WikiAnesthesia - User contributions [en]

Ketorolac

2024-02-14T20:16:47Z

Seanmliu: Updated blank article

{{Infobox drug reference
| trade_names = Toradol
| drug_class = NSAID
| drug_class_color =
| uses = Post-op pain
| contraindications = Renal disease or injury, peptic ulcer disease, GI bleeding
| routes = IV, IM, oral
| dosage = IV or IM: 30mg once, if needed can repeat q6h up to 120mg daily
| dosage_calculation = ketorolac
| mechanism = Inhibition of COX (COX-1 > COX-2)
| time_onset = 10-15 minutes
| duration = 2-4 hours
}}

Ketorolac is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that is frequently used intra-op for management of post-op pain.

== Uses ==

* Post-op pain management

== Contraindications ==

=== Absolute contraindications ===

* GFR < 30mL/min

=== Precautions ===

* Chronic renal disease
* AKI
* GI bleeding
* Peptic ulcer disease

== Pharmacology ==

=== Pharmacodynamics ===

==== Mechanism of action ====

* NSAID that inhibits COX
* Of the NSAIDs, most selective for COX-1 inhibition over COX-2

==== Adverse effects ====

* COX-1 selectivity increases risk for GI tract irritation and bleeding
* Thromboembolic disease is always a consideration when using NSAIDs, although ketorolac has lower risk for exacerbating thromboembolic disease compared to more COX-2 selective agents like celecoxib

=== Pharmacokinetics ===

* Highly protein bound
* Almost completely renally eliminated

== Chemistry and formulation ==

== History ==

== References ==
<ref>Toda C, Naguib M. Peripherally acting analgesics. In: Flood P, Rathmell JP, and Urman RD (eds). Stoelting’s Pharmacology & Physiology in Anesthetic Practice. Sixth edition. Philadelphia, Pennsylvania; Wolters Kluwer; 2022: 257-65.</ref><ref>{{Cite web|title=Nonsteroidal Anti-inflammatory Drugs|url=https://www.openanesthesia.org/keywords/nonsteroidal-anti-inflammatory-drugs/|url-status=live}}</ref><ref>Colvin L. Physiology and pharmacology of pain. In: Thompson, JP, Moppett IK, and Wiles M (eds). Smith and Aitkenhead’s Textbook of Anaesthesia. 7th ed. Edinburgh; Elsevier; 2019: 99-120.</ref><ref>Aronson JK. Non-steroidal anti-inflammatory drugs. In: Aronson, JK. Meyler’s Side Effects of Drugs: the International Encyclopedia of Adverse Drug Reactions and Interactions. Sixteenth edition. Amsterdam, Netherlands; Elsevier; 2016: 236-72.</ref><ref>Hurley R, Elkassabany NM, Wu CL. Acute postoperative pain. In: Miller’s Anesthesia. 9th ed. Philadelphia; Elsevier; 2020:2620-22.</ref><ref>{{Citation|last=Mahmoodi|first=Ahmad N.|title=Ketorolac|date=2024|url=http://www.ncbi.nlm.nih.gov/books/NBK545172/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=31424756|access-date=2024-02-14|last2=Kim|first2=Peggy Y.}}</ref><ref>{{Cite journal|last=Buckley|first=Micaela M.-T.|last2=Brogden|first2=Rex N.|date=1990-01-01|title=Ketorolac|url=https://doi.org/10.2165/00003495-199039010-00008|journal=Drugs|language=en|volume=39|issue=1|pages=86–109|doi=10.2165/00003495-199039010-00008|issn=1179-1950}}</ref>
[[Category:Drug reference]]

Porphyria

2024-02-13T20:51:07Z

Seanmliu: Updated blank article

{{Infobox comorbidity
| other_names =
| anesthetic_relevance = High
| anesthetic_management = Avoid prolonged fasting, prioritize post-op pain control, avoid drugs that can trigger an acute crisis
| specialty = Hematology
| signs_symptoms = Abdominal pain, neuropathies, hypertension
| diagnosis = Urine and serum testing for porphyrins
| treatment = Heme and/or glucose injection
| image =
| caption =
}}

Porphyrias are a group of hereditary diseases that cause interruptions in heme synthesis, resulting in accumulation of porphyrins. These accumulations have adverse affects across organ systems that often make anesthetic management of these patients challenging, requiring special considerations starting in the pre-operative period. Patients with porphyrias can be categorized as having acute or non-acute porphyria, with Acute Intermittent Porphyria (AIP) being the most common type. Acute patients will require alterations in anesthetic management, while non-acute patients can be managed like patients without porphyria.

