WikiAnesthesia - User contributions [en]

Veno-Venous Bypass

2022-08-14T20:33:11Z

SLindberg:

{{Infobox comorbidity
| anesthetic_relevance = High
| anesthetic_management = Monitoring for complications
| specialty = General and Vascular Surgery
| image =
| caption =
}}

A technique employed to mitigate the effects of obstructing the vena cava.<ref>{{Cite journal|last=Gurusamy|first=Kurinchi Selvan|last2=Koti|first2=Rahul|last3=Pamecha|first3=Viniyendra|last4=Davidson|first4=Brian R|date=2011-03-16|editor-last=Cochrane Hepato-Biliary Group|title=Veno-venous bypass versus none for liver transplantation|url=https://doi.wiley.com/10.1002/14651858.CD007712.pub2|journal=Cochrane Database of Systematic Reviews|language=en|doi=10.1002/14651858.CD007712.pub2}}</ref>

== Anesthetic implications ==

=== History: ===
Occlusion of the inferior vena cava at the level of the diaphragm reduces venous return to the right atrium by up to 60%. Historically this technique provided an alternative route of venous return during liver transplant. Advances in surgical technique particularly, piggyback implantation with partial occlusion of the ICV, have reduced the dependence on VVB at many centers in the United States.

=== Technique: ===
The bypass circuit consists of a heparin bonded tubing, a centrifugal pump, and a heat exchanger. Inflow catheters are typically placed by the surgeons via cutdown. One canula is placed in the greater saphenous vein with its tip extending to the external iliac vein. A second inflow canula is placed into the portal system, either the portal vein or one of the mesenteric veins. Blood aspirated from these two canulas flows through the circuit to a centrifugal pump and through a heat exchanger finally re-entering the circulation above the caval obstruction via a canula placed into the subclavian vein or the internal jugular vein.

High flow, heparin bonding and the absence of an oxygenator obviate the need for systemic heparinization during VVB.

Initiation of bypass flow is sequential, initially inflow from the femoral is opened and bypass is initiated. Once stable flow is established the portal system drainage is added to the circuit. It is important to quantify the flow from the femoral system and the additional flow from the portal system. To adequately decompress the portal system an additional one liter per minute of additional flow should accompany the addition of portal inflow. Total flow is typically on the order of 2 to 4 liters per minute.

Alternatively percutaneous canulas may be placed by anesthesia, but this is not common.<ref>{{Cite journal|last=Sakai|first=Tetsuro|last2=Gligor|first2=Silviu|last3=Diulus|first3=John|last4=McAffee|first4=Richard|last5=Wallis Marsh|first5=J.|last6=Planinsic|first6=Raymond M.|date=2010-09|title=Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists: Percutaneous veno-venous bypass in liver transplantation|url=https://onlinelibrary.wiley.com/doi/10.1111/j.1399-0012.2009.01145.x|journal=Clinical Transplantation|language=en|volume=24|issue=5|pages=585–591|doi=10.1111/j.1399-0012.2009.01145.x}}</ref>

=== Complications: ===

* [[Venous Air Embolism]]
* Circuit disconnect and hemorrhage
* Thrombosis

=== Monitoring: ===
Invasive arterial pressure monitoring is imperative to demonstrate adequacy of venous return and cardiac output.

Air embolism is not caused by circuit disconnection and sudden aspiration of large volumes of air, the centrifugal pump will seize and stop flow once air enters the pump head. Rather air embolism is caused by slow aspiration most commonly from cracks, or partially open fittings. A small steam of bubbles will pass through the pump and accumulate in the right heart and pulmonary artery. A small leak is typically not obvious to the naked eye, but may be detected by making a high point in the tubing after the heat exchanged where air can accumulate. A more sensitive means of detection is trans esophageal echo cardiography. Persistent presence of air in the right atrium should prompt immediate cessation of flow through the bypass circuit and examination for points of air entry.

Flow through the system should be monitored, when flow drops to low levels (threshold vary by institution but on the order of 400 cc per minute) the risk of thrombosis increases. Low flow should be brought to the attention of the surgeons, if flow can not be increased the bypass should be discontinued.<ref>{{Cite journal|last=Kim|first=H.Y.|last2=Ko|first2=J.S.|last3=Joh|first3=J.|last4=Lee|first4=S.|last5=Kim|first5=G.S.|date=2018-11|title=Weaning of Veno-venous Bypass in Liver Transplantation: A Single Center Experience|url=https://linkinghub.elsevier.com/retrieve/pii/S0041134518304081|journal=Transplantation Proceedings|language=en|volume=50|issue=9|pages=2657–2660|doi=10.1016/j.transproceed.2018.03.075}}</ref>

== Related surgical procedures ==
Liver transplant, Liver resection, nephrectomy for RCC with extension into the IVC, other surgery requiring extended duration of caval obstruction

== References ==

# Gurusamy, Kurinchi Selvan; Koti, Rahul; Pamecha, Viniyendra; Davidson, Brian R (2011-03-16). Cochrane Hepato-Biliary Group (ed.). "Veno-venous bypass versus none for liver transplantation". ''Cochrane Database of Systematic Reviews''. [[Doi (identifier)|doi]]:10.1002/14651858.CD007712.pub2.
# Sakai, Tetsuro; Gligor, Silviu; Diulus, John; McAffee, Richard; Wallis Marsh, J.; Planinsic, Raymond M. (2010-09). "Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists: Percutaneous veno-venous bypass in liver transplantation". ''Clinical Transplantation''. 24 (5): 585–591.
# Kim, H.Y.; Ko, J.S.; Joh, J.; Lee, S.; Kim, G.S. (2018-11). "Weaning of Veno-venous Bypass in Liver Transplantation: A Single Center Experience". ''Transplantation Proceedings''. 50 (9): 2657–2660.

[[Category:Comorbidities]]

Awake craniotomy

2022-08-14T20:29:37Z

SLindberg: minor addition

{{Infobox surgical case reference
| anesthesia_type = Scalp block
MAC
GA-awake-GA
| airway = Noninvasive O2
LMA
| lines_access = PIV x2
Arterial line
Central line
| monitors = Standard
5-lead ECG
Temperature
Urine output
ABP
CVP
Neuromonitoring
± Precordial doppler
| considerations_preoperative = Comprehensive patient consultation
Baseline neuro exam
| considerations_intraoperative = Scalp block required
Risk of seizure
| considerations_postoperative =
}}An '''awake craniotomy''' is a surgical procedure that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Patients are typically sedated during line placement and cranial opening, and then awakened once the dura is opened. Due to the unconventional nature of the surgery, this technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education.

The procedure can be performed using either monitored anesthesia care (MAC) or using an asleep-awake-asleep (SAS) technique. A recent meta-analysis suggests that MAC was associated with lower likelihood of failure and shorter procedure time, while SAS was associated with lower incidence of intraoperative seizure.<ref>{{Cite journal|last=Natalini|first=Daniele|last2=Ganau|first2=Mario|last3=Rosenkranz|first3=Ruben|last4=Petrinic|first4=Tatjana|last5=Fitzgibbon|first5=Karina|last6=Antonelli|first6=Massimo|last7=Prisco|first7=Lara|date=2020-01-16|title=Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/31972627|journal=Journal of Neurosurgical Anesthesiology|doi=10.1097/ANA.0000000000000675|issn=1537-1921|pmid=31972627}}</ref> The use of non-pharmacological anxiolytic techniques (e.g. hypnosis) to achieve success with an awake-awake-awake technique has also been reported.<ref>{{Cite journal|last=Zemmoura|first=Ilyess|last2=Fournier|first2=Eric|last3=El-Hage|first3=Wissam|last4=Jolly|first4=Virginie|last5=Destrieux|first5=Christophe|last6=Velut|first6=Stéphane|date=2016|title=Hypnosis for Awake Surgery of Low-grade Gliomas: Description of the Method and Psychological Assessment|url=https://pubmed.ncbi.nlm.nih.gov/26313220|journal=Neurosurgery|volume=78|issue=1|pages=53–61|doi=10.1227/NEU.0000000000000993|issn=1524-4040|pmid=26313220|via=}}</ref>

==Preoperative management==

===Patient consultation===
Detailed consultation to psychologically prepare the patient is essential to set expectations and address questions to minimize anxiety intraoperatively.<ref name=":2">{{Cite journal|last=Kulikov|first=Alexander|last2=Lubnin|first2=Andrey|date=2018|title=Anesthesia for awake craniotomy|url=https://pubmed.ncbi.nlm.nih.gov/29994938|journal=Current Opinion in Anaesthesiology|volume=31|issue=5|pages=506–510|doi=10.1097/ACO.0000000000000625|issn=1473-6500|pmid=29994938|via=}}</ref>
*Perform prior to the day of surgery
*Should include the neuropsychology team that will be performing intraoperative testing
* Discuss non-medical modalities of intraoperative anxiety management (as feasible)
**Music, hypnosis, phone calls, etc.

The patient experience of the surgical procedure should also be discussed in detail:
*Lines and foley catheter will be placed under sedation
**May experience the feeling of a full bladder when awakened
*Patient's head will be unable to move
**Will likely feel pressure
**Pain is possible, but can be addressed
**May experience dry mouth
*Patient will be able to communicate with the OR staff at all times while awake
*Patient should be encouraged to communicate any and all concerns during the operation
**discomfort with position should be addressed early before pt becomes distressed
**presence of aura, indicating impending seizure
*Patient will be asked to perform tasks and/or answer questions throughout the procedure

=== Patient evaluation ===
{| class="wikitable"
|+
! System
!Considerations
|-
| Neurologic
|
Neuro exam to establish baseline function and deficits. Consider signs and symptoms of:<ref>{{Cite journal|last=Buckner|first=JC|date=2007|title=Central nervous system tumors|url=|journal=Mayo Clin Proc|volume=82(10)|pages=1271-86|via=}}</ref>
*Increased ICP
*Impingement of motor areas
*Intracranial bleeding.
|-
|Cardiovascular
|
Evaluate for comorbidities which may be exacerbated by intraoperative stress during the procedure (i.e. being under drapes, head clamped in Mayfield pins, surgical sounds, etc.).
Increased ICP may result in [[Cushing's triad]] of HTN, bradycardia, and irregular respiratory pattern.<ref name=":0">{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2014|isbn=978-1-4511-7660-5|location=New York|pages=31-36}}</ref>
|-
|Pulmonary
|
Significant comorbidities (e.g. advanced COPD requiring supplemental oxygen or history of exacerbation, asthma with history of exacerbations requiring rescue inhaler use, etc.) should be assessed in advance to determine suitability for this procedure.

Detailed airway exam to estimate risk of airway compromise during sedation. OSA, morbid obesity, abnormal upper airway anatomy are relative contraindications to awake technique.
|-
|Gastrointestinal
|
Due to the lack of a protected airway and risk of aspiration, relative contraindications to this procedure include:
*History of nausea or vomiting (especially if present on the day of surgery)
* History of uncontrolled [[GERD]]
**If in Mayfield pins, active GERD may trigger coughing, resulting in potential for injury to head and neck
|-
|Endocrine
|
In patients with a history of diabetes, intraoperative glucose should be closely monitored.
*Hypoglycemia and extreme hyperglycemia may result in altered mental status that could interfere with neurological monitoring, disinhibition, and airway compromise.
|}

===Labs and studies===
*Complete blood count
* Metabolic panel
*Coagulation panel
*Type and screen

===Operating room setup===

*Be aware of type of table and head support to be employed to adjust anesthesia technique accordingly

===Patient preparation and premedication===
*For patients who are used to a morning cup of coffee, consider caffeine 200 mg PO before surgery to reduce the risk of withdrawal headache<ref>{{Cite journal|last=Potters|first=Jan-Willem|last2=Klimek|first2=Markus|date=2015|title=Awake craniotomy: improving the patient's experience|url=https://pubmed.ncbi.nlm.nih.gov/26263121/|journal=Current Opinion in Anaesthesiology|volume=28|issue=5|pages=511–516|doi=10.1097/ACO.0000000000000231|issn=1473-6500|pmid=26263121|via=}}</ref>
*glycopyrolate is an effective antisialagogue

=== Regional and neuraxial techniques===
{{#ev:youtube|https://www.youtube.com/watch?v=5mTEa7ZdM_g|480|right|Video demonstration of a scalp block}}
[[Scalp block|Scalp blocks]] are essential to achieve adequate analgesia during the awake phase.<ref name=":0" />
*Typically placed during the pre-awake phase using bupivacaine 0.5% or ropivacaine 0.5% (with epinephrine)
**If faster onset is desired, can be pre-blocked with buffered lidocaine 2%
**Placement prior to pinning and exposure will reduce anesthetic requirements
* Can be supplemented during the awake phase using buffered lidocaine 2%

==Intraoperative management==

===Monitoring and access===

*Arterial line
*CVC vs PICC
*Large bore IV(s)
*Microphone for patient to communicate
*± Precordial doppler

===Induction and airway management===
The pre-awake phase of the procedure involves line placement, positioning, and cranial opening. This phase may be achieved using MAC or general anesthesia with similar outcomes, and largely depends on institution and practitioner preference.<ref name=":2" /> The decision on what technique will be informed by experience with the surgical team, a common determining factor is the duration of the pre-awake phase.

