WikiAnesthesia - User contributions [en]

Awake fiberoptic intubation

2026-03-17T22:19:03Z

Spate215:

'''<big>Introduction</big>'''
* Fiberoptic intubation remains the gold standard for securing the airway in patients with a known or anticipated difficult airway. When performed by experienced clinicians, this technique can be accomplished with efficiency comparable to that of video laryngoscopy1.
*Bronchoscopes may be rigid or flexible; however, the flexible fiberoptic bronchoscope is preferred for awake intubations, as it allows for both oral and nasal approaches. This review will focus specifically on the oral awake fiberoptic technique.
*Modern fiberoptic bronchoscopes are typically connected to a video monitor, enabling real-time visualization of airway anatomy by the entire care team. In addition to visualization, the instrument’s working channel permits suctioning of secretions, supplemental oxygen delivery, and administration of topical anesthetics or other medications.

'''<big>Indications</big>'''

* History of prior difficult airway management, particularly in patients with documented multiple failed intubation attempts.
*Clinical examination findings that suggest a potentially challenging airway—such as those associated with facial or airway trauma, infection, or anatomic distortion
*Cervical spine pathology or those in whom neck manipulation must be minimized

'''<big>Anatomy/Innervation</big>'''

* Glossopharyngeal Nerve
** Supplies innervation to the oropharynx, vallecula, and base of tongue
* Vagus Nerve
** Provides innervation the posterior pharynx, vocal cords, and trachea via two principle nerve branches (Superior Laryngeal Nerve + Recurrent Laryngeal Nerve)
*** Superior Laryngeal Nerve
**** Sensory: Above the vocal cords
**** Motor: Cricothyroid Muscle
*** Recurrent Laryngeal Nerve
**** Sensory: Below the vocal cords
**** Motor: Posterior Cricoarytenoid Muscles

'''<big>Preparation</big>'''

* '''Sedation'''
** The entire point of this procedure to keep the patient awake and to maintain spontaneous ventilation. Therefore, it is critical that we do not over sedate the patient and potentially cause apnea or collapse of airway structures
** However, with the being said, this is an incredibly uncomfortable and anxiety producing procedure for patients and therefore warrants some level of sedation, if able
** Commonly used medications:
*** Midazolam
*** Precedex
**** Can be adminsitered as either bolus or infusion
*** Remifentanil
*** Fentanyl
**** 25-50 mcg intermittent bolus can help blunt cough/gag reflex without causing significant apnea.
*** Ketamine
**** If using Ketamine, consider administering Glycopyrrolate (0.2 mg IV) to help minimize the production of secretions. It must be given atleast 20 minutes prior to intubation to see effects.
**** It can also cause patients to clench their jaw or become dissociated with the inability to follow commands
*** Propofol
** Of note, systematic reviews and meta analyses have shown that there is no significant difference in the success rate between all of the different sedation options.
*** The only difference that was noted was that there were lower frequency of desaturations when Precedex was used.
* '''Localizing'''
** Goal is to anesthetize the oral cavity, pharynx, larynx, and trachea (anatomy and innervation noted above)
** The following tools can be used to localize:
*** Atomizer
**** Allows for direct spray of structures with Lidocaine 4%.
**** Target the tonsils, uvula, and vocal cords
*** Nebulizer
**** Attached to a green face mask that has Lidocaine 4% in the chamber
**** This will take the longest time, but can be useful for the patient to inhale if you have > 15 minutes for the nebulization to be fully effective
*** Lollipops
**** Place gauze around a tongue depressor and cover it in Lidocaine jelly/ointment. Have the patient place this in their mouth as deep as tolerated and allow them to suck on it. Every few minutes, advance the tongue depressor further as the prior portion of the pharynx should have become numb.
**** The lidocaine will melt and release droplets that will spread
*** Injection of lidocaine via fiberoptic scope
**** You can either inject from the side port of the scope or you can place an epidural catheter down the working channel and spray lidocaine via the multiple orifices at the end of the catheter
*** Other
**** You can have the patient gargle a 2% viscous lidocaine solution for 1 minute to start. This is often done in the endoscopy suite prior to EGDs
** Nerve Blocks
*** Glossopharyngeal Nerve
**** Achieved by introducing local anesthetic near the anterior tonsillar pillars
*** Superior Laryngeal Nerve
**** Inject on either side of the greater cornu of the hyoid bone
*** Recurrent Laryngeal Nerve
**** Can be done via a transtracheal block. Needle is inserted through the cricothyroid membrane while aspirating until air returns. Once you have air, inject local. The patient will cough, which will help spread local anesthetic upwards.
**** Encourage the patient to suppress cough until the needle has been removed (I know, easier said than done)
* '''Positioning'''
** Sit the patient up in a neutral position
** Chin lift and jaw thrust can help move the soft tissue and epiglottis out of the way to help with initial placement of the fiberoptic scope.
** It can be easier for the operator of the scope to be directly facing the patient. However, some providers like to be behind the patient. Ultimately, goal is to be in the most comfortable position.
* '''Other Supplies'''
** Scopes of varying sizes and calibers
** ETTs of varying sizes