== Anesthetic implications ==

=== Preoperative optimization ===

* Avoid prolonged fasting (>2 hours)
* Encourage clear carbohydrate fluids (i.e. gatorade) up to 2 hours before surgery
* Can also opt for dextrose infusions until surgery

=== Intraoperative management ===

* General and regional/neuraxial can be safely used
* Drugs to avoid that can precipitate acute crisis:
** Barbiturates
** Etomidate
** Phenobarbital
** Ketamine
** Diazepam
** Phenytoin

=== Postoperative management ===

* Ensure adequate pain control, as excessive pain can be a trigger for acute crisis

== Pathophysiology ==

* Porphyrins are compounds important in the synthesis of heme
* Porphyria occurs when the synthesis of heme is interrupted, resulting in the accumulation of porphyrins

<ref>{{Cite journal|last=Kauppinen|first=Raili|date=January 15, 2005|title=Porphyrias|url=https://doi.org/10.1016/S0140-6736(05)17744-7|journal=Lancet}}</ref>

== Signs and symptoms ==
Can be separated into acute vs nonacute, with non-acute primarily only having dermatologic symptoms

Acute:

* Abdominal pain
* Weakness/neuropathies
* Hypertension
* Tachyarrhythmias
* Respiratory arrest secondary to bulbar muscle weakness

== Diagnosis ==

* Urine δ-amino levulinic acid (ALA) and porphobilinogen (PBG) levels

== Treatment ==

=== Medication ===

* heme arginate

=== Prognosis ===

* Good when acute crisis is recognized and treated appropriately
* Few symptoms, if any, between crises

== Epidemiology ==

* More common in females
* Typically present around ages 15-40

== References<ref>{{Cite web|title=Login Selection - Lane Medical Library, Stanford University Medical Center|url=https://lane.stanford.edu/discoveryLoginPage.html?entityID=https%3A%2F%2Flane.stanford.edu%2Fshibboleth&return=https%3A%2F%2Flane.stanford.edu%2FShibboleth.sso%2FLogin%3FSAMLDS%3D1%26target%3Dss%253Amem%253A6c191971fb4f07c3781eb00caacf19e9c2e2215f7c6c1b74454b333725ac3620|access-date=2024-02-13|website=lane.stanford.edu}}</ref><ref>{{Cite journal|last=Wilson-Baig|first=N.|last2=Badminton|first2=M.|last3=Schulenburg-Brand|first3=D.|date=2021-02|title=Acute hepatic porphyria and anaesthesia: a practical approach to the prevention and management of acute neurovisceral attacks|url=https://pubmed.ncbi.nlm.nih.gov/33889432/|journal=BJA education|volume=21|issue=2|pages=66–74|doi=10.1016/j.bjae.2020.09.005|issn=2058-5357|pmc=7810766|pmid=33889432}}</ref><ref>{{Cite journal|last=Wilson-Baig|first=N.|last2=Badminton|first2=M.|last3=Schulenburg-Brand|first3=D.|date=2021-02|title=Acute hepatic porphyria and anaesthesia: a practical approach to the prevention and management of acute neurovisceral attacks|url=https://pubmed.ncbi.nlm.nih.gov/33889432/|journal=BJA education|volume=21|issue=2|pages=66–74|doi=10.1016/j.bjae.2020.09.005|issn=2058-5357|pmc=7810766|pmid=33889432}}</ref><ref>{{Cite web|last=openanesthesia|title=Porphyrias: Anesthetic Considerations|url=https://www.openanesthesia.org/keywords/porphyrias-anesthetic-considerations/|access-date=2024-02-13|website=OpenAnesthesia|language=en-US}}</ref> ==

[[Category:Comorbidities]]

Dexamethasone

2024-02-13T20:17:40Z

Seanmliu: Updated blank article

{{Infobox drug reference
| trade_names = Decadron
| drug_class = Steroid
| drug_class_color =
| uses = PONV, analgesia
| contraindications = Relative: Diabetes/hyperglycemia, altered mental status, lymphoma, infection
| routes = IV
| dosage = PONV: 4-8mg
Analgesia: 0.1mg/kg
| dosage_calculation =
| mechanism = Unclear but likely related to steroidal anti-inflammatory action
| adverse_effects = Hyperglycemia, altered mental status, delayed wound healing
| time_onset = 1-2 hrs
| duration = 36-72 hrs
}}

Dexamethasone is a corticosteroid commonly used in anesthetic practice for management of PONV and pain. While the mechanism of action of steroids is well known, the mechanism of dexamethasone in prevention of PONV is not well understood.