If using MAC:

*Provide sedation using:<ref name=":0" />
**Midazolam 1-10 mg IV (titrated incremental doses)
**Dexmedetomidine 0.2-0.7 mcg/kg/hr
**Propofol 25-50 mcg/kg/min
*Place lines with field blocks using buffered lidocaine for patient comfort

If using general anesthesia:<ref name=":1" />

*Induce with propofol
*LMA use is typical, but use ETT if indicated
*Remifentanil is the preferred narcotic due to rapid titratability

===Positioning===
Positioning will vary depending on the surgical approach.<ref name=":1" /> Patients can be positioned supine, semi-laterally, or laterally.

The patient's head is typically secured in a pinned frame.

*Pin sites should be infiltrated with local anesthetic

===Maintenance and surgical considerations===

====Intraoperative seizures====
Seizures may occur during intraoperative stimulation mapping. Rates of incidence vary widely, ranging between 3-16%.<ref name=":1" /> Untreated intraoperative seizures may precipitate catastrophic complications. If seizures are generalized they may induce breath holding, and valsalva. Increased intrathoracic pressure suddenly decreases venous drainage from the brain and transcranial herniation can occur rapidly.

Intraoperative seizures must be rapidly recognized and treated, as postictal delirium can preclude effective neuropsychological monitoring and necessitate abortion of the procedure. Seizures can be treated using:<ref name=":1">{{Cite journal|last=Meng|first=Lingzhong|last2=McDonagh|first2=David L.|last3=Berger|first3=Mitchel S.|last4=Gelb|first4=Adrian W.|date=2017|title=Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner|url=https://pubmed.ncbi.nlm.nih.gov/28181184/|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=64|issue=5|pages=517–529|doi=10.1007/s12630-017-0840-1|issn=1496-8975|pmid=28181184|via=}}</ref>

*Cold water irrigation of the surgical field
*Low doses of propofol (30-50 mg)

There is limited evidence to support the use of levetiracetam for seizure prophylaxis.<ref>{{Cite journal|last=Pourzitaki|first=Chryssa|last2=Tsaousi|first2=Georgia|last3=Apostolidou|first3=Eirini|last4=Karakoulas|first4=Konstantinos|last5=Kouvelas|first5=Dimitrios|last6=Amaniti|first6=Ekaterini|date=2016|title=Efficacy and safety of prophylactic levetiracetam in supratentorial brain tumour surgery: a systematic review and meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/26945547/|journal=British Journal of Clinical Pharmacology|volume=82|issue=1|pages=315–325|doi=10.1111/bcp.12926|issn=1365-2125|pmc=4917799|pmid=26945547|via=}}</ref>

===Emergence ===

==Postoperative management==

===Disposition===

* Typically ICU for frequent neuro exams

===Pain management ===

* Scalp block will provide analgesia for 12-16 hours
* If supplemental analgesia is required
** Acetaminophen
** Use narcotics with caution as can interfere with neurologic examination

===Potential complications===

==Procedure variants==

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

==References==
<references />
[[Category:Surgical procedures]]
[[Category:Neurosurgery]]

Veno-Venous Bypass

2022-08-14T19:14:32Z

SLindberg: finished entry for VVB

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

A technique employed to mitigate the effects of obstructing the vena cava.<ref>{{Cite journal|last=Gurusamy|first=Kurinchi Selvan|last2=Koti|first2=Rahul|last3=Pamecha|first3=Viniyendra|last4=Davidson|first4=Brian R|date=2011-03-16|editor-last=Cochrane Hepato-Biliary Group|title=Veno-venous bypass versus none for liver transplantation|url=https://doi.wiley.com/10.1002/14651858.CD007712.pub2|journal=Cochrane Database of Systematic Reviews|language=en|doi=10.1002/14651858.CD007712.pub2}}</ref>

== Anesthetic implications ==

=== History: ===
Occlusion of the inferior vena cava at the level of the diaphragm reduces venous return to the right atrium by up to 60%. Historically this technique provided an alternative route of venous return during liver transplant. Advances in surgical technique particularly, piggyback implantation with partial occlusion of the ICV, have reduced the dependence on VVB at many centers in the United States.

=== Technique: ===
The bypass circuit consists of a heparin bonded tubing, a centrifugal pump, and a heat exchanger. Inflow catheters are typically placed by the surgeons via cutdown. One canula is placed in the greater saphenous vein with its tip extending to the external iliac vein. A second inflow canula is placed into the portal system, either the portal vein or one of the mesenteric veins. Blood aspirated from these two canulas flows through the circuit to a centrifugal pump and through a heat exchanger finally re-entering the circulation above the caval obstruction via a canula placed into the subclavian vein or the internal jugular vein.

High flow, heparin bonding and the absence of an oxygenator obviate the need for systemic heparinization during VVB.

Initiation of bypass flow is sequential, initially inflow from the femoral is opened and bypass is initiated. Once stable flow is established the portal system drainage is added to the circuit. It is important to quantify the flow from the femoral system and the additional flow from the portal system. To adequately decompress the portal system an additional one liter per minute of additional flow should accompany the addition of portal inflow. Total flow is typically on the order of 2 to 4 liters per minute.

Alternatively percutaneous canulas may be placed by anesthesia, but this is not common.<ref>{{Cite journal|last=Sakai|first=Tetsuro|last2=Gligor|first2=Silviu|last3=Diulus|first3=John|last4=McAffee|first4=Richard|last5=Wallis Marsh|first5=J.|last6=Planinsic|first6=Raymond M.|date=2010-09|title=Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists: Percutaneous veno-venous bypass in liver transplantation|url=https://onlinelibrary.wiley.com/doi/10.1111/j.1399-0012.2009.01145.x|journal=Clinical Transplantation|language=en|volume=24|issue=5|pages=585–591|doi=10.1111/j.1399-0012.2009.01145.x}}</ref>

=== Complications: ===

* [[Venous Air Embolism]]
* Circuit disconnect and hemorrhage
* Thrombosis

=== Monitoring: ===
Invasive arterial pressure monitoring is imperative to demonstrate adequacy of venous return and cardiac output.

Air embolism is not caused by circuit disconnection and sudden aspiration of large volumes of air, the centrifugal pump will seize and stop flow once air enters the pump head. Rather air embolism is caused by slow aspiration most commonly from cracks, or partially open fittings. A small steam of bubbles will pass through the pump and accumulate in the right heart and pulmonary artery. A small leak is typically not obvious to the naked eye, but may be detected by making a high point in the tubing after the heat exchanged where air can accumulate. A more sensitive means of detection is trans esophageal echo cardiography. Persistent presence of air in the right atrium should prompt immediate cessation of flow through the bypass circuit and examination for points of air entry.

Flow through the system should be monitored, when flow drops to low levels (threshold vary by institution but on the order of 400 cc per minute) the risk of thrombosis increases. Low flow should be brought to the attention of the surgeons, if flow can not be increased the bypass should be discontinued.<ref>{{Cite journal|last=Kim|first=H.Y.|last2=Ko|first2=J.S.|last3=Joh|first3=J.|last4=Lee|first4=S.|last5=Kim|first5=G.S.|date=2018-11|title=Weaning of Veno-venous Bypass in Liver Transplantation: A Single Center Experience|url=https://linkinghub.elsevier.com/retrieve/pii/S0041134518304081|journal=Transplantation Proceedings|language=en|volume=50|issue=9|pages=2657–2660|doi=10.1016/j.transproceed.2018.03.075}}</ref>

== Related surgical procedures ==
Liver transplant, Liver resection, nephrectomy for RCC with extension into the IVC, other surgery requiring extended duration of caval obstruction

== References ==

# Gurusamy, Kurinchi Selvan; Koti, Rahul; Pamecha, Viniyendra; Davidson, Brian R (2011-03-16). Cochrane Hepato-Biliary Group (ed.). "Veno-venous bypass versus none for liver transplantation". ''Cochrane Database of Systematic Reviews''. [[Doi (identifier)|doi]]:10.1002/14651858.CD007712.pub2.
# Sakai, Tetsuro; Gligor, Silviu; Diulus, John; McAffee, Richard; Wallis Marsh, J.; Planinsic, Raymond M. (2010-09). "Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists: Percutaneous veno-venous bypass in liver transplantation". ''Clinical Transplantation''. 24 (5): 585–591.
# Kim, H.Y.; Ko, J.S.; Joh, J.; Lee, S.; Kim, G.S. (2018-11). "Weaning of Veno-venous Bypass in Liver Transplantation: A Single Center Experience". ''Transplantation Proceedings''. 50 (9): 2657–2660.

[[Category:Comorbidities]]

Veno-Venous Bypass

2022-08-14T16:48:46Z

SLindberg: skeleton of new surgical technique page for VVB

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

A technique employed to mitigate the effects of obstructing the vena cava.

== Anesthetic implications ==

=== History: ===
Occlusion of the inferior vena cava at the level of the diaphragm reduces venous return to the right atrium by up to 60%. Historically this technique provided an alternative route of venous return during liver transplant. Advances in surgical technique particularly, piggyback implantation with partial occlusion of the ICV, have reduced the dependence on VVB at many centers in the United States.

=== Technique: ===
The bypass circuit consists of a heparin bonded tubing, a centrifugal pump, and a heat exchanger.

=== Complications: ===

== Related surgical procedures ==
Liver transplant, Liver resection, nephrectomy for RCC with extension into the IVC, other surgery requiring extended duration of caval obstruction

== Pathophysiology ==

== Signs and symptoms ==

== Diagnosis ==

== Treatment ==

=== Medication ===

=== Surgery ===

=== Prognosis ===

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

2022-08-14T15:12:47Z

SLindberg: new page, VVB technique primarily used for liver transplant

The '''table of contents''' is a non-comprehensive list of articles the editors of WikiAnesthesia feel should exist and will continuously evolve as the site grows from contributions from the anesthesia community.

Links which are '''<span style="color:#337AB7">blue</span>''' already exist on the wiki (but would surely benefit from additions and revisions). Links which are '''<span style="color:#9B1B2F">red</span>''' do not currently exist as articles on the site. Articles may exist in more than one location in the table of contents.

Please see our '''[[WikiAnesthesia:Author guide|author guide]]''' for instructions on how to start editing content on the site.