'''References'''

# Rosenstock CV, Thøgersen B, Afshari A, et al. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trial. Anesthesiology. 2012;116(6):1210-6.

Awake fiberoptic intubation

2026-01-17T20:39:33Z

Spate215:

'''<big>Introduction</big>'''
* Fiberoptic intubation remains the gold standard for securing the airway in patients with a known or anticipated difficult airway. When performed by experienced clinicians, this technique can be accomplished with efficiency comparable to that of video laryngoscopy.
*Bronchoscopes may be rigid or flexible; however, the flexible fiberoptic bronchoscope is preferred for awake intubations, as it allows for both oral and nasal approaches. This review will focus specifically on the oral awake fiberoptic technique.
*Modern fiberoptic bronchoscopes are typically connected to a video monitor, enabling real-time visualization of airway anatomy by the entire care team. In addition to visualization, the instrument’s working channel permits suctioning of secretions, supplemental oxygen delivery, and administration of topical anesthetics or other medications.

'''<big>Indications</big>'''

* History of prior difficult airway management, particularly in patients with documented multiple failed intubation attempts.
*Clinical examination findings that suggest a potentially challenging airway—such as those associated with facial or airway trauma, infection, or anatomic distortion
*Cervical spine pathology or those in whom neck manipulation must be minimized

'''<big>Anatomy/Innervation</big>'''

* Glossopharyngeal Nerve
** Supplies innervation to the oropharynx, vallecula, and base of tongue
* Vagus Nerve
** Provides innervation the posterior pharynx, vocal cords, and trachea via two principle nerve branches (Superior Laryngeal Nerve + Recurrent Laryngeal Nerve)
*** Superior Laryngeal Nerve
**** Sensory: Above the vocal cords
**** Motor: Cricothyroid Muscle
*** Recurrent Laryngeal Nerve
**** Sensory: Below the vocal cords
**** Motor: Posterior Cricoarytenoid Muscles

'''<big>Preparation</big>'''