== Uses ==

* PONV: DREAM study found that inclusion of dexamethasone (8mg IV) at the time of induction reduced PONV and PRN anti-emetic usage across patient groups<ref>{{Cite journal|last=DREAMS Trial Collaborators and West Midlands Research Collaborative|date=2017-04-18|title=Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial)|url=https://pubmed.ncbi.nlm.nih.gov/28420629/|journal=BMJ (Clinical research ed.)|volume=357|pages=j1455|doi=10.1136/bmj.j1455|issn=1756-1833|pmc=5482348|pmid=28420629}}</ref>
** Given its longer onset, most effective when given at induction
** Typical dose 4-8mg IV
* Analgesia: meta-analysis found that dexamethasone effective at reducing pain scores and opioid consumption post op<ref>{{Cite journal|last=De Oliveira|first=Gildàsio S.|last2=Almeida|first2=Marcela D.|last3=Benzon|first3=Honorio T.|last4=McCarthy|first4=Robert J.|date=2011-09|title=Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials|url=https://pubmed.ncbi.nlm.nih.gov/21799397/|journal=Anesthesiology|volume=115|issue=3|pages=575–588|doi=10.1097/ALN.0b013e31822a24c2|issn=1528-1175|pmid=21799397}}</ref>
** Dose: 0.1mg/kg
** Found to have most consistent effect when given at time of induction

== Contraindications ==

=== Absolute contraindications ===

* systemic fungal infection

=== Precautions ===
See below for adverse effects

* In cases of adrenal insufficiency, consider using hydrocortisone as dexamethasone has minimal mineralocorticoid effect

== Pharmacology ==

=== Pharmacodynamics ===
Dexamethasone is a corticosteroid associated with all the typical side effects seen with most steroids used in practice.

==== Mechanism of action ====
As a steroid, it is thought to exert its clinical effects through anti-inflammatory action<ref>{{Cite journal|last=Holte|first=Kathrine|last2=Kehlet|first2=Henrik|date=2002-11|title=Perioperative Single-Dose Glucocorticoid Administration: Pathophysiologic Effects and Clinical Implications|url=https://journals.lww.com/journalacs/citation/2002/11000/perioperative_single_dose_glucocorticoid.14.aspx|journal=Journal of the American College of Surgeons|language=en-US|volume=195|issue=5|pages=694|doi=10.1016/S1072-7515(02)01491-6|issn=1879-1190}}</ref>

* inhibits both cyclooxygenase and lipoxygenase pathways <ref>{{Cite web|url=https://academic.oup.com/edrv/article/21/1/55/2423840|access-date=2024-02-13|website=academic.oup.com}}</ref>
* inhibits of spinal cord nociceptive processing<ref>{{Cite journal|last=Svensson|first=Camilla I.|last2=Yaksh|first2=Tony L.|date=2002-04|title=The Spinal Phospholipase-Cyclooxygenase-Prostanoid Cascade in Nociceptive Processing|url=https://www.annualreviews.org/doi/10.1146/annurev.pharmtox.42.092401.143905|journal=Annual Review of Pharmacology and Toxicology|language=en|volume=42|issue=1|pages=553–583|doi=10.1146/annurev.pharmtox.42.092401.143905|issn=0362-1642}}</ref>
* inhibits release of bradykinin<ref>{{Cite journal|last=Hargreaves|first=Kenneth M|last2=Costello|first2=Ann|date=1990-08|title=Glucocorticoids suppress levels of immunoreactive bradykinin in inflamed tissue as evaluated by microdialysis probes|url=http://doi.wiley.com/10.1038/clpt.1990.132|journal=Clinical Pharmacology and Therapeutics|volume=48|issue=2|pages=168–178|doi=10.1038/clpt.1990.132|issn=0009-9236}}</ref>