If you add a new article which is not currently listed but has a natural place in the table of contents, please edit this list to include it. We kindly ask that you do not make major changes to the table of contents before running it by an [{{fullurl:Special:ListUsers|group=editor}} editor] first.
=[[:Category:Surgical procedures|Surgical procedures]]=

==[[:Category:Cardiac surgery|Cardiac surgery]]==
*[[Aortic procedures]]
**[[Aortic aneurysm repair|Aortic aneurysm repair (AAA)]]
**[[Aortoplasty for supravalvular stenosis]]
**[[Repair of aortic aneurysm with graft]]
*[[Circulatory assist procedures]]
**[[Cardiopulmonary bypass|Cardiopulmonary bypass (CPB)]]
**[[Extracorporeal membrane oxygenation|Extracorporeal membrane oxygenation (ECMO)]]
**[[Insertion of permanently implantable aortic counterpulsation ventricular assist device|Insertion of permanently implantable aortic counterpulsation ventricular assist device (VAD)]]
**[[Insertion of percutaneous ventricular assist device|Insertion of percutaneous ventricular assist device (pVAD)]]
**[[Implantation of total replacement heart system]]
*[[Electrophysiology procedures]]
**[[Insertion of pacemaker or ICD]]
**[[Intracardiac catheter ablation for the treatment of arrhythmia]]
**[[Loop recorder implantation]]
*[[Myocardial procedures]]
**[[Excision of intracardiac tumor]]
**[[Ventriculomyotomy]]
**[[Ventricular aneurysmectomy]]
*[[Cardiac revascularization procedures]]
**[[Coronary artery bypass graft|Coronary artery bypass graft (CABG)]]
**[[Off-pump and minimally invasive coronary artery bypass grafting|Off-pump and minimally invasive coronary artery bypass grafting (OPCAB)]]
**[[Percutaneous transluminal coronary angioplasty|Percutaneous transluminal coronary angioplasty (PTCA)]]
**[[Transmyocardial laser revascularization]]
**[[Coronary endarterectomy]]
*[[Pericardial procedures]]
**[[Pericardiocentesis]]
**[[Pericardiectomy]]
*[[Septal procedures]]
**[[Septal myectomy/myotomy]]
**[[Transcatheter closure of ASD or VSD]]
**[[Open repair of ASD or VSD]]
*Transplant procedures
**[[Heart transplant]]
**[[Heart-lung transplant]]
**[[Lung transplant]]
*[[Valvular procedures]]
**[[Transcatheter aortic valve replacement|Transcatheter aortic valve replacement (TAVR)]]
**[[Transcatheter mitral valve replacement|Transcatheter mitral valve replacement (TMVR)]]
**[[Aortic valve repair or replacement|Aortic valve repair or replacement (AVR)]]
**[[Mitral valve repair or replacement|Mitral valve repair or replacement (MVR)]]
**[[Tricuspid valve repair or replacement]]
**[[Percutaneous balloon valvuloplasty]]

==[[:Category:General surgery|General surgery]]==
*[[Biliary tract surgery]]
**[[Cholecystectomy]]
**[[Excision of bile duct tumor]]
**[[Choledochal cyst excision or anastomosis]]
**[[Percutaneous transhepatic biliary drainage]]
**[[Percutaneous transhepatic cholangiography]]
**[[Endoscopic retrograde cholangiopancreatography]]
*[[Breast surgery]]
**[[Mastectomy]]
**[[Breast biopsy]]
**[[Breast lumpectomy]]
**[[Sentinel lymph node biopsy]]
*[[Colorectal surgery]]
**[[Anorectal surgery]]
***[[Hemorrhoidectomy]]
***[[Lateral internal sphincterotomy]]
***[[Incision and drainage of perianal abscess]]
***[[High resolution anoscopy|High resolution anoscopy (HRA)]]
***[[Sacral nerve stimulation for fecal incontinence]]
**[[Colectomy]]
**[[Pelvic exenteration]]
**[[Proctectomy]]
**[[Rectal prolapse surgery]]
***[[Mucosal sleeve resection|Mucosal sleeve resection (Delorme Procedure)]]
***[[Perineal rectosigmoidectomy]]
***[[Rectopexy]]
*[[Endocrine surgery]]
**[[Adrenalectomy]]
***[[Excision of pheochromocytoma]]
**[[Thyroidectomy]]
**[[Parathyroidectomy]]
*[[Esophageal surgery]]
**[[Cervical esophagostomy]]
**[[Esophagectomy]]
***[[Thoracoabdominal esophagectomy]]
***[[Minimally invasive esophagectomy]]
***[[Transhiatal esophagectomy]]
***[[Ivor Lewis esophagectomy]]
***[[McKeown esophagectomy]]
**[[Esophageal diverticulectomy]]
***[[Zenker's divericulectomy]]
**[[Esophagomyotomy]]
***[[Heller myotomy]]
**[[Esophagastric fundoplication]]
***[[Nissen fundoplication]]
**[[Surgical repair of esophageal perforation or rupture]]
*[[Hepatic surgery]]
**[[Hepatic resection]]
**[[Hepatorrhaphy]]
**[[Liver transplant]]
***[[Veno-Venous Bypass]]
*[[Intestinal surgery]]
**[[Appendectomy]]
**[[Closure of enteric fistula]]
**[[Duodenotomy]]
**[[Enterolysis procedure|Enterolysis procedure (Lysis of adhesions)]]
**[[Inguinal hernia repair]]
**[[Meckel's diverticulectomy]]
**[[Ostomy procedure]]
**[[Small bowel resection]]
**[[Ventral hernia repair]]
*[[Pancreatic surgery]]
**[[Pancreatectomy]]
**[[Pancreaticoduodenectomy|Pancreaticoduodenectomy (Whipple procedure)]]
*[[Splenic surgery]]
**[[Splenectomy]]
**[[Splenorrhaphy|Splenorrhaphy (Repair of ruptured spleen)]]
*[[Stomach surgery]]
**[[Gastric resection|Gastric resection (Gastrectomy)]]
**[[Percutaneous endoscopic gastrostomy|Percutaneous endoscopic gastrostomy (PEG)]]
**[[Gastric or duodenal perforation repair]]
**[[Bariatric surgery]]
***[[Gastric bypass surgery]]
****[[Roux-en-Y gastric bypass]]
****[[Biliopancreatic diversion with duodenal switch|Biliopancreatic diversion with duodenal switch (BPD/DS)]]
***[[Gastric restrictive surgery]]
****[[Laparoscopic adjustable gastric banding]]
****[[Open vertical sleeve gastrectomy]]
*[[Trauma surgery]]
*[[Hyperthermic intraperitoneal chemotherapy surgery|Hyperthermic intraperitoneal chemotherapy surgery (HIPEC)]]

==[[:Category:Interventional radiology procedures|Interventional radiology procedures]]==
*[[Superior vena cava recanalization]]

==[[:Category:Oral and maxillofacial surgery|Oral and maxillofacial surgery]]==
*[[Dental extraction]]

==[[:Category:Neurosurgery|Neurosurgery]]==
*[[Functional neurosurgery]]
**[[Deep brain stimulation|Deep brain stimulation (DBS)]]
**[[Vagus nerve stimulation|Vagus nerve stimulation (VNS)]]
**[[Responsive neurostimulation|Responsive neurostimulation (RNS)]]
*[[Intracranial neurosurgery]]
**[[Awake craniotomy|Awake craniotomy]]
**[[Bifrontal craniotomy for CSF leak]]
**[[Craniocervical decompression]]
**[[Craniotomy for intracranial aneurysm]]
**[[Craniotomy for cerebral embolectomy]]
**[[Craniotomy for intracranial vascular malformations]]
**[[Craniotomy for extracranial-intracranial revascularization|Craniotomy for extracranial-intracranial revascularization (EC-IC bypass)]]
**[[Craniotomy for tumor resection]]
**[[Craniotomy for trauma]]
**[[Transphenoidal resection of pituitary tumor]]
**[[Craniotomy for resection of epileptogenic focus]]
*[[Spinal neurosurgery]]
**[[Anterior cervical spine surgery]]
**[[Posterior cervical spine surgery]]
**[[Anterior thoracic spine surgery]]
**[[Posterior thoracic spine surgery]]
**[[Anterior lumbar/lumbosacral spine surgery]]
**[[Posterior lumbar/lumbosacral spine surgery]]
*[[CSF aspiration, diversion, or shunt procedures]]
**[[Ventriculocisternostomy|Ventriculocisternostomy (Torkildsen shunt)]]
**[[Ventriculoperitoneal shunt|Ventriculoperitoneal shunt (VP shunt)]]
**[[Ventriculoatrial shunt|Ventriculoatrial shunt (VA shunt)]]
*[[Carotid endarterectomy|Carotid endarterectomy (CEA)]]
*Neuro interventional radiology procedures
**[[Cerebral angiogram]]

==[[:Category:Obstetric and gynecologic surgery|Obstetric and gynecologic surgery]]==
*[[Cesarean section]]
*[[Dilation and curettage|Dilation and curettage (D&C)]]
*[[Endometrial ablation]]
*[[Hysterectomy|Hysterectomy (TAH)]]
*[[Hysteroscopy]]
*[[Myomectomy|Myomectomy (Fibroidectomy)]]
*[[Oophorectomy|Oophorectomy (BSO)]]
*[[Ovarian torsion surgery]]
*[[Pelvic exenteration]]
*[[Tubal ligation]]
*[[Vaginectomy]]

==[[:Category:Ophthalmology|Ophthalmology]]==
*[[Cataract surgery|Cataract surgery]]
*[[Corneal transplant]]
*[[Traveculectomy]]
*[[Ectropion repair]]
*[[Entropion repair]]
*[[Ptosis repair]]
*[[Eyelid reconstruction]]
*[[Pterygium excision]]
*[[Repair of ruptured of lacerated globe]]
*[[Dacryocystorhinostomy|Dacryocystorhinostomy (DCR)]]
*[[Enucleation]]
*[[Orbitotomy]]

==[[:Category:Orthopedic surgery|Orthopedic surgery]]==
*[[Foot and ankle surgery]]
*[[Hand surgery]]
**[[Hand or digit replantation]]
**[[Carpal tunnel release]]
**[[Fixation of fractures and dislocations of the wrist and hand]]
**[[Wrist arthroscopy]]
**[[Darrach procedure]]
**[[Arthrodesis of the wrist]]
**[[Excision of ganglion of the wrist]]
**[[Palmar and digital fasciectomy]]
**[[Repair of laceracted nerves/tendons of the hand]]
*[[Hip surgery]]
**[[Hip arthroplasty|Hip arthroplasty (THA)]]
*[[Lower leg surgery]]
**[[Open reduction and interal fixation of the tibial plateau fracture]]
*[[Joint replacement surgery]]
**[[Hip arthroplasty|Hip arthroplasty (THA)]]
**[[Knee arthroplasty|Knee arthroplasty (TKA)]]
**[[Shoulder arthroplasty|Shoulder arthroplasty (TSA)]]
*[[Knee surgery]]
**[[Knee arthroplasty|Knee arthroplasty (TKA)]]
*[[Orthopedic oncology surgery]]
*[[Shoulder surgery]]
**[[Shoulder arthroplasty|Shoulder arthroplasty (TSA)]]
*[[Spine surgery]]
*[[Sports surgery]]

==[[:Category:Otolaryngology|Otolaryngology]]==
*Airway procedures
**[[Bronchoscopy]]
**[[Deep extubation]]
**[[Laryngoscopy]]
*[[Ear, audiovestibular, and temporal bone procedures]]
**[[Cochlear implant surgery]]
**[[Tympanoplasty and/or mastoidectomy]]
*[[Esophageal surgery]]
**[[Esophageal diverticulectomy]]
**[[Esophagoscopy]]
*[[Jaw surgery]]
**[[Maxillary and mandibular osteotomy]]
**[[Temporomandibular joint surgery]]
*[[Pharyngeal surgery]]
**[[Glossectomy]]
**[[Tonsillectomy and/or adenoidectomy]]
*[[Nasal surgery]]
**[[Rhinectomy]]
**[[Rhinoplasty and/or septoplasty]]
*[[Neck surgery]]
**[[Brachial cleft cyst excision]]
**[[Cricothyroidotomy]]
**[[Laryngectomy]]
**[[Laryngoplasty]]
**[[Lymph node biopsy]]
**[[Platysmaplasty|Platysmaplasty (Neck lift)]]
**[[Submandibular gland excision]]
**[[Thyroid radiofrequency ablation]]
**[[Tracheal resection]]
**[[Tracheotomy]]
*[[Salivary and parotid surgery]]
**[[Parotidectomy]]
*[[Sinus surgery]]
**[[Functional endoscopic sinus surgery|Functional endoscopic sinus surgery (FESS)]]
**[[Maxillectomy]]

==[[:Category:Pediatric surgery|Pediatric surgery]]==
*[[Pediatric cardiac surgery]]
**[[Anastomosis of pulmonary artery to aorta]] (Redirects: [[Damus-Kaye-Stan procedure]])
**[[Ascending aorta to pulmonary artery shunt]] (Redirects: [[Waterson shunt]])
**[[Banding of pulmonary artery]]
**[[Descending aorta to pulmonary artery shunt]] (Redirects: [[Potts-Smith shunt]])
**[[Excision of coarctation of aorta]]
**[[Repair of pulmonary venous stenosis]]
**[[Repair of anomalous pulmonary venous return]]
**[[Repair of hypoplastic or interrupted aortic arch]]
**[[Repair of transposition of the great arteries]]
**[[Repair of truncus arteriosus]] (Redirects: [[Rastelli procedure]])
**[[Repair of patent ductus arteriosus]]
**[[Subclavian to pulmonary artery shunt]] (Redirects: [[Blalock-Taussig shunt]])
**[[Superior vena cava to pulmonary artery]] (Redirects: [[Glenn procedure]])
**Transcatheter Pulmonary Valve Implantation
**Cardiac Catheterization
*[[Pediatric neurosurgery]]
*[[Pediatric otorhinolaryngology]]
**[[Myringotomy for ear tubes]]
*[[Pediatric urology]]

==[[:Category:Plastic and reconstructive surgery|Plastic and reconstructive surgery]]==
*[[Burn surgery]]
**[[Burn wound debridement]]
**[[Burn wound skin grafting]]
**[[Burn wound scar revision]]
**[[Laser treatment for burn scar]]
*[[Panniculectomy]]
*[[Platysmaplasty|Platysmaplasty (Neck lift)]]

