The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. This disease affects multiple organ systems that have anesthetic implications including cardiovascular health, renal disease, peripheral neurologic function, and gastrointestinal emptying requiring preoperative optimization and intraoperative control.

Cystic fibrosis patients have an acquired form of diabetes as the most common co-morbidity of cystic fibrosis (20% of adolescents and 40-50% of adults).<ref>{{Cite journal|last=Association|first=American Diabetes|date=2021-01-01|title=2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021|url=https://care.diabetesjournals.org/content/44/Supplement_1/S15|journal=Diabetes Care|language=en|volume=44|issue=Supplement 1|pages=S15–S33|doi=10.2337/dc21-S002|issn=0149-5992|pmid=33298413}}</ref>

==Anesthetic implications==

===Preoperative optimization===

* No overt indications for case cancellations for poorly controlled diabetes<ref>{{Cite journal|last=Vann|first=Mary Ann|date=2014-06|title=Management of Diabetes Medications for Patients Undergoing Ambulatory Surgery|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227514000226|journal=Anesthesiology Clinics|language=en|volume=32|issue=2|pages=329–339|doi=10.1016/j.anclin.2014.02.008}}</ref><ref>{{Cite journal|last=Joshi|first=Girish P.|last2=Chung|first2=Frances|last3=Vann|first3=Mary Ann|last4=Ahmad|first4=Shireen|last5=Gan|first5=Tong J.|last6=Goulson|first6=Daniel T.|last7=Merrill|first7=Douglas G.|last8=Twersky|first8=Rebecca|date=2010-12|title=Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery:|url=http://journals.lww.com/00000539-201012000-00009|journal=Anesthesia & Analgesia|language=en|volume=111|issue=6|pages=1378–1387|doi=10.1213/ANE.0b013e3181f9c288|issn=0003-2999}}</ref> except if patients are in diabetes ketoacidosis (DKA) or hyperosmolar osmotic non-ketotic crisis (HONK)
* Postoperative blood glucose greater than 140 mg/dL is found in as many as 40% of patient undergoing non-cardiac surgery and almost 25% of those patients demonstrate a blood glucose greater than 180 mg/dL during the operative and immediate post-operative period<ref>{{Cite journal|last=Frisch|first=A.|last2=Chandra|first2=P.|last3=Smiley|first3=D.|last4=Peng|first4=L.|last5=Rizzo|first5=M.|last6=Gatcliffe|first6=C.|last7=Hudson|first7=M.|last8=Mendoza|first8=J.|last9=Johnson|first9=R.|last10=Lin|first10=E.|last11=Umpierrez|first11=G. E.|date=2010-08-01|title=Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery|url=http://care.diabetesjournals.org/cgi/doi/10.2337/dc10-0304|journal=Diabetes Care|language=en|volume=33|issue=8|pages=1783–1788|doi=10.2337/dc10-0304|issn=0149-5992|pmc=PMC2909062|pmid=20435798}}</ref><ref>{{Cite journal|last=Levetan|first=C. S.|last2=Passaro|first2=M.|last3=Jablonski|first3=K.|last4=Kass|first4=M.|last5=Ratner|first5=R. E.|date=1998-02-01|title=Unrecognized Diabetes Among Hospitalized Patients|url=http://care.diabetesjournals.org/cgi/doi/10.2337/diacare.21.2.246|journal=Diabetes Care|language=en|volume=21|issue=2|pages=246–249|doi=10.2337/diacare.21.2.246|issn=0149-5992}}</ref>
* Data shows mixed reduction of mortality with good blood glucose control in surgical patients<ref>{{Cite journal|last=Buchleitner|first=Ana Maria|last2=Martínez-Alonso|first2=Montserrat|last3=Hernández|first3=Marta|last4=Solà|first4=Ivan|last5=Mauricio|first5=Didac|date=2012-09-12|editor-last=Cochrane Metabolic and Endocrine Disorders Group|title=Perioperative glycaemic control for diabetic patients undergoing surgery|url=https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007315.pub2|journal=Cochrane Database of Systematic Reviews|language=en|doi=10.1002/14651858.CD007315.pub2}}</ref>, but a reduction in surgical site infection risk<ref>{{Cite journal|last=Kroin|first=Jeffrey S.|last2=Buvanendran|first2=Asokumar|last3=Li|first3=Jinyuan|last4=Moric|first4=Mario|last5=Im|first5=Hee-Jeong|last6=Tuman|first6=Kenneth J.|last7=Shafikhani|first7=Sasha H.|date=2015-06|title=Short-Term Glycemic Control Is Effective in Reducing Surgical Site Infection in Diabetic Rats:|url=http://journals.lww.com/00000539-201506000-00018|journal=Anesthesia & Analgesia|language=en|volume=120|issue=6|pages=1289–1296|doi=10.1213/ANE.0000000000000650|issn=0003-2999}}</ref>
* Consider case delay alongside surgery team if BG > 250 mg/dL and case is elective and a prothesis or synthetic biofilm will be inserted into the patient during surgery (i.e. prothesis, intraocular lens, joint replacement, graft, etc).
* Obtain pre-operative HgA1c if one has not been obtained via primary care in last 3 months prior to surgery
** If HgA1c > 8.0 - evidence shows greater incidence of post-operative hyperglycemia during patient recovery