==== Adverse effects ====

* Hyperglycemia
* Altered mental status
* Short term use not associated with surgical site infection<ref>{{Cite journal|last=Corcoran|first=Tomás B.|last2=Myles|first2=Paul S.|last3=Forbes|first3=Andrew B.|last4=Cheng|first4=Allen C.|last5=Bach|first5=Leon A.|last6=O’Loughlin|first6=Edmond|last7=Leslie|first7=Kate|last8=Chan|first8=Matthew T.V.|last9=Story|first9=David|last10=Short|first10=Timothy G.|last11=Martin|first11=Catherine|date=2021-05-06|title=Dexamethasone and Surgical-Site Infection|url=http://www.nejm.org/doi/10.1056/NEJMoa2028982|journal=New England Journal of Medicine|language=en|volume=384|issue=18|pages=1731–1741|doi=10.1056/NEJMoa2028982|issn=0028-4793}}</ref>, but anesthesiologists and surgeons may often choose to avoid dexamethasone if concerned about pre-existing infection
* Impaired post op wound healing

=== Pharmacokinetics ===

== Chemistry and formulation ==

== History ==

== References ==

[[Category:Drug reference]]

Incision and drainage of perianal abscess

2024-02-13T19:40:09Z

Seanmliu: All updates to the page from blank

{{Infobox surgical procedure
| anesthesia_type = [[MAC]], General, spinal
| airway = Face Mask, [[LMA]], [[ETT]]
| lines_access = PIV
| monitors = Standard
| considerations_preoperative = Airway and respiratory evaluation if considering prone position
| considerations_intraoperative = Prone position
| considerations_postoperative =
}}

Incision and drainage (I&D) of perianal abscess is a procedure for treatment of abscesses at and around the anal verge. Patients typically have co-morbidities such as inflammatory bowel disease, malignancy, or traumatic injury leading to perianal abscesses. Many patients often have repeated I&Ds before resolution of their abscesses. These patients tend to be males in their 40-50s but can across all patient populations.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Standard evaluation
May be prone positioning so concern for airway difficulty may change anesthetic technique
|-
|Neurologic
|
|-
|Cardiovascular
|Standard evaluation
|-
|Pulmonary
|Evaluate for any signs/symptoms or co-morbidities that would signal decreased respiratory reserve, as patient positioning may be affected (lithotomy vs prone)
|-
|Gastrointestinal
|
|-
|Hematologic
|Blood loss from I&D of perianal abscesses is rare
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|Check with surgeon for ERAS protocol
|}

=== kLabs and studies===

* CBC
* BMP

=== Regional and neuraxial techniques ===

* Spinal can be used if MAC/general anesthesia is contraindicated

* Epidurals can often spare the anal region.

== Intraoperative management ==

=== Monitoring and access ===

* Standard monitors
* PIV

=== Induction and airway management ===

* If MAC: standard induction, face mask
* If general: prone position requires ETT over LMA. Standard induction unless concerned about aspiration
* If spinal: aim for L1-L2 level of analgesia, face mask for airway

=== Positioning ===

* Prone preferred
* If concerned about respiratory reserve, can consider lithotomy after discussion with surgeon

=== Maintenance and surgical considerations ===

* Standard Maintenance

* Pain is usually greatest with initial incision, requiring up front analgesia

=== Emergence ===

* Standard emergence
* Standard PONV prophylaxis

== Postoperative management ==

=== Disposition ===
Typically outpatient procedure

=== Pain management ===

* Pain usually greatest intra-op, can be treated with rapid acting analgesics such as fentanyl, ketamine, or remifentanil given duration of procedure is short
* Post-op pain usually improved compared to pre-op, consider multi-modal adjuncts to long acting opioids if needed

=== Potential complications ===

* Sepsis
* Positioning can lead to axillary nerve damage or peroneal nerve damage (if lithotomy)
* Conversion from MAC to general

== Procedure variants ==

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

== References ==
<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2022|isbn=1496371259|pages=618-620}}</ref><ref>{{Citation|last=Sigmon|first=David F.|title=Perianal Abscess|date=2024|url=http://www.ncbi.nlm.nih.gov/books/NBK459167/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29083652|access-date=2024-02-13|last2=Emmanuel|first2=Bishoy|last3=Tuma|first3=Faiz}}</ref>
[[Category:Surgical procedures]]