==[[:Category:Thoracic surgery|Thoracic surgery]]==
*[[Bronchopulmonary lavage]]
*[[Chest wall resection]]
*[[Diaphragmatic plication]]
*[[Drainage of empyema]]
*[[Endobronchial ultrasound-guided transbronchial needle aspiration]] (Redirects: [[EBUS-TBNA]])
*[[Lobectomy]] (Redirects: [[Wedge resection]])
*[[Lung volume reduction surgery]]
*[[Mediastinal tumor resection]]
*[[Mediastinoscopy]]
*[[Surgery for pleural mesothelioma|Pleural mesothelioma]]
*[[Pneumonectomy]]
*[[Repair of pectus excavatum or carinatum]]
*[[Thoracoplasty]]
*[[Thymectomy]]
*[[Tracheal resection]]
*[[Video-assisted thoracoscopic surgery]] (Redirects: [[VATS]])

==[[:Category:Vascular surgery|Vascular surgery]]==
*[[Arteriovenous access for hemodialysis]]
*[[Carotid endarterectomy|Carotid endarterectomy (CEA)]]
*[[Endovascular aortic repair|Endovascular aortic repair (TEVAR)]]
*[[Infrainguinal arterial bypass]]
*[[Lumbar sympathectomy]]
*[[Permanent vascular access]]
*[[Thoracic outlet syndrome surgery]]
*[[Transjugular intrahepatic portosystemic shunts|Transjugular intrahepatic portosystemic shunts (TIPS)]]
*[[Varicose vein stripping and ablation]]
*[[Femoral artery endarterectomy]]

==[[:Category:Urology|Urology]]==
*[[Brachytherapy]]
*[[Circumcision]]
*[[Cystectomy]]
*[[Cystoscopy]]
*[[Hypospadias repair]]
*[[Kidney transplant]]
*[[Lithotripsy]]
*[[Nephrectomy]]
*[[Nephrostomy]]
*[[Orchiectomy]]
*[[Penectomy]]
*[[Percutaneous nephrolithotomy or nephrolithotripsy]]
*[[Prostatectomy|Prostatectomy (TURP)]]
*[[Pelvic exenteration]]
*[[Suprapubic cystostomy]]
*[[Transurethral resection of bladder tumor|Transurethral resection of bladder tumor (TURBT)]]

==[[:Category:Out-of-operating room procedures|Out-of-operating room procedures]]==
*[[Cardioversion]]
*[[Electroconvulsive therapy|Electroconvulsive therapy (ECT)]]
*[[Gastroenterology procedures]]
**[[Endoscopic retrograde cholangiopancreatography|Endoscopic retrograde cholangiopancreatography (ERCP)]]
**[[Colonoscopy]]
**[[Upper GI endoscopy|Upper GI endoscopy (EGD)]]

=[[Airway management]]=
*[[Airway anatomy]]
*[[Airway assessment]]
*[[Aspiration under anesthesia]]
*[[Cormack-Lehane grading system]]
*[[Deep extubation]]
*[[Difficult airway algorithm]]
*[[Endobronchial intubation]] (Redirects: [[Mainstem intubation]])
*[[Mallampati score]]
*[[One-lung ventilation]]
**[[Bronchial blocker]]
**[[Double-lumen endotracheal tube]]
*[[Pediatric airway management]]
*[[Preoxygenation]]
*[[Transtracheal ventilation]]

==[[Airway equipment]]==
*[[Bougie]]
*[[Breathing circuits]] (Redirects: [[Ayre's T-piece]], [[Bain system]], [[Jackson-Rees]], [[Lack system]], [[Magill system]], [[Mapleson A]], [[Mapleson B]], [[Mapleson C]], [[Mapleson D]], [[Mapleson E]], [[Mapleson F]], [[Waters bag]])
*[[Bronchial blocker]]
*Endotracheal tubes
**[[Double-lumen endotracheal tube]] (Redirects: [[DLT]], [[Double-lumen endobronchial tube]])
**[[Endotracheal tube]] (Redirects: [[ETT]])
**[[Electromyographic endotracheal tube]] (Redirects: [[EMG ETT]], [[NIM EMG ETT]])
**[[Laser-resistant endotracheal tube]] (Redirects: [[Laser ETT]])
**[[Microlaryngeal endotracheal tube]] (Redirects: [[Microlaryngoscopy tube]], [[MLT]])
**[[Reinforced endotracheal tube]] (Redirects: [[Armored endotracheal tube]], [[Wire-reinforced endotracheal tube]])
**[[Ring-Adair-Elwyn endotracheal tube]] (Redirects: [[Nasal RAE ETT]], [[Oral RAE ETT]], [[RAE ETT]])
*Laryngoscope blades
**[[Macintosh laryngoscope blade]] (Redirects: [[MAC]])
**[[Miller laryngoscope blade]] (Redirects: [[Miller]])
**[[Wis-Hipple laryngoscope blade]] (Redirects: [[Miller]])
*[[Lighted stylet]] (Redirects: [[Lightwand]])
*[[Magill forceps]]
*Noninvasive ventilation
**[[Bag valve mask]] (Redirects: [[Ambu bag]], [[BVM]])
**[[Nasal cannula]]
**[[Non-rebreather mask]]
**[[High-flow nasal cannula]] (Redirects: [[HFNC]])
*Supraglottic airways
**[[Combitube]] (Redirects: [[Esophageal-tracheal double-lumen tube]])
**[[Laryngeal tube]] (Redirects: [[King LT]])
**[[Nasopharyngeal airway]] (Redirects: [[Nasal airway]])
**[[Oropharyngeal airway]] (Redirects: [[Oral airway]])
**Laryngeal mask airways
***[[Laryngeal mask airway]] (Redirects: [[LMA]])
***[[LMA Fastrach]] (Redirects: [[Intubating LMA]])
***[[LMA ProSeal]]
***[[LMA Unique]]
***[[LMA Supreme]]
***[[I-gel LMA]] (Redirects: [[IGel LMA]])
*[[Video laryngoscopes]]
**[[C-Mac]]
**[[Glidescope]]
*[[Yankauer suction tip]]

==[[:Category:Airway procedures|Airway procedures]]==
*[[Cricothyrotomy]] (Redirects: [[Cric]], [[Crike]], [[Thyrocricotomy]], [[Cricothyroidotomy]], [[Needle cricothyrotomy]])
*[[Endotracheal intubation]] (Redirects: [[Intubation]])
**[[Asleep fiberoptic intubation]]
**[[Awake fiberoptic intubation]]
**[[Nasal intubation]]
**[[Oral intubation]]
**[[Retrograde intubation]]
*[[Laryngoscopy]]
**[[Direct laryngoscopy]] (Redirects: [[DL]])
**[[Indirect laryngoscopy]] (Redirects: [[Fiberoptic laryngoscopy]], [[VL]], [[Video laryngoscopy]])
*[[Tracheotomy]] (Redirects: [[Tracheostomy]])

=Anatomy and physiology=
*[[Acid-base homeostasis]]
*[[Cerebral physiology]]
*[[Consciousness]]
*[[Cardiovascular anatomy and physiology]]
*[[Gastrointestinal physiology]]
*[[Hematology]]
* [[Hepatic physiology]]
* [[Renal physiology]]
* [[Respiratory physiology]]

= [[:Category:Comorbidities|Comorbidities]] =

== [[Acid-base disorders]] ==
* [[Metabolic acidosis]] (Redirects: [[Anion gap metabolic acidosis]], [[Diabetic ketoacidosis]], [[DKA]], [[High anion gap metabolic acidosis]], [[Hyperchloremic acidosis]], [[Ketoacidosis]], [[Lactic acidosis]], [[Nongap metabolic acidosis]], [[Normal anion gap metabolic acidosis]], [[Renal tubular acidosis]], [[RTA]])
* [[Metabolic alkalosis]] (Redirects: [[Contraction alkalosis]])
* [[Respiratory acidosis]]
* [[Respiratory alkalosis]]

== Cardiovascular disorders ==
* [[Acute coronary syndrome]] (Redirects: [[MI]], [[Myocardial infarction]], [[Myocardial ischemia]], [[Unstable angina]])
* [[Angina pectoris]] (Redirects: [[Prinzmetal's angina]], [[Stable angina]])
* [[Aortic aneurysm]]
* [[Aortic dissection]] (Redirects: [[Type A dissection]], [[Type B dissection]])
* [[Aortic rupture]]
* [[Arteriovenous malformation]] (Redirects: [[AVM]], [[Cerebral arteriovenous malformation]], [[Cerebral AVM]])
* [[Brugada syndrome]]
* [[Cardiac arrhythmias]]
** [[Asystole]]
** [[Atrial fibrillation]] (Redirects: [[Afib]])
** [[Atrial flutter]] (Redirects: [[Aflutter]])
** [[Bradycardia]] (Redirects: [[Sinus bradycardia]])
** [[Drug-induced QT prolongation]] (Redirects: [[QT prolongation]])
** [[Junctional rhythm]]
** [[Long QT syndrome]] (Redirects: [[Romano-Ward syndrome]])
** [[Pulseless electrical activity]] (Redirects: [[PEA]])
** [[Sick sinus syndrome]] (Redirects: [[Tachycardia-bradycardia syndrome]])
** [[Ventricular fibrillation]]
** [[Wandering atrial pacemaker]]
** [[Wolff-Parkinson-White syndrome]] (Redirects: [[WPW]])
** [[Heart block]] (Redirects: [[Atrioventricular block]], [[AV block]], [[SA block]], [[Sinoatrial block]])
*** [[Bundle branch block]] (Redirects: [[Bifascicular block]])
**** [[Left anterior fascicular block]] (Redirects: [[LAFB]])
**** [[Left bundle branch block]] (Redirects: [[LBBB]])
**** [[Left posterior fascicular block]] (Redirects: [[LPFB]])
**** [[Right bundle branch block]] (Redirects: [[RBBB]])
*** [[First-degree atrioventricular block]] (Redirects: [[1st-degree atrioventricular block]])
*** [[Second-degree atrioventricular block]] (Redirects: [[2nd-degree atrioventricular block]], [[Mobitz I]], [[Mobitz II]], [[Wenckebach block]])
*** [[Third-degree atrioventricular block]] (Redirects: [[3rd-degree atrioventricular block]], [[Complete heart block]], [[Trifascicular block]])
** [[Premature contraction]]
*** [[Premature atrial contraction]] (Redirects: [[PAC]])
*** [[Premature junctional contraction]] (Redirects: [[PJC]])
*** [[Premature ventricular contraction]] (Redirects: [[PVC]])
** [[Tachycardia]]
*** [[Supraventricular tachycardia]] (Redirects: [[SVT]])
**** [[Atrioventricular reentrant tachycardia]] (Redirects: [[AVRT]])
**** [[AV-nodal reentrant tachycardia]] (Redirects: [[AVNRT]])
**** [[Multifocal atrial tachycardia]]
**** [[Sinus tachycardia]]
*** [[Ventricular tachycardia]]
* [[Cardiac tamponade]]
* [[Cardiomyopathy]]
** [[Arrhythmogenic cardiomyopathy]]
** [[Dilated cardiomyopathy]]
** [[Hypertrophic cardiomyopathy]] (Redirects: [[HOCM]])
** [[Restrictive cardiomyopathy]]
** [[Takotsubo cardiomyopathy]] (Redirects: [[Broken heart syndrome]], [[Stress cardiomyopathy]])
** [[Tachycardia-induced cardiomyopathy]]
* Cardiomegaly
** [[Left atrial enlargement]] (Redirects: [[LAE]])
** [[Left ventricular hypertrophy]] (Redirects: [[LVH]])
** [[Right atrial enlargement]] (Redirects: [[RAE]])
** [[Right ventricular hypertrophy]] (Redirects: [[RVH]])
* [[Congenital heart defects]]
** [[Absent pulmonary valve syndrome]]
** [[Aortopulmonary septal defects]]
*** [[Aortopulmonary window]]
*** [[Double outlet right ventricle]] (Redirects: [[DORV]])
*** [[Persistent truncus arteriosus]] (Redirects: [[PTA]])
*** [[Taussig-Bing syndrome]]
*** [[Transposition of the great vessels]] (Redirects: [[d-TGA]], [[dextro-Transposition of the great arteries]], [[l-TGA]], [[levo-Transposition of the great arteries]], [[TGA]], [[TGV]])
** [[Atrial septal defect]] (Redirects: [[ASD]], [[Sinus venosus atrial septal defect]])
** [[Atrioventricular septal defect]] (Redirects: [[Atrioventricular canal defect]], [[Endocardial cushion defect]], [[AVSD]], [[Ostium primum atrial septal defect]])
** [[Bicuspid aortic valve]]
** [[Cor triatriatum]]
** [[Coronary artery anomaly]] (Redirects: [[AAOCA]], [[Anomalous aortic origin of a coronary artery]])
** [[Crisscross heart]]
** [[Dextrocardia]]
** [[Ebstein's anomaly]]
** [[Hypoplastic left heart syndrome]]
** [[Hypoplastic right heart syndrome]] (Redirects: [[Uhl anomaly]])
** [[Lutembacher's syndrome]]
** [[Tetralogy of Fallot]]
** [[Ventricular inversion]]
** [[Ventricular septal defect]] (Redirects: [[VSD]])
* [[Congenital vascular malformations]]
** [[Aberrant subclavian artery]]
** [[Anomalous pulmonary venous connection]] (Redirects: [[Partial anomalous pulmonary venous connection]], [[Scimitar syndrome]], [[Total anomalous pulmonary venous connection]])
** [[Aneurysm of sinus of Valsalva]]
** [[Coarctation of the aorta]]
** [[Congenital stenosis of vena cava]]
** [[Double aortic arch]]
** [[Interrupted aortic arch]]
** [[Overriding aorta]]
** [[Patent ductus arteriosus]] (Redirects: [[PDA]])
** [[Persistent left superior vena cava]]
** [[Pulmonary atresia]]
** [[Right-sided aortic arch]]
** [[Stenosis of pulmonary artery]]
** [[Vascular ring]]
* [[Coronary artery disease]] (Redirects: [[CAD]])
* [[Coronary steal syndrome]] (Redirects: [[Cardiac steal syndrome]])
* [[Endocarditis]] (Redirects: [[Acute bacterial endocarditis]], [[Infective endocarditis]], [[Nonbacterial thrombotic endocarditis]], [[Subacute bacterial endocarditis]])
* [[Heart failure]] (Redirects: [[Biventricular heart failure]], [[CHF]], [[Congestive heart failure]], [[Left-sided heart failure]], [[Right-sided heart failure]])
** [[Heart failure with reduced ejection fraction]] (Redirects: [[HFrEF]], [[Systolic heart failure]])
** [[Heart failure with preserved ejection fraction]] (Redirects: [[HFpEF]], [[Diastolic dysfunction]], [[Diastolic heart failure]])
** [[Pulmonary heart disease]]
* [[Gestational hypertension]]
* [[Hypertension (comorbidity)]] (Redirects: [[Essential hypertension]], [[HTN]])
* [[Pericardial effusion]]
* [[Pericarditis]]
* [[Peripheral artery disease]] (Redirects: [[PAD]])
* [[Pulmonary embolism]] (Redirects: [[PE]])
* [[Pulmonary heart disease]] (Redirects: [[Cor pulmonale]])
* [[Pulmonary hypertension]] (Redirects: [[PAH]], [[PH]], [[Pulmonary arterial hypertension]])
* [[Shock]]
** [[Cardiogenic shock]]
** [[Obstructive shock]]
** [[Distributive shock]] (Redirects: [[Septic shock]])
* [[Valvular heart disease]]
** [[Aortic stenosis]]
** [[Aortic regurgitation]]
** [[Mitral stenosis]]
** [[Mitral regurgitation]]
** [[Mitral valve prolapse]] (Redirects: [[MVP]])
** [[Pulmonary valve stenosis]]
** [[Pulmonary valve regurgitation]] (Redirects: [[Pulmonary valve insufficiency]])
** [[Tricuspid stenosis]] (Redirects: [[TS]])
** [[Tricuspid regurgitation]]