* '''Sedation'''
** The entire point of this procedure to keep the patient awake and to maintain spontaneous ventilation. Therefore, it is critical that we do not over sedate the patient and potentially cause apnea or collapse of airway structures
** However, with the being said, this is an incredibly uncomfortable and anxiety producing procedure for patients and therefore warrants some level of sedation, if able
** Commonly used medications:
*** Midazolam
*** Precedex
**** Can be adminsitered as either bolus or infusion
*** Remifentanil
*** Fentanyl
**** 25-50 mcg intermittent bolus can help blunt cough/gag reflex without causing significant apnea.
*** Ketamine
**** If using Ketamine, consider administering Glycopyrrolate (0.2 mg IV) to help minimize the production of secretions. It must be given atleast 20 minutes prior to intubation to see effects.
**** It can also cause patients to clench their jaw or become dissociated with the inability to follow commands
*** Propofol
** Of note, systematic reviews and meta analyses have shown that there is no significant difference in the success rate between all of the different sedation options.
*** The only difference that was noted was that there were lower frequency of desaturations when Precedex was used.
* '''Localizing'''
** Goal is to anesthetize the oral cavity, pharynx, larynx, and trachea (anatomy and innervation noted above)
** The following tools can be used to localize:
*** Atomizer
**** Allows for direct spray of structures with Lidocaine 4%.
**** Target the tonsils, uvula, and vocal cords
*** Nebulizer
**** Attached to a green face mask that has Lidocaine 4% in the chamber
**** This will take the longest time, but can be useful for the patient to inhale if you have > 15 minutes for the nebulization to be fully effective
*** Lollipops
**** Place gauze around a tongue depressor and cover it in Lidocaine jelly/ointment. Have the patient place this in their mouth as deep as tolerated and allow them to suck on it. Every few minutes, advance the tongue depressor further as the prior portion of the pharynx should have become numb.
**** The lidocaine will melt and release droplets that will spread
*** Injection of lidocaine via fiberoptic scope
**** You can either inject from the side port of the scope or you can place an epidural catheter down the working channel and spray lidocaine via the multiple orifices at the end of the catheter
*** Other
**** You can have the patient gargle a 2% viscous lidocaine solution for 1 minute to start. This is often done in the endoscopy suite prior to EGDs
** Nerve Blocks
*** Glossopharyngeal Nerve
**** Achieved by introducing local anesthetic near the anterior tonsillar pillars
*** Superior Laryngeal Nerve
**** Inject on either side of the greater cornu of the hyoid bone
*** Recurrent Laryngeal Nerve
**** Can be done via a transtracheal block. Needle is inserted through the cricothyroid membrane while aspirating until air returns. Once you have air, inject local. The patient will cough, which will help spread local anesthetic upwards.
**** Encourage the patient to suppress cough until the needle has been removed (I know, easier said than done)
* '''Positioning'''
** Sit the patient up in a neutral position
** Chin lift and jaw thrust can help move the soft tissue and epiglottis out of the way to help with initial placement of the fiberoptic scope.
** It can be easier for the operator of the scope to be directly facing the patient. However, some providers like to be behind the patient. Ultimately, goal is to be in the most comfortable position.
* '''Other Supplies'''
** Scopes of varying sizes and calibers
** ETTs of varying sizes

Awake fiberoptic intubation

2026-01-17T20:33:03Z

Spate215:

'''<big>Introduction</big>'''
* This is the mainstay for securing the airway for a patient who is known to be a true difficult airway
* Studies have shown that providers who are skilled with the fiberoptic scope can intubate as quickly as one would with a video laryngoscope
* Bronchoscopes
** Can be either rigid or flexible, however flexible is more appropriate for awake fiberoptics as it can allow for both an oral or nasal approach. We will focus on oral awake fiberoptic intubations in this article
** Will be attached to screen to allow other parties to see the airway anatomy
** Can be used to suction, oxygenate, or administer medications as it has a working channel

'''<big>Indications</big>'''

* Previously noted to be difficult intubation
* Hx of multiple failed intubation attempts
* Clinical exams that is suggestive of difficult airway (i.e. trauma, infection)
* Cervical Spine disease or inability to manipulate the neck

'''<big>Anatomy/Innervation</big>'''

* Glossopharyngeal Nerve
** Supplies innervation to the oropharynx, vallecula, and base of tongue
* Vagus Nerve
** Provides innervation the posterior pharynx, vocal cords, and trachea via two major nerve branches (Superior Laryngeal Nerve + Recurrent Laryngeal Nerve)
*** Superior Laryngeal Nerve
**** Sensory: Above the vocal cords
**** Motor: Cricothyroid Muscle
*** Recurrent Laryngeal Nerve
**** Sensory: Below the vocal cords
**** Motor: Posterior Cricoarytenoid Muscles

'''<big>Preparation</big>'''