===== Pre-operative medication adjustments: =====
{| class="wikitable"
|+
!Drug Class
!Medication
!Day before Surgery
!Day of surgery
!Notes
|-
|DPP-4 inhibitors
|Sitagliptin/Saxagliptin
lidagliptin/linagliptin
|Take
|Take
|
|-
|Alpha-glucosidase
inhibitors
|Acarbose/Miglitol
|Take
|Do not take
|
|-
|Sulfonylureas
|Glipizide/glyburide
|Take
|Do not take
|
|-
|SGLT-2 inhbitors
|dapagliflozin/canagliflozin
empagliflozin
|Hold 3 days prior
to surgery<ref name=":0">{{Cite journal|last=Research|first=Center for Drug Evaluation and|date=2021-01-11|title=FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections|url=https://www.fda.gov/drugs/drug-safety-and-availability/fda-revises-labels-sglt2-inhibitors-diabetes-include-warnings-about-too-much-acid-blood-and-serious|journal=FDA|language=en}}</ref>
|Do not take
|Can cause euglycemic DKA<ref name=":1">{{Cite journal|last=Seger|first=Christian D.|last2=Xing|first2=Hanning|last3=Wang|first3=Libing|last4=Shin|first4=John S.|date=2021-01-14|title=Intraoperative Diagnosis of Sodium-Glucose Cotransporter 2 Inhibitor–Associated Euglycemic Diabetic Ketoacidosis: A Case Report|url=https://journals.lww.com/10.1213/XAA.0000000000001380|journal=A&A Practice|language=en|volume=15|issue=1|pages=e01380|doi=10.1213/XAA.0000000000001380|issn=2575-3126}}</ref> if not stopped in advance of surgery
|-
|SGLT-2 inhibitors
|ertugliflozin
|Hold 4 days prior
to surgery<ref name=":0" />
|Do not take
|Can cause euglycemic DKA<ref name=":1" /> if not stopped in advance of surgery
|-
|Biguanides
|metformin/Metformin ER
|Take
| +/- take
|Hold if patient has renal/hepatic insufficiency, COPD or CHF or if
team anticipates potential for AKI or hepatic shock during case
|-
|GLP-1 agonist
|exenatide/exenatide ER
|Take
|Do not take
|
|-
|GLP-1 agonist
|dulaglutide
|Take
|Do not take
|
|-
|GLP-1 agonist
|semaglutide
|Take
|Do not take
|
|-
|GLP-1 agonist
|liraglutide
|Take
|Do not take
|
|-
|Amylin mimetics
|pramlintide
|Take
|Do not take
|
|-
|
|
|
|
|
|-
|Long acting insulin
|Glargine/detemir/degludec
|Take 80% of dose
|Take 80% of dose
|Coordinate with patient's endocrinologist
|-
|U-500 insulin
|
|Take usual dose
|Take 50% of dose
|Coordinate with patient's endocrinologist
|-
|70/30 insulin
|
|Take usual dose
|Change to NPH
and give 50% of dose
|Coordinate with patient's endocrinologist
|-
|70/25 insulin
|
|Take usual dose
|Change to NPH
and give 50% of dose
|Coordinate with patient's endocrinologist
|-
|50/50 insulin
|
|Take usual dose
|Change to NPH
and give 50% of dose
|Coordinate with patient's endocrinologist
|-
|NPH insulin
|
|Take usual dose
|Take 50% of dose
|Coordinate with patient's endocrinologist
|-
|Prandial insulin
|
|Take usual mealtime dose
|Do not take
|Coordinate with patient's endocrinologist
|-
|Insulin pump
|
|
|Set at 80% basal rate
|Coordinate with patient's endocrinologist
|}

===Intraoperative management===

=== Postoperative management===

==Related surgical procedures ==

==Pathophysiology ==

==Signs and symptoms ==

==Diagnosis==
Diagnosis of diabetes can be made by a variety of ways:

# Fasting plasma glucose ≥ 126mg/dL
# Two-hour plasma glucose ≥ 200mg/dL
# A1C ≥ 6.5 prior to initiating anti-hyperglycemic medications

==Treatment==

===Medication===

===Surgery===

===Prognosis===

==Epidemiology==
The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. According to the 2017 National Diabetes Statistics Report from the Center for Disease Control (CDC), 10.5% of the U.S. population has diabetes with an estimated 21.4% of those who have the disease are still not diagnosed.<ref>{{Cite web|date=2020-09-28|title=National Diabetes Statistics Report, 2020 {{!}} CDC|url=https://www.cdc.gov/diabetes/data/statistics-report/index.html|access-date=2021-07-12|website=www.cdc.gov|language=en-us}}</ref>