== Cerebrovascular disorders ==
* [[Anterior spinal artery syndrome]] (Redirects: [[Beck's syndrome]])
* [[Carotid artery stenosis]]
* [[Moyamoya disease]]
* [[Epidural hematoma]]
* [[Intracranial aneurysm]] (Redirects: [[Berry aneurysm]], [[Saccular aneurysm]])
* [[Intracranial hemorrhage]] (Redirects: [[Intracerebral hemorrhage]], [[Intraparenchymal hemorrhage]], [[Intraventricular hemorrhage]], [[SAH]], [[Subarachnoid hemorrhage]])
* [[Stroke]] (Redirects: [[Cerebral infarction]], [[Cerebrovascular accident]], [[CVA]], [[Hemorrhagic stroke]], [[Ischemic stroke]])
* [[Subdural hematoma]] (Redirects: [[SDH]])
* [[Vertebrobasilar insufficiency]] (Redirects: [[Subclavian steal syndrome]], [[VBI]])

== Electrolyte disorders ==
* [[Hypercalcemia]]
* [[Hyperkalemia]]
* [[Hypernatremia]]
* [[Hypocalcemia]]
* [[Hypokalemia]]
* [[Hyponatremia]] (Redirects: [[Hypotonic hyponatremia]], [[Isotonic hyponatremia]])

== Endocrine disorders ==
* [[Acromegaly]]
* [[Adrenal insufficiency]] (Redirects: [[Addison's disease]])
* [[Carcinoid syndrome]]
* [[Congenital adrenal hyperplasia]]
* [[Cushing's syndrome]]
* [[Diabetes insipidus]]
* [[Diabetes mellitus]]
** [[Gestational diabetes]]
** [[Type 1 diabetes]] (Redirects: [[DM1]], [[T1D]])
** [[Type 2 diabetes]] (Redirects: [[DM2]], [[T2D]])
* [[Hyperaldosteronism]] (Redirects: [[Bartter syndrome]], [[Conn syndrome]])
* [[Hyperlipidemia]] (Redirects: [[HLD]])
* [[Hyperparathyroidism]]
* [[Hyperthyroidism]] (Redirects: [[Graves' disease]], [[Thyrotoxicosis]])
* [[Hypoaldosteronism]]
* [[Hypoparathyroidism]]
* [[Hypothyroidism]] (Redirects: [[Cretinism]], [[Euthyroid sick syndrome]], [[Hashimoto's thyroiditis]], [[Myxedema]])
* [[Kallmann syndrome]]
* [[Multiple endocrine neoplasia]] (Redirects: [[Sipple syndrome]], [[Wagenmann-Froboese syndrome]], [[Wermer syndrome]])
* [[Obesity]]
* [[Pheochromocytoma]]
* [[Porphyria]] (Redirects: [[Acute intermittent porphyria]], [[AIP]])
* [[Serotonin syndrome]]
* [[Syndrome of inappropriate antidiuretic hormone secretion]] (Redirects: [[SIADH]])

== Gastrointestinal disorders ==
* [[Acute liver failure]] (Redirects: [[ALF]], [[Fulminant hepatic failure]], [[Hepatic encephalopathy]])
* [[Chronic liver disease]]
** [[Cirrhosis]] (Redirects: [[Chronic liver failure]])
** [[Hepatocellular carcinoma]]
* [[Gastroesophageal reflux disease]] (Redirects: [[Acid reflux]], [[GERD]], [[Heartburn]])
* [[Hepatitis]]

== Genetic disorders ==
* [[Amyloidosis]]
* [[Andersen-Tawil syndrome]]
* [[Antithrombin III deficiency]]
* [[Arrhythmogenic cardiomyopathy]]
* [[Bartter syndrome]]
* [[Bernard-Soulier syndrome]]
* [[Brugada syndrome]]
* [[Congenital adrenal hyperplasia]]
* [[Congenital afibrinogenemia]]
* [[Crouzon syndrome]]
* [[Cystic fibrosis]] (Redirects: [[CF]])
* [[Down syndrome]] (Redirects: [[Trisomy 21]])
* [[Dysfibrinogenemia]]
* [[Edwards syndrome]] (Redirects: [[Trisomy 18]])
* [[Ehlers-Danlos syndromes]] (Redirects: [[EDS]])
* [[Epidermolysis bullosa]] (Redirects: [[EB]])
* [[Fabry disease]]
* [[Factor V Leiden]]
* [[Fanconi syndrome]]
* [[Friedreich's ataxia]]
* [[Gitelman syndrome]]
* [[Glanzmann's thrombasthenia]]
* [[Glycogen storage disease]] (Redirects: [[Aldolase A deficiency]], [[Andersen disease]], [[Cori's disease]], [[Forbes' disease]], [[Hers' disease]], [[McArdle disease]], [[Pompe disease]], [[Tarui's disease]], [[von Gierke's disease]])
* [[Gray platelet syndrome]]
* [[Hemophilia]]
* [[Hereditary hemorrhagic telangiectasia]] (Redirects: [[HHT]], [[Osler-Weber-Rendu syndrome]])
* [[Hermansky-Pudlak syndrome]]
* [[Huntington's disease]]
* [[Hypoprothrombinemia]]
* [[Hypertrophic cardiomyopathy]]
* [[Jervell and Lange-Nielsen syndrome]]
* [[Kallmann syndrome]]
* [[Klippel-Feil syndrome]]
* [[Liddle's syndrome]]
* [[Long QT syndrome]]
* [[Marfan syndrome]]
* [[May-Hegglin anomaly]]
* [[Multiple endocrine neoplasia]]
* [[Noonan syndrome]]
* [[Pierre Robin sequence]]
* [[Protein C deficiency]]
* [[Protein S deficiency]]
* [[Loeys-Dietz syndrome]]
* [[Muscular dystrophy]] (Redirects: [[Becker muscular dystrophy]], [[Duchenne muscular dystrophy]], [[Limb-girdle muscular dystrophy]], [[Myotonic muscular dystrophy]])
* [[Neurofibromatosis]]
* [[Mucopolysaccharidosis]] (Redirects: [[Hunter syndrome]], [[Hurler syndrome]], [[Maroteaux-Lamy syndrome]], [[Morquio syndrome]], [[Natowicz syndrome]], [[Sanfilippo syndrome]], [[Scheie syndrome]], [[Sly syndrome]])
* [[Sickle cell disease]]
* [[Timothy syndrome]]
* [[Treacher Collins syndrome]]
* [[VACTERL association]]
* [[von Willebrand disease]]

== Head and neck disorders ==
* [[Epiglottitis]]
* [[Laryngomalacia]]
* [[Laryngotracheal stenosis]]
* [[Pharyngeal abscess]] (Redirects: [[Peritonsillar abscess]], [[Retropharyngeal abscess]])
* [[Pharyngitis]] (Redirects: [[Strep throat]], [[Tonsillitis]])

== Hematologic disorders ==
* [[Coagulopathies]]
** [[Disseminated intravascular coagulation]] (Redirects: [[DIC]], [[Purpura fulminans]])
** Hypercoagulable disorders
*** [[Antiphospholipid syndrome]] (Redirects: [[APLS]], [[APS]])
*** [[Antithrombin III deficiency]] (Redirects: [[ATIII deficiency]])
*** [[Essential thrombocythemia]]
*** [[Factor V Leiden]]
*** [[Protein C deficiency]]
*** [[Protein S deficiency]]
** Hypocoagulable disorders
*** [[Evans syndrome]]
*** [[Bernard-Soulier syndrome]]
*** [[Congenital afibrinogenemia]]
*** [[Dysfibrinogenemia]]
*** [[Glanzmann's thrombasthenia]]
*** [[Gray platelet syndrome]]
*** [[Hemophilia]] (Redirects: [[Factor IX deficiency]], [[Factor VII deficiency]], [[Factor VIII deficiency]], [[Factor X deficiency]], [[Factor XI deficiency]], [[Factor XII deficiency]], [[Factor XIII deficiency]], [[Haemophilia]], [[Hemophilia A]], [[Hemophilia B]], [[Hemophilia C]])
*** [[Heparin-induced thrombocytopenia]] (Redirects: [[HIT]], [[HITT]])
*** [[Hermansky-Pudlak syndrome]]
*** [[Hypoprothrombinemia]]
*** [[Thrombocytopenic purpura]] (Redirects: [[Idiopathic thrombocytopenic purpura]], [[ITP]], [[Thrombotic Thrombocytopenic purpura]], [[TTP]], [[Upshaw–Schulman syndrome]])
*** [[May-Hegglin anomaly]]
*** [[von Willebrand disease]] (Redirects: [[vWD]])

== Mediastinal disorders ==
* [[Mediastinal mass]]
* [[Mediastinitis]]
* [[Pneumomediastinum]] (Redirects: [[Mediastinal emphysema]])

== Musculoskeletal disorders ==
* Congenital musculoskeletal disorders
** [[Craniosynostosis]]
** [[Down syndrome]]
** [[Goldenhar syndrome]]
** [[Klippel-Feil syndrome]] (Redirects: [[KFS]])
** [[Pierre Robin sequence]] (Redirects: [[PRS]])
** [[Treacher Collins syndrome]] (Redirects: [[TCS]])