* '''Sedation'''
** The entire point of this procedure to keep the patient awake and to maintain spontaneous ventilation. Therefore, it is critical that we do not over sedate the patient and potentially cause apnea of collapse of airway structures
** However, with the being said, this is an incredibly uncomfortable and anxiety producing procedure for patients
** Commonly used medications:
*** Midazolam
*** Precedex
**** Can be adminsitered as either bolus or infusion
*** Remifentanil
*** Fentanyl
**** 25-50 mcg intermittent bolus can help blunt cough/gag reflex without causing significant apnea.
*** Ketamine
**** If using Ketamine, consider administering Glycopyrrolate (0.2 mg IV) to help minimize the production of secretions. It must be given atleast 20 minutes prior to intubation to see effects.
**** It can also cause patients to clench their jaw or become dissociated with the inability to follow commands
*** Propofol (low dose)
** Of note, systematic reviews and meta analysese have shown that there is no significant difference in the success rate between all of the different medication options.
*** The only difference that was noted was that there were lower frequency of desaturations when Precedex was used.
* '''Localizing'''
** Goal is to anesthetize the oral cavity, pharynx, larynx, and trachea (anatomy and innervation noted above)
** The following tools can be used to localize:
*** Atomizer
**** Allows for direct spray of structures with Lidocaine 4%.
**** Target the tonsils, uvula, and vocal cords
*** Nebulizer
**** Attached to a green face mask that has Lidocaine 4% in it.
**** This will take the longest time, but can be useful for the patient to inhale if you have > 15 minutes for the nebulization to be fully effective
*** Lollipops
**** Place gauze around a tongue depressor and cover it in Lidocaine jelly/ointment. Have the patient place this as deep in their mouth as tolerated and allow them to suck on it. Every few minutes, advance the tongue depressor further as the prior portion of the pharynx should have become numb.
**** The lidocaine will melt and release droplets that will spread
*** Injection of lidocaine via fiberoptic scope
**** You can either inject from the side port of the scope or you can place an epidural catheter down the working channel and spray lidocaine via the multiple orifices at the end of the catheter
*** Other
**** You can have the patient gargle a 2% viscous lidocaine solution for 1 minute to start. This is often done in the endoscopy suite prior to EGDs
** Nerve Blocks
*** Glossopharyngeal Nerve
**** Achieved by introducing local anesthetic near the anterior tonsillar pillars
*** Superior Laryngeal Nerve
**** Inject on either side of the greater cornu of the hyoid bone
*** Recurrent Laryngeal Nerve
**** Can be done via a transtracheal block. Needle is inserted through the cricothyroid membrane while aspirating uncle air returns. Once you have air, inject local. The patient will cough, which will help spread local anesthetic upwards.
**** Encourage the patient to suppress cough until the needle has been removed (I know, easier said than done)
* '''Positioning'''
** Sit the patient up in a neutral position
** Chin lift and jaw thrust can help move the soft tissue and epiglottis out of the way to help with initial placement of the fiberoptic scope.
** It can be easier for the operator of the scope to be directly facing the patient. However, some providers like to be behind the patient. Ultimately, goal is to be in the most comfortable position.
* '''Other Supplies'''
** Scopes of varying sizes and calibers
** ETTs of varying sizes

Postoperative nausea and vomiting

2026-01-17T19:33:02Z

Spate215:

'''<big>Introductions</big>'''

* PONV is a major problem faced in the perioperative setting by anesthesiologists
* It is known to be one of the major factors, along with pain, that prolongs PACU stays, which can be significantly consequential in the ambulatory setting.
** Each episode of vomiting is thought to prolong the PACU stay by ~ 25 minutes
** There is also an increase risk of aspiration and airway compromise

'''<big>Risk Factors</big>'''

*Patient Related
**History of PONV or motion sickness
** Female sex
** Young age (< 50 years old)
** Use of volatile anesthetics
** Use of post-operative opiates
** Non-smoking status
*Anesthetic Related
**Use of volatile anesthetics (Sevoflurance, Isoflurane, Desflurane) or N2O
**Opioid use
**Etomidate (worse when used w/ opioids)
*Surgery Related
**Prolonged surgery (therefore, prolonged exposure to anesthetics)
**Laparoscopic surgery, cholecystectomies, inner/middle ear cases, and gynecological surgery

'''<big>Apfel Score</big>'''

* The Apfel score is a points system that is used based on patient risk factors to predict their risk of developing PONV
* 1 point is given for the following risk factors
** Female Gender
** Non-Smoker
** Hx of PONV or Motion Sickness
** Postoperative Opioids
* Each score is associated with the following risk:
** 0 = 10%
** 1 = 20%
** 2 = 40%
** 3 = 60%
** 4 = 80%

'''<big>Prophylaxis</big>'''