==References==

<references />

[[Category:Comorbidities]]

Diabetes mellitus

2021-07-13T14:46:02Z

Diabetes mellitus

2021-07-12T13:28:57Z

Nkamdar: Added introduction

Diabetes is an endocrine, metabolic disorder marked by high levels of blood glucose. Three classifications of diabetics exist: (1) Type 1 Diabetes where an immune mediated destruction of pancreatic beta cells occurs causing a total reduction in endogenous insulin and thus causing hyperglycemia; (2) Type II Diabetes where patients experience increasing insulin resistance for the level of endogenous insulin thus causing hyperglycemia; and (3) Gestational Diabetes in which hyperglycemia occurs in the second or third trimester of pregnancy. The diagnosis of diabetes is made based on fasting blood glucose levels and hemoglobin A1c levels. The diabetic population in the United States is both increasing in incidence and prevalence within the last decade. According to the 2017 National Diabetes Statistics Report from the Center for Disease Control (CDC), 10.5% of the U.S. population has diabetes with an estimated 21.4% of those who have the disease are still not diagnosed.<ref>{{Cite web|date=2020-09-28|title=National Diabetes Statistics Report, 2020 {{!}} CDC|url=https://www.cdc.gov/diabetes/data/statistics-report/index.html|access-date=2021-07-12|website=www.cdc.gov|language=en-us}}</ref>
----[[Diabetes mellitus#%20ednref1|[i]]] T. N. N. D. I. Clearinghouse, ''National Diabetes Statistics Report'' (23/6/2014), pp. 1–12{{Infobox comorbidity
| other_names =
| anesthetic_relevance = High
| anesthetic_management = Preoperative HgA1c value
Preoperative glucose value
Preoperative medication adjustment
Insulin administration
Post-operative glucose
| specialty = Endocrine
| signs_symptoms = Excessive thirst
Polyuria
Polydypsia
Glucosuria
Peripheral neuropathy
Ocular degeneration
Cardiovascular disease
| diagnosis = HgA1c
Fasting glucose
| treatment = Oral anti-hyperglycemics
Exogenous insulin administration
| image =
| caption =
}}

== Anesthetic implications ==

=== Preoperative optimization ===

=== Intraoperative management ===

=== Postoperative management ===

== Related surgical procedures ==

== Pathophysiology ==

== Signs and symptoms ==

== Diagnosis ==

== Treatment ==

=== Medication ===

=== Surgery ===

=== Prognosis ===

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

Kidney transplant

2021-07-12T01:48:04Z

Nkamdar:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2, arterial line, +/- central line
| monitors = Standard, 5-lead ECG
| considerations_preoperative = ESRD patients should have potassium checked preop
| considerations_intraoperative = Mannitol, lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time
}}

Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
|-
|Cardiovascular
|CHF is common in undialyzed patients
|-
|Respiratory
|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
|-
|Gastrointestinal
|Gastroparesis may occur in diabetic patients with autonomic neuropathy
|-
|Hematologic
|Many patients will have chronic anemia as a result of low EPO
|-
|Renal
|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds
|-
|Endocrine
|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
|-
|Other
|
|}

=== Labs and studies ===
CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)

BMP (pay attention to K which may be elevated in ESRD)

=== Operating room setup ===

* Prepare a-line setup
* Have mannitol, furosemide, heparin in room

=== Patient preparation and premedication ===

* Midazolam, tylenol

=== Regional and neuraxial techniques ===

* Epidural or CSE may be used for postop pain management

== Intraoperative management ==

=== Monitoring and access ===

* After induction of anesthesia, a 3-way foley catheter is placed into the bladder.
* ± A-line for blood pressure monitoring and frequent lab draws, avoiding the side of the AV fistula

=== Induction and airway management ===
- If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used

=== Positioning ===
- Supine

- Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.

=== Maintenance and surgical considerations ===

* Standard maintenance
* Anticipate prolonged drug effects for renally metabolized/excreted medications
** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)

=== Emergence ===

* Patients are usually extubated in the OR
* Ensure adequate NMB reversal

== Postoperative management ==

=== Disposition ===

* Usually to PACU
* Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU

=== Pain management ===

* PCA
* Epidural

=== Potential complications ===

* Fistula thrombosis if improperly padded
* Hemorrhage
* Delayed urine output, dialysis may be needed until renal function returns
* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]

Diabetes mellitus

2021-07-12T01:41:02Z

Nkamdar: Started page. Created skeleton.

Cochlear implant surgery

2021-07-12T01:28:13Z

Nkamdar: procedure variants

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

==Preoperative management==

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

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

==Intraoperative management==

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

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

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

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

===Emergence===

==Postoperative management==

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

=== Post-op considerations ===

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

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

===Potential complications===
*PONV

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

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

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

==References==

[[Category:Surgical procedures]]

<references />

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