== [[Neonatal emergencies]] ==
* [[Abdominal wall defects]]
** [[Gastroschisis]]
** [[Omphalocele]]
* [[Choanal atresia]]
* [[Congenital diaphragmatic hernia]]
* [[Esophageal atresia]]
* [[Intestinal obstruction]]
** [[Congenital aganglionic megacolon]] (Redirects: [[Hirschsprung's disease]])
** [[Intestinal atresia]]
** [[Intestinal malrotation]] (Redirects: [[Volvulus]]
** [[Meconium ileus]]
* [[Necrotizing enterocolitis]] (Redirects: [[NEC]])
* [[Pyloric stenosis]]
* [[Spina bifida]]
* [[Tracheoesophageal fistula]]

== Neurologic disorders ==
* [[Amyotrophic lateral sclerosis]] (Redirects: [[ALS]])
* [[Autonomic dysreflexia]]
* [[Chronic pain (comorbidity)]]
* [[Dementia]]
* [[Dysautonomia]]
* [[Essential tremor]]
* [[Huntington's disease]]
* [[Multiple sclerosis]]
* [[Myasthenia gravis]]
* [[Parkinson's disease]]
* [[Seizures]] (Redirects: [[Epilepsy]])
* [[Stroke]]

== Obstetric disorders==
* [[Amniotic fluid embolism]] (Redirects: [[AFE]])
* [[Ectopic pregnancy]]
* [[Fetal distress]]
* [[Gestational hypertension]]
* [[Gestational diabetes]]
* [[Nuchal cord]]
* [[HELLP syndrome]]
* [[Obstetrical bleeding]]
* [[Placenta accreta spectrum]] (Redirects: [[Accreta]], [[Increta]], [[Percreta]], [[Placenta accreta]], [[Placenta increta]], [[Placenta percreta]])
* [[Umbilical cord prolapse]]
* [[Uterine rupture]]
* [[Vasa previa]]

== Psychiatric disorders ==
* [[Generalized Anxiety disorder]] (Redirects: [[Anxiety]], [[GAD]])
* [[Major depressive disorder]] (Redirects: [[Depression]], [[MDD]])
* [[Substance abuse]] (Redirects: [[Drug abuse]])

== Pulmonary disorders ==
* [[Acute respiratory distress syndrome]] (Redirect: [[ARDS]])
* [[Asthma]]
* [[Atelectasis]]
* [[Chronic obstructive pulmonary disease]] (Redirects: [[COPD]])
* [[Cystic fibrosis]]
* [[Lung cancer]]
* [[Obstructive sleep apnea]] (Redirects: [[OSA]])
* [[Pleural effusion]]
* [[Pneumonia]]
* [[Pneumothorax]]
* [[Pulmonary edema]]
* [[Pulmonary embolism]] (Redirects: [[PE]])
* [[Pulmonary hypertension]]
* [[Severe acute respiratory syndrome coronavirus 2]] (Redirects: [[Coronavirus]], [[COVID-19]], [[SARS-CoV-2]])

== Renal disorders ==
* [[Acute renal failure]]
* [[Bartter syndrome]]
* [[Diabetes insipidus]]
* [[Chronic kidney disease]] (Redirects: [[CKD]])
* [[Fanconi syndrome]]
* [[Gitelman syndrome]]
* [[Liddle's syndrome]]
* [[Uremia]]

=Perioperative management=
*[[Enhanced recovery after surgery|Enhanced recovery after surgery (ERAS)]]
*[[Perioperative prevention of chronic pain]]
*[[Perioperative visual loss]]
==Preoperative management==
*[[Preoperative patient assessment]]
*[[Preoperative medication management|Preoperative medication management]]
*[[NPO guidelines]]
==Postoperative management==
*[[Postoperative pain management]]
===Postoperative complications===
*[[Dental injury]]
*[[Intraoperative awareness]]
*[[Postoperative nausea and vomiting|Postoperative nausea and vomiting (PONV)]]
*[[Residual neuromuscular blockade]]

=Intraoperative emergencies=
*[[Acute coronary syndrome]] (Redirects: [[MI]], [[Myocardial infarction]], [[Myocardial ischemia]])
*[[Amniotic fluid embolism]] (Redirects: [[AFE]])
*[[Anaphylaxis]]
*[[Asystole]]
*[[Bradycardia (intraoperative emergency)]]
*[[Bronchospasm]]
*[[Cardiac arrest]]
*[[Delayed emergence]]
*[[Difficult airway algorithm]]
*[[Fire (intraoperative emergency)]] (Redirects: [[Airway fire]])
*[[Hypertension (intraoperative emergency)]]
*[[Hypotension (intraoperative emergency)]]
*[[Hypoxemia (intraoperative emergency)]]
*[[Laryngospasm]]
*[[Local anesthetic systemic toxicity]] (Redirects: [[LAST]])
*[[Malignant Hyperthermia]]
*[[Oxygen failure]]
*[[Pneumothorax]]
*[[Power failure]]
*[[Total spinal anesthesia]]
*[[Transfusion reaction]]
*[[Pulseless electrical activity]] (Redirects: [[PEA arrest]])
*[[Supraventricular tachycardia (intraoperative emergency)]] (Redirects: [[SVT (intraoperative emergency)]])
*[[Venous air embolism]] (Redirects: [[VAE]])
*[[Ventricular fibrillation]] (Redirects: [[VF]], [[Vfib]])
*[[Ventricular tachycardia]] (Redirects: [[Monomorphic ventricular tachycardia]], [[Polymorphic ventricular tachycardia]], [[Torsades de pointes]], [[VT]], [[Vtach]])

=Intraoperative monitoring=
*[[Arterial blood pressure]] (Redirects: [[ABP]])
*[[Capnography]] (Redirects: [[End-tidal CO2]], [[EtCO2]])
*[[Central venous pressure]] (Redirects: [[CVP]])
*[[Cerebral oximetry]] (Redirects: [[ScO2]])
*[[Core temperature]]
*[[Echocardiography]]
**[[Transesophageal echocardiography]] (Redirects: [[TEE]])
**[[Transthoracic echocardiography]] (Redirects: [[TTE]])
*[[Electrocardiography]] (Redirects: [[5-lead electrocardiogram]], [[ECG]])
*[[Electroencephalography]] (Redirects: [[BIS]], [[Bispectral index]], [[EEG]], [[Entropy monitoring]], [[Patient state index]], [[PSI]], [[SedLine]], [[Spectral edge frequency]])
*[[Intracranial pressure]] (Redirects: [[ICP]])
*[[Neuromonitoring]]
**[[Brainstem auditory evoked potentials]] (Redirects: [[BAEPs]])
**[[Motor evoked potentials]] (Redirects: [[MEPs]])
**[[Somatosensory evoked potentials]] (Redirects: [[SSEPs]])
**[[Visual evoked potentials]] (Redirects: [[VEPs]])
*[[Pleth variability index]] (Redirects: [[PVI]])
*[[Pulse oximetry]] (Redirects: [[Plethysmography]], [[SpO2]])
*[[Pulse pressure variation]] (Redirects: [[PPV]])
*[[Precordial doppler]]
*[[Pulmonary artery pressure]] (Redirects: [[PAP]])
*[[Peripheral IV]] (Redirects: [[IV]], [[Large bore IV]], [[PIV]])
*[[Urine output]] (Redirects: [[UOP]])

= Neuraxial and regional anesthesia =
* [[Local anesthetics]]
* [[Local anesthetic adjuvants]]
* [[Local anesthetic toxicity]] (Redirects: [[LAST]])

==[[Neuraxial anesthesia]]==
*[[Caudal anesthesia]]
*[[Combined spinal-epidural anesthesia]] (Redirects: [[CSE]])
*[[Epidural anesthesia]] (Redirects: [[Epidural]])
**[[Lumbar epidural]]
**[[Thoracic epidural]]
*[[Post-dural-puncture headache]] (Redirects: [[PDPH]])
*[[Spinal anesthesia]] (Redirects: [[Spinal]])
*[[Total spinal anesthesia]]

== [[Regional anesthesia]] ==
* [[Bier block]]
* [[Local anesthetics]]
* [[Local anesthetic adjuvants]]

=== [[Head and neck nerve blocks]] ===
* [[Blocks for awake tracheal intubation]]
* [[Cervical plexus block]]
* [[Scalp block]]

=== [[Upper extremity nerve blocks]] ===
* [[Blocks at the elbow]]
* [[Brachial plexus blocks]]
** [[Interscalene block]]
** [[Supraclavicular block]]
** [[Infraclavicular block]]
** [[Axillary block]]
* [[Digital block]]
* [[Wrist block]]

=== [[Thoracic and abdominal wall blocks]] ===
* [[Intercostal nerve block]]
* [[Pectoralis nerve block]]
* [[Quadratus lumborum block]] (Redirects: [[QL block]])
* [[Serratus plane block]]
* [[Transversus abdominis plane block]] (Redirects: [[TAP block]])
* [[Truncal block]] (Redirects: [[Iliohypogastric nerve block]], [[Ilioinguinal nerve block]], [[Rectus sheath block]])

=== [[Lower extremity nerve blocks]] ===
* [[Ankle block]]
* [[Fascia iliaca block]]
* [[Femoral nerve block]]
* [[Lumbar plexus block]]
* [[Obturator nerve block]]
* [[Popliteal nerve block]]
* [[Saphenous nerve block]]
* [[Sciatic nerve block]]

= Pharmacology =
* [[Equianalgesic]] (Redirects: [[MME]], [[Morphine milligram equivalent]])
* [[Pharmacodynamics]]
* [[Pharmacokinetics]]
** [[Blood-gas partition coefficient]]
** [[Context sensitive half-life]]
** [[Drug metabolism]]
** [[Elimination]]
** [[Ion trapping]]
** [[Redistribution]]

== Drug reference ==
=== Acetylcholinesterase inhibitors ===
* [[Edrophonium]]
* [[Neostigmine]] (Redirects: [[Bloxiverz]])
* [[Physostigmine]]

=== [[Adrenergic receptor modulators]] ===
Redirects: [[Alpha agonists]], [[Alpha antagonists]], [[Beta agonists]]
* Alpha-1 agonists
** [[Ephedrine]]
** [[Epinephrine]] (Redirects: [[Adrenaline]])
** [[Norepinephrine]] (Redirects: [[Noradrenaline]])
** [[Phenylephrine]] (Redirects: [[Neosynephrine]])
* Alpha-1 antagonists
** [[Labetalol]]
** [[Phenoxybenzamine]]
** [[Phentolamine]]
* Alpha-2 agonists
** [[Clonidine]] (Redirects: [[Catapres]])
** [[Dexmedetomidine]] (Redirects: [[Precedex]])
* Beta agonists
** Beta-1 selective agonists
*** [[Dobutamine]]
** [[Ephedrine]]
** [[Epinephrine]]
** [[Isoprenaline]] (Redirects: [[Isoproterenol]])
** [[Norepinephrine]]
* [[Beta blockers]] (Redirects: [[Beta antagonists]])
** Beta-1 selective antagonists
*** [[Esmolol]] (Redirects: [[Brevibloc]])
*** [[Metoprolol]]
** [[Labetalol]]

=== [[Analgesics]] ===
* [[Acetaminophen]] (Redirects: [[Tylenol]])
* [[Analgesic adjuvants]]
** [[Gabapentin]] (Redirects: [[Neurontin]])
** [[Ketamine]]
** [[Lidocaine]]
** [[Pregabalin]] (Redirects: [[Lyrica]])
* [[Nonsteroidal anti-inflammatory drugs]] (Redirects: [[NSAIDs]])
** [[Aspirin]] (Redirects: [[Acetylsalicylic acid]])
** [[Celecoxib]] (Redirects: [[Celebrex]])
** [[Ibuprofen]]
** [[Ketorolac]] (Redirects: [[Toradol]])
* [[Opioid analgesics]]
** [[Alfentanil]]
** [[Buprenorphine]]
** [[Codeine]]
** [[Fentanyl]]
** [[Hydrocodone]]
** [[Hydromorphone]]
** [[Methadone]]
** [[Meperidine]]
** [[Morphine]]
** [[Oxycodone]]
** [[Remifentanil]]
** [[Sufentanil]]

=== [[Antibiotics]] ===
* [[Cefazolin]] (Redirects: [[Ancef]], [[Kefzol]])
* [[Clindamycin]] (Redirects: [[Cleocin]])
* [[Vancomycin]]

=== Anticholinergics ===
* [[Atropine]]
* [[Glycopyrrolate]]