* Regional nerve blocks can be used to reduce the amount of peri-operative opioids required
* If patient requires general anesthesia, you can substitute volatile anesthetic with a propofol-based TIVA approach
* N2O is a common culprit of PONV, and therefore should be avoided. If it needs to be used, less than 1 hour of exposure is preferred
* Appropriately volume resuscitate the patient to keep them well hydrate
**Can also be achieved by preoperative administration of carbohydrate drinks
* If the patient has 1-2 risk factors, administer 2 anti-emetic agents
* If the patient has 2+ risk factors, consider administered 3-4 anti-emetic agents

'''<big>Treatment</big>'''

* There are many medications that can be used to treat PONV. The main receptors that they work at to prevent/treat nausea and vomiting include: M1 (muscarinic), D2 (Dopamine), H1 (Histamine), 5HT3 (Serotonin), and NK1 (Substance P)
* These receptors are located at the area postrema of the brain

'''<big>Medication Classes</big>'''

* 5HT3 Receptor Antagonists
** Ex (Dose): Ondansetron (4-8 mg IV), Granisetron (0.35-3 mg IV)
** MoA: Targets the area postrema
** Side Effects: Headache, lightheadedness, dizziness, constipation, QTc prolongation
* Steroids
** Ex (Dose): Dexamethasone (4-8 mg IV)
** MoA: Unclear, believed to inhibit prostaglandins peripherally
** Side Effects: Insomnia, increased energy, mood changes
**Be weary of administering in patient's with uncontrolled diabetes or sepsis
* NK1 Receptor Antagonists
** Ex (Dose): Aprepitant (40 mg PO)
** MoA: Targets the nucleus tractus solitaries and area postrema
** Side Effects: Moderate inhibitor of CYP3A4
* Dopamine Antagonists
** Ex (Dose): Metoclopramide (10 mg), Prochlorperazine (5-10 mg IV)
** MoA: Targets the area postrema
** Side Effects: Extrapyramidal effects muscle stiffness, tremors, restlessness (akathisia), or involuntary facial movements (dyskinesia) and dystonia
* Anticholingerics
** Ex (Dose): Scopolamine (patch administered 2-4 hours pre op), Promethazine (6.25 mg)
** MoA: Antagonizes muscarinic receptors of the vestibular apparatus and the nucleus of the tractus solitarus
** Side Effects: Sedation, dry mouth, visual disturbance. Can precipitate acute angle closure glaucoma in susceptible patients
* Phenothiazines
** Ex (Dose): Promethazine (6.25 mg), Prochlorperazine (5-10 mg)
** MoA: Antagonize D2-dopamine receptors in the area postrema of the midbrain; also have M1-muscarinic and H1-histamine blocking effects5
** Side Effects: Sedation, extrapyramidal effects, hypotension
* Butyrophenones
** Ex (Dose): Droperidol (0.625 mg IV), Haloperidol (0.5-2 mg IM/IV)
** MoA: Antagonize central dopaminergic receptors
** Side Effects: Sedation, agitation, extrapyramidal effects, hypotension, QT prolongation/Torsades

Postoperative nausea and vomiting

2026-01-17T01:36:57Z

Spate215:

'''<big>Introductions</big>'''

* PONV is a major problem faced in the perioperative setting by anesthesiologists
* It is known to be one of the major factors, along with pain, that prolongs PACU stays, which can be significantly consequently in the ambulatory setting.
** Each episode of vomiting is thought to prolong the PACU stay by ~ 25 minutes
** There is also an increase risk of aspiration

'''<big>Risk Factors</big>'''

*Patient Related
**History of PONV or motion sickness
** Female sex
** Young age (< 50 years old)
** Use of volatile anesthetics
** Use of post-operative opiates
** Non-smoking status
*Anesthetic Related
**Use of volatile anesthetics (Sevoflurance, Isoflurane, Desflurane) or N2O
**Opioid use
*Surgery Related
**Prolonged surgery (therefore, prolonged exposure to anesthetics)
**Laparoscopic surgery, cholecystectomies, and gynecological surgery

'''<big>Apfel Score</big>'''

* The Apfel score is a points system that is used based on patient risk factors to predict their risk of developing PONV
* 1 point is given for the following risk factors
** Female Gender
** Non-Smoker
** Hx of PONV or Motion Sickness
** Postoperative Opioids
* Each score is associated with the following risk:
** 0 = 10%
** 1 = 20%
** 2 = 40%
** 3 = 60%
** 4 = 80%

'''<big>Prophylaxis</big>'''

* Regional nerve blocks can be used to reduce the amount of perioperative opioids required
* If patient requires general anesthesia, you can substitute volatile anesthetic with a propofol-based TIVA approach
* N2O is a common culprit of PONV, and therefore should be avoided. If it needs to be used, less than 1 hour of exposure is preferred
* Appropriately volume resuscitate the patient to keep them well hydrate
* If the patient has 1-2 risk factors, administer 2 anti-emetic agents
* If the patient has 2+ risk factors, consider administered 3-4 anti-emetic agents

'''<big>Treatment</big>'''

* There are many medications that can be used to treat PONV. The main receptors that they work at to prevent/treat nausea and vomiting include: M1 (muscarinic), D2 (Dopamine), H1 (Histamine), 5HT3 (Serotonin), and NK1 (Substance P)
* These receptors are located at the area postrema of the brain

'''<big>Medication Classes</big>'''

* 5HT3 Receptor Antagonists
** Ex (Dose): Ondansetron (4-8 mg IV), Granisetron (0.35-3 mg IV)
** MoA: Targets the area postrema
** Side Effects: Headache, lightheadedness, dizziness, constipation, QTc prolongation
* Steroids
** Ex (Dose): Dexamethasone (4-8 mg IV)
** MoA: Unclear, believed to inhibit prostaglandins peripherally
** Side Effects: Insomnia, increased energy, mood changes
* NK1 Receptor Antagonists
** Ex (Dose): Aprepitant (40 mg PO)
** MoA: Targets the nucleus tractus solitaries and area postrema
** Side Effects: Moderate inhibitor of CYP3A4
* Dopamine Antagonists
** Ex (Dose): Metoclopramide (10 mg), Prochlorperazine (5-10 mg IV)
** MoA: Targets the area postrema
** Side Effects: Extrapyramidal effects muscle stiffness, tremors, restlessness (akathisia), or involuntary facial movements (dyskinesia) and dystonia
* Anticholingerics
** Ex (Dose): Scopolamine (patch administered 2-4 hours pre op), Promethazine (6.25 mg)
** MoA: Antagonizes muscarinic receptors of the vestibular apparatus and the nucleus of the tractus solitarus
** Side Effects: Sedation, dry mouth, visual disturbance
* Phenothiazines
** Ex (Dose): Promethazine (6.25 mg), Prochlorperazine (5-10 mg)
** MoA: Antagonize D2-dopamine receptors in the area postrema of the midbrain; also have M1-muscarinic and H1-histamine blocking effects5
** Side Effects: Sedation, extrapyramidal effects, hypotension
* Butyrophenones
** Ex (Dose): Droperidol (0.625 mg IV), Haloperidol (0.5-2 mg IM/IV)
** MoA: Antagonize central dopaminergic receptors
** Side Effects: Sedation, agitation, extrapyramidal effects, hypotension

Omphalocele

2026-01-15T21:30:11Z

Spate215:

'''<big>Definition</big>'''

* Direct abdominal defect that causes a portion of the intestines and other abdominal organs to herniate '''WITH''' a covering membrane/peritoneal sac
* Typically located midline, and can be anywhere along the upper/mid/lower abdomen.
* Approximately 50–70% of cases are associated with additional congenital anomalies
** ASDs, VSDs and Tetralogy of Fallot are most common
** Also associated with Beckwith-Wiedemann Syndrome, Marshal-Smith, Meckel Gruber, and Pentalogy of Cantrell
** Chromosomal abnormalities (Trisomy 13, 14, 15, 18, 21) are common

'''<big>Diagnosis</big>'''

* Identified via ultrasound during prenatal screening
* Elevated AFP can help confirm the diagnosis
** Levels of AFP tend to be higher in Gastroschisis compared to Omphalocele

 '''<big>Epidemiology/Prognosis</big>'''

* Occurs in 1.5-3 per 10,000 births
* Outcomes are variable, but are dependent on the level of other comorbidities
** Survival rates are > 40-70%

'''<big>Embryology</big>'''

* During normal embryologic development, the intestinal tract physiologically herniates into the umbilical cord at approximately the sixth week of gestation, with expected return to the abdominal cavity by around the twelfth week.
* In Omphalocele, bowel fails to return into the abdomen and remains in the umbilical cord.