=== Antidotes ===
* [[Andexanet alfa]] (Redirects: [[Andexxa]])
* [[Atropine]]
* [[Dantrolene]]
* [[Flumazenil]]
* [[Glucagon]]
* [[Hydroxocobalamin]] (Redirects: [[Vitamin B12]])
* [[Idarucizumab]] (Redirects: [[Praxbind]])
* [[Methylene blue]] (Redirects: [[Methylthioninium chloride]])
* [[Physostigmine]]
* [[Naloxone]]
* [[Protamine]]
* [[Sugammadex]] (Redirects: [[Bridion]])

=== [[Antiemetics]] ===
* [[Aprepitant]] (Redirects: [[Fosaprepitant]], [[Emend]])
* [[Dexamethasone]]
* [[Granisetron]] (Redirects: [[Kytril]])
* [[Haloperidol]] (Redirects: [[Haldol]])
* [[Metoclopramide]] (Redirects: [[Reglan]])
* [[Ondansetron]] (Redirects: [[Zofran]])
* [[Prochlorperazine]] (Redirects: [[Compazine]])
* [[Promethazine]] (Redirects: [[Phenergan]])
* [[Propofol]]
* [[Scopolamine]] (Redirects: [[Hyoscine]])

=== Antifibrinolytics ===
* [[Tranexamic acid]] (Redirects: [[TXA]])

=== Antihistamines ===
* [[Diphenhydramine]] (Redirects: [[Benadryl]])
* [[Famotidine]] (Redirects: [[Pepcid]])

=== Antithrombotics ===
* Antiplatelet drugs
** [[Aspirin]]
** [[Clopidogrel]] (Redirects: [[Plavix]])
** [[Ticagrelor]] (Redirects: [[Brilinta]])
* Anticoagulants
** [[Apixaban]] (Redirects: [[Eliquis]])
** [[Argatroban]]
** [[Dabigatran]] (Redirects: [[Pradaxa]])
** [[Fondaparinux]]
** [[Heparin]]
** [[Low-molecular-weight heparin]] (Redirects: [[Enoxaparin]], [[Lovenox]], [[LMWH]])
** [[Rivaroxaban]] (Redirects: [[Xarelto]])
** [[Warfarin]] (Redirects: [[Coumadin]])
* Thrombolytics
** [[Tissue plasminogen activator]] (Redirects: [[Alteplase]], [[tPA]])
** [[Streptokinase]]

=== Anxiolytics ===
* [[Diazepam]]
* [[Lorazepam]]
* [[Midazolam]]

=== Benzodiazepines ===
* [[Diazepam]] (Redirects: [[Valium]])
* [[Flumazenil]]
* [[Lorazepam]] (Redirects: [[Ativan]])
* [[Midazolam]] (Redirects: [[Versed]])

=== [[Chronotropes]] ===
Redirects: [[Negative chronotropes]], [[Positive chronotropes]]
* Negative chronotropes
** [[Adenosine]]
** [[Beta blockers]]
*** [[Esmolol]]
*** [[Labetalol]]
*** [[Metoprolol]]
* Positive chronotropes
** [[Atropine]]
** [[Dobutamine]]
** [[Dopamine]]
** [[Ephedrine]]
** [[Epinephrine]]
** [[Glycopyrrolate]]
** [[Isoprenaline]]
** [[Milrinone]]
** [[Norepinephrine]]

* Electrolytes
** [[Calcium chloride]]
** [[Calcium gluconate]]
** [[Magnesium sulfate]]
** [[Potassium chloride]]

=== Diuretics ===

* [[Furosemide]]
* [[Mannitol]]

=== [[General anesthetics]] ===
* [[Inhalational anesthestics]] (Redirects: [[Volatile anesthetics]])
** [[Chloroethane]] (Redirects: [[Ethyl chloride]])
** [[Chloroform]]
** [[Cyclopropane]]
** [[Desflurane]] (Redirects: [[Suprane]])
** [[Diethyl ether]] (Redirects: [[Ether]])
** [[Enflurane]]
** [[Halothane]] (Redirects: [[Fluothane]])
** [[Isoflurane]] (Redirects: [[Forane]])
** [[Methoxyflurane]]
** [[Nitrous oxide]]
** [[Sevoflurane]] (Redirects: [[Ultane]])
** [[Xenon]]
* [[Intravenous anesthetics]]
** [[Etomidate]] (Redirects: [[Amidate]])
** [[Ketamine]] (Redirects: [[Esketamine]], [[Ketalar]])
** [[Methohexital]] (Redirects: [[Brevital]])
** [[Propofol]] (Redirects: [[Diprivan]])
** [[Thiopental]] (Redirects: [[Sodium pentothal]])

=== Imaging dyes ===
* [[Fluorescein]]
* [[Indocyanine green]]
* [[Methylene blue]] (Redirects: [[Methylthioninium chloride]])

=== [[Inodilators]] ===
* [[Dobutamine]]
* [[Milrinone]] (Redirects: [[Primacor]])

=== [[Inotropes]] ===
Redirects: [[Negative inotropes]], [[Positive inotropes]]
* Negative inotropes
** [[Beta blockers]]
* Positive inotropes
** [[Calcium chloride]]
** [[Calcium gluconate]]
** [[Dobutamine]]
** [[Dopamine]]
** [[Ephedrine]]
** [[Epinephrine]]
** [[Isoprenaline]]
** [[Milrinone]]
** [[Norepinephrine]]

=== [[Intravenous fluids]] ===
* [[Albumin]]
* [[Hetastarch]] (Redirects: [[Hydroxyethyl starch]])
* [[Intravenous sugar solution]] (Redirects: [[D5]], [[D50]], [[D5W]], [[D5NS]], [[D5LR]])
* [[Normal saline]] (Redirects: [[NS]])
* [[Lactated Ringer's]] (Redirects: [[LR]])
* [[Normosol]]
* [[Plasma-lyte]]
* [[Sodium bicarbonate]]

=== [[Local anesthetics]] ===
* [[Benzocaine]]
* [[Bupivacaine]] (Redirects: [[Marcaine]])
* [[Chloroprocaine]] (Redirects: [[Nesacaine]])
* [[Procaine]] (Redirects: [[Novocain]], [[Novocaine]])
* [[Lidocaine]] (Redirects: [[Xylocaine]])
* [[Mepivacaine]] (Redirects: [[Carbocaine]])
* [[Ropivacaine]] (Redirects: [[Naropin]])
* [[Tetracaine]]

=== [[Local anesthetic adjuvants]] ===
* [[Clonidine]]
* [[Epinephrine]]
* [[Fentanyl]]
* [[Hydromorphone]]
* [[Ketamine]]
* [[Midazolam]]
* [[Morphine]]
* [[Neostigmine]]
* [[Sufentanil]]
* [[Sodium bicarbonate]]

=== [[Neuromuscular blockers]] ===
* [[Cisatracurium]] (Redirects: [[Nimbex]])
* [[Mivacurium]]
* [[Rocuronium]] (Redirects: [[Zemuron]])
* [[Succinylcholine]] (Redirects: [[Anectine]])
* [[Vecuronium]]

=== [[Opioids]] ===
* [[Opioid analgesics]]
** Opium alkaloids and derivatives
*** [[Buprenorphine]] (Redirects: [[Subutex]])
*** [[Codeine]]
*** [[Hydrocodone]] (Redirects: [[Vicodin]])
*** [[Hydromorphone]] (Redirects: [[Dilaudid]])
*** [[Morphine]]
*** [[Oxycodone]] (Redirects: [[Oxycontin]], [[Roxicodone]])
** Synthetic opioids
*** [[Alfentanil]] (Redirects: [[Alfenta]])
*** [[Fentanyl]] (Redirects: [[Sublimaze]])
*** [[Methadone]]
*** [[Meperidine]] (Redirects: [[Demerol]], [[Pethidine]])
*** [[Remifentanil]] (Redirects: [[Ultiva]])
*** [[Sufentanil]] (Redirects: [[Sufenta]])
** [[Tramadol]] (Redirects: [[Ultram]])
* Opioid antagonists
** [[Naloxone]] (Redirects: [[Narcan]])
** [[Naltrexone]]
* [[Buprenorphine/naltrexone]] (Redirects: [[Suboxone]])

=== [[Sedative hypnotics]] ===
* [[Dexmedetomidine]]
* [[Etomidate]]
* [[Ketamine]]
* [[Methohexital]]
* [[Midazolam]]
* [[Propofol]]
* [[Thiopental]]

=== Steroids ===
* [[Dexamethasone]] (Redirects: [[Decadron]])
* [[Hydrocortisone]]

=== [[Uterotonics]] ===
* [[Carboprost]] (Redirects: [[Hemabate]])
* [[Methylergometrine]] (Redirects: [[Methergine]], [[Methylergonovine]])
* [[Misoprostol]] (Redirects: [[Cytotec]])
* [[Oxytocin]] (Redirects: [[Pitocin]])

=== [[Vasodilators]] ===
* Calcium channel blockers
** [[Clevidipine]] (Redirects: [[Cleviprex]])
** [[Nicardipine]] (Redirects: [[Cardene]])
** [[Nimodipine]] (Redirects: [[Nimotop]])
* Nitrovasodilators
** [[Nitric oxide]] (Redirects: [[NO]])
** [[Nitroglycerin]]
** [[Nitroprusside]] (Redirects: [[Nipride]], [[SNP]], [[Sodium nitroprusside]])
* Pulmonary vasodilators
** [[Nitric oxide]] (Redirects: [[NO]])
** [[Epoprostenol]] (Redirects: [[Flolan]], [[Prostacyclin]], [[Prostaglandin I2]])
* [[Dobutamine]]
* [[Fenoldopam]] (Redirects: [[Corlopam]])
* [[Hydralazine]]
* [[Milrinone]]
* [[Sildenafil]] (Redirects: [[Revatio]], [[Viagra]])

=== [[Vasoconstrictors]] ===
* [[Ephedrine]]
* [[Epinephrine]]
* [[Phenylephrine]]
* [[Norepinephrine]]
* [[Dopamine]]
* [[Vasopressin]] (Redirects: [[Vasostrict]])

=== Other drugs ===
* [[Octreotide]]

=[[:Category:Transfusion medicine|Transfusion medicine]]=
==[[:Category:Blood products|Blood products]]==
*[[Packed red blood cells|Packed red blood cells (pRBCs)]]
*[[Fresh frozen plasma|Fresh frozen plasma (FFP)]]
*[[Platelets]]
*[[Cryoprecipitate]]

=Procedures in anesthesia =
*[[Airway procedures]]
*[[Neuraxial anesthesia]]
*[[Regional anesthesia]]
*Vascular access procedures
**[[Arterial line]]
**Central line
***[[Central venous catheter|Central venous catheter (CVC)]]
***[[Introducer sheath|Introducer sheath (Cordis)]]
***[[Peripherally inserted central catheter|Peripherally inserted central catheter (PICC)]]
**[[Peripheral IV|Peripheral IV (PIV)]]
**Midline Catheter
**[[Microintroducer]]
**[[Rapid infusion catheter|Rapid infusion catheter (RIC)]]

=[[Subspecialties in anesthesia]]=
*[[Cardiothoracic anesthesia]]
*[[Critical care medicine]]
*[[Neuroanesthesia]]
*[[Obstetric anesthesia]]
*[[Pain medicine]]
*[[Pediatric anesthesia]]
*[[Pediatric cardiac anesthesia]]
*[[Perioperative medicine]]
*[[Regional anesthesia and acute pain]]
*[[Transplant anesthesia]]

Liver transplant

2022-08-07T21:56:19Z

SLindberg: multiple minor edits, and a couple of sections

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

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

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

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

{| class="wikitable"
|+
!System
! Considerations
|-
|Neurologic
|
*Patients with liver disease are at risk for encephalopathy.
*Mental status may be further depressed by coexisting metabolic derangements, including hyponatremia and hypoglycemia.
*The failure of hepatic clearance of various toxins, such as ammonia, can lead to alterations in endogenous neurotransmitters and neuro-signaling pathways, largely involving y-aminobutyric acid (GABA), glutamate and nitric oxide.
*Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
*Acute fulminant hepatic failure may be accompanied by elevated intracranial pressure and varying degrees of coma.
*Preoperative placement of intracranial pressure monitors may guide peri-operative neuroprotective strategies, with the goal to maintain adequate cerebral perfusion pressure.
*Patients may be unable to consent for surgery, and may exhibit delayed emergence following anesthesia.
*A thorough baseline neurologic and mental status exam is necessary prior to surgery, to assist with assessment following transplantation and anesthetic exposure.
|-
|Cardiovascular
|
* Systemic circulatory changes result in a hyperkinetic blood flow in most vascular beds, resulting in increased cardiac output and elevated circulating blood volume. Nitric oxide, cannabinoids, and cGMP have been implicated in the pathogenesis of this state. This is often further associated with lower PVR to accommodate this dynamic circulatory state.<ref>{{Cite journal|last=Møller|first=Søren|last2=Bendtsen|first2=Flemming|date=2018-04|title=The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis|url=https://onlinelibrary.wiley.com/doi/10.1111/liv.13589|journal=Liver International|language=en|volume=38|issue=4|pages=570–580|doi=10.1111/liv.13589}}</ref>
*Systemic vasodilation results from circulation of vasoactive mediators and vasodilators, as well as low grade endotoxin, which are not cleared by the compromised liver.
*Due to high circulating blood volume, many patients will have elevated filling pressures, reflected as high CVP, PCWP and PADP. However, transpulmonary pressure gradients are often normal.
*Decompensated liver failure is often accompanied by some degree of diastolic dysfunction, chronotropic incompetence and catecholamine insensitivity.
*A common finding on ECG is prolongation of QTc. When pronounced care must be taken to avoid medications known to prolong the QT interval. Magnesium levels should be maintained greater than 2 mg/dl.
*A subset of patients will manifest signs of cirrhotic cardiomyopathy, further characterized by conduction abnormalities/rhythm disturbances, alterations in calcium handling at the myocyte level and depressed myocardial performance.
*A very small subset of patients will have pulmonary hypertension, a pathological condition defined as a mean pulmonary artery pressure (mPAP) of greater than 25 mm Hg at rest, with a PCWP less than 15 mm Hg, and elevated pulmonary vascular resistance. Portopulmonary hypertension (PPHTN) further includes presence of portosystemic shunt. It is essential for portopulmonary hypertension (PPHTN) to be identified early, as significant perioperative mortality exists in patients with severe disease (mPAP>45, with associated elevation in PVR). There is a general consensus that there is a prohibitively high risk of intra and postoperative mortality in patients with mPAP> 45 mm Hg and PVR that exceeds 250 dynes/s/cm-5 .
*Early referral for initiation of pulmonary vasodilators (ie prostacyclin, PDE5 inhibitor, endothelin antagonist) is recommended, to evaluate response to therapy/disease reversibility and candidacy for future liver transplantation. Associated right ventricular dysfunction may recover, but correlates with severity of pressure overload.
* Echocardiography is routinely performed to evaluate RV function, LV systolic function, and measure RVSP. In the presence of elevated RVSP, right heart catheterization will be performed to assess RV function, measure cardiac output, and determine presence of elevation in pulmonary vascular resistance. If the diagnosis of PPHTN is made, treatment can be initiated and transplantation may be deferred. A favorable response to vasodilators is ideal, as this indicates presence of a reactive pulmonary bed and confers potential therapeutic options in the event of a precipitous rise in pulmonary artery pressures intraoperatively (application of inhaled nitric oxide or epoprostenol).
*Dobutamine stress echocardiography is an ideal preoperative screening assessment, as it can identify metabolic imbalance and ischemic risk, as well as underlying structural abnormalities. This test has a negative predictive value of 92-97%, with a negative test predicting good prognosis and low likelihood of major adverse cardiac events (Donovan et al, 1996; Cotton et al, 2002). If ischemic changes are present, a left heart catheterization should be performed to determine presence of severe coronary arteriopathy that may warrant intervention (angioplasty/stent v revascularization) prior to transplantation.
*The presence of coronary artery disease is associated with higher morbidity and mortality (Plotkin et al, 1996).
|-
| Pulmonary
|
*Pulmonary abnormalities are common in patients with advanced liver disease. Presence of intrapulmonary shunt, ventilation-perfusion defects, and abnormalities in lung compliance are frequently encountered. Many transplant recipients are of advanced age, and thus have changes in FRC, closing capacity, and lung elasticity which may result in challenges with ventilation and gas exchange.
*Restrictive lung disease, largely secondary to presence of ascites and pleural effusions, may be noted during positive pressure ventilation. Careful attention is necessary during induction of anesthesia, to optimize patient position and pre-oxygenation, to mitigate ensuing hypoxemia that may occur during brief apnea.
*Lung protective ventilation with appropriately calculated tidal volume (6-8 cc/kg PBW) and application of PEEP should be employed during surgery, to minimize ventilator induced lung injury.
*Hypoxemia may be present secondary to hepatopulmonary syndrome (HPS) which, if severe, may persist for months following transplantation.
*HPS may present as asymptomatic cyanosis, though patients often endorse platypnea and orthodeoxia. Etiology is likely related to elaboration of vasoactive mediators (ie nitric oxide), which result in formation of abnormal pulmonary vascular communications, resulting in A-V shunt. This diagnosis can be confirmed by echocardiogram with “bubble” study, which will reveal presence of bubbles/agitated saline in the left atrium, 3-5 cycles after injection. Some correction of hypoxemia with 100% oxygen confers a favorable post-operative prognosis.
|-
|Gastrointestinal
|
*Portal hypertension is present in the majority of patients receiving liver transplantation. This may manifest as severe GI bleed, gastric and esophageal varices, ascites, and previous portosystemic shunts. All patients with decompensated liver disease are at risk for delayed gastric emptying and, as such, rapid sequence intubation is strongly encouraged. Close attention to ascitic drainage during dissection is essential, and volume replacement with colloid rich solution is generally pursued to minimize hemodynamic changes associated with rapid fluid shifts. The presence of severe cirrhosis and portal hypertension often leads to engorgement of collateral vessels in the splanchnic and portal circulation, which may increase risk of massive bleeding during the dissection phase and vascular/hepatic mobilization. Ongoing GI bleed may continue intra-operatively. Some clinicians advocate management with octreotide to mitigate bleeding risk. Appropriate blood product transfusions and volume replacement is necessary in response to signs of ongoing bleeding and hypovolemia.
|-
|Hematologic
|
*The predominant hematologic abnormality in patients awaiting liver transplantation is anemia. This results from occult or clinical bleeding, malnutrition/malabsorption, hemolysis, and reduced production red blood cells production, often exacerbated by co-existing renal disease.
*Thrombocytopenia secondary to thrombopoietin deficiency and splenic sequestration is common in patients with portal hypertension, and functional platelet defects may be exacerbated by uremia.
*Coagulation defects result from reduced production of clotting factors and inhibitors, vitamin K deficiency, abnormalities in fibrinolysis, and reduced clearance of activated factors (Amitrano et al, 2002; Kawasaki at al, 1999; Ingeberg et al 1985; Rubin et al, 1979).
*Associated trauma (secondary to surgery), sepsis, bleeding, or shock, may result in secondary fibrinolysis and disseminated intravascular coagulation (DIC).
*Deficiencies in inhibitors and serine proteases, such as plasminogen activator inhibitor, may increase risk for thrombosis in certain patients.
*Many individuals with biliary disease and associated autoimmune pathology, may have concomitant hypercoagulable conditions, increasing risk of vascular thrombosis after re-perfusion.
*Due to the complexity of hematologic derangements, it is imperative to approach transfusion strategies in a data-driven and clinically influenced manner. Interpretation of TEG, as well as clinical bleeding or hypercoagulability in the surgical field, should be primary variables used to impact decisions regarding transfusion with plasma, platelets, cryoprecipitate and administration of recombinant synthetic factors.
*Catastrophic consequences of inappropriate transfusion strategies include hepatic artery thrombosis with subsequent graft failure.
|-
|Renal
|
*Many patients with end-stage liver disease will have associated renal insufficiency or renal failure.
* Generally patients with chronic renal failure will be listed for combined liver-kidney transplantation.
*Etiology of renal failure is often multifactorial, and related to relative hypoperfusion of the renal bed with acute kidney injury, acute tubular necrosis related to medication administration (contrast, etc), and possible acute interstitial nephritis.
*Patients may carry the diagnosis of hepatorenal syndrome (HRS), which occurs as a result of intense renal vasoconstriction prompted by renin-angiotensin activation in response to profound splanchnic vasodilation. HRS is often reversible with liver transplantation.
*Some patients will require acute hemodialysis in the period prior to transplantation.
*It is essential to determine associated anuria/oliguria, clinical response to diuretic therapy, associated metabolic derangements, and volume status in this patient population. Patients may require dialysis prior to commencement of transplant.
* It is rare to utilize intraoperative RRT, however, acute changes in potassium secondary to transfusion and reduced clearance, may warrant this therapy.
*Our strategy to manage this select patient population involves: limitation of exogenous potassium administration, red blood cell washing by perfusion prior to administration, gentle supplementation with bicarbonate containing fluids, possible diuretic challenge, and close monitoring of electrolytes.
*Crystalloid administration may be limited in this patient population in the presence of clinical hypervolemia with associated portal hypertension.
|-
|Endocrine
|
*A myriad of metabolic perturbations may be present in the liver transplant recipient.
* Hypoglycemia is common in patients with advanced disease, due to impairment in gluconeogenesis.
*Patients may require supplementation with dextrose prior to surgery.
*A sign of graft function in the neohepatic phase, is hyperglycemia/insulin requirement in response to steroid administration.
*Patients often present with impaired temperature regulation resulting in hypothermia, prior to reperfusion of the new graft.
*As previously detailed, careful attention to application of external body warmers and warmed fluid administration, is essential to maintain normothermia and optimize hemostatic conditions.
*On occasion, patients with severe portal hypertension may also present with hyponatremia. This can occur as a result of altered renal free water handling/elimination and water retention resulting from activation of ADH in the setting of splanchnic vasodilation. These derangements may be exacerbated by concomitant sodium dietary restriction and use of diuretic therapy.
*Rapid correction of sodium intra-operatively should be avoided, to reduce clinical risk of CPM. This may involve supplementation of solute-rich colloid administration with hypotonic fluids intra-operatively, to maintain baseline sodium levels.
|-
|ID
|
*Patients with end-stage liver disease are at high risk of infections. Altered hepatic clearance and dysregulation of Kupffer cell function, combined with poor underlying nutritional status, result in a functional immunocompromised state.
*Not uncommonly, these patients are treated, at the time of transplant, for biliary infections, spontaneous bacterial peritonitis (SBP), aspiration pneumonia, or cellulitis. Active septicemia or severe infection without treatment/source control, are contraindications to transplant.
* Appropriate selection of antimicrobials is necessary, and should be guided by infection source, probable or confirmed infectious pathogens, and patient history (previous infectious culprits/colonization). Standard antimicrobial prophylaxis is: cefazolin/metronidazole, or cefotetan.
*If there is concern for SBP at the time of transplantation, or if donor variables present concerns for possible infection/contamination, antimicrobial selection should be adjusted accordingly.
*Re-dosing of antibiotics should be guided by agent selection, blood loss, and recipient renal function.
|}

===Labs and studies===

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

===Operating room setup===

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

===Patient preparation and premedication===

* Generally sedative premedication is avoided due to patient susceptibility to exacerbation of underlying hepatic encephalopathy.

===Regional and neuraxial techniques===

* Avoided due to coagulopathy.

== Intraoperative management<ref>{{Cite journal|last=Adelmann|first=Dieter|last2=Kronish|first2=Kate|last3=Ramsay|first3=Michael A.|date=2017-09|title=Anesthesia for Liver Transplantation|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227517300472|journal=Anesthesiology Clinics|language=en|volume=35|issue=3|pages=491–508|doi=10.1016/j.anclin.2017.04.006}}</ref>==

===Monitoring and access===

* Large bore PIVs
* arterial line (at some institutions it is common to place two arterial lines)
* Central access (often large-bore volume line and an infusion line).
** Common practice can include introducer catheter for volume and a triple lumen catheter for infusions.
** CVP monitoring.
* Intraoperative TEE and/or pulmonary artery catheter are routine in many centers

===Induction and airway management===

* Increased intra-abdominal pressure and high probability of gastroparesis necessitate rapid sequence induction.
* Induction dose of propofol should be reduced in patients with severe liver disease due to altered pharmacodynamics (low albumin level), and increased sensitivity.
* Non depolarizing neuromuscular blocking agents should be chosen with patients organ function in mind. Often Cis-atricurium is chosen due to its predictable metabolism.

===Positioning===

* Supine

===Maintenance and surgical considerations===

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

===Emergence===

==Postoperative management==

===Disposition===

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

=== Pain management===

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

===Potential complications===

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

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]

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

WikiAnesthesia - User contributions [en]

Veno-Venous Bypass

Awake craniotomy

Veno-Venous Bypass

Veno-Venous Bypass

Table of contents

Liver transplant