 '''<big>Surgical/Medical Management</big>'''

* The initial resuscitation for patients with Omphalocele is quite similar to those with Gastroschisis.
** Frequently delivered via cesarean section to minimize the risk of additional bowel injury during passage through the vaginal canal, although the mode of delivery may ultimately be individualized based on obstetric considerations.
** The overarching treatment goal is reduction of the herniated intestinal contents into the abdominal cavity, followed by closure of the fascial and skin defects.
** Management strategies are influenced by several factors, including the size and type of the defect, the size and gestational maturity of the infant, and the presence of associated comorbidities.
* The key differences for Omphalocele compared to Gastroschisis include:
** A decrease urgency to operatively close the defect
** Instead, the goal is to initially cover the sac to protect the herniated contents
** Then you can let them epithelialize over time with silver sulfadiazine (if a primary closure if not permitted). Once the sac has completely epithelialized and the sac is well formed, the surgical team can reduce the abdominal contents and perform a ventral hernia repair. This can be typically done around 6-12 months of age.

 '''<big>Anesthetic Considerations</big>'''

'''Preoperative'''

* Obtain a CBC, CMP and T&S
** Blood loss is typically unexpected however there will be lots of evaporative losses than sometimes may be best treated with blood
** Evaluate whether there are any electrolyte issues
* NGT placement to decompress the stomach and decrease the risk of aspiration
* Address any other comorbidities (VACTERL) associated with the pathology
** Can be valuable to get a preoperative echocardiogram due to the rate of ASDs, VSDs, and TOFs

'''Intraoperative'''

* Standard ASA Monitors
** Temperature will be particularly important given the large amount of heat loss from the open abdomen
* Induction
** Position the patient in reverse trendelenberg to minimize the pressure from the abdominal contents on the lungs
** RSI to minimize aspiration risk
* Lines
** PIVs for resuscitation
** Arterial Line
** Central Lines for CVP monitoring and postoperative parenteral nutrition administration
* Maintenance
** Patient can be maintained w/ either volatile or IV anesthetics
** Avoid N2O due to risk of bowel distension
** Maintain paralysis to help with abdominal closure
** When surgical team is closing the abdomen, have close discussion with surgical team as this may cause decreased diaphragmatic excursion, compression of the lungs, increased airway pressures.
*** If at any point there are an increase in the peak inspiratory pressures > 35 or intra-abdominal pressure > 20, there should be an active discussion with the surgical team about reopening and performing a staged repair.

'''Postoperative'''

* Disposition to the NICU
* Anticipate post operative ventilation requirements
* Continue to monitor intra-abdominal pressures
* Early enteral feeding and TPN discontinuation can decrease length of stay and infection risk

'''<big>Resources</big>'''

* Gropper M, et al. ''Miller's Anesthesia.'' Chapter 77: Pediatric Anesthesia. Section: Omphalocele and Gastroschisis. 9th ed.

* Ledbetter DJ. Gastroschisis and Omphalocele. Surg Clin North Am. 2006;86(2):249-60. PubMed

Gastroschisis

2026-01-15T21:30:02Z

Spate215:

'''<big>Definition</big>'''

* Direct abdominal defect that causes a portion of the intestines and other abdominal organs to herniate '''WITHOUT''' a covering membrane/peritoneal sac
* Typically located on the right side of the umbilicus
* Approximately 10–20% of cases are associated with additional congenital anomalies.
**Commonly reported associated abnormalities include undescended testes, Meckel’s diverticulum, and intestinal duplication.

'''<big>Diagnosis</big>'''
* Identified via ultrasound during prenatal screening
* Elevated AFP can help confirm the diagnosis
** Levels of AFP tend to be higher in Gastroschisis compared to Omphalocele

 '''<big>Epidemiology/Prognosis</big>'''

* Occurs in 3-4 out of 10000 births
* Outcomes are variable, but are highly dependent on the amount of organs/intestines that have herniated and the prior level of prenatal care
** Survival rates are > 90%

 '''<big>Embryology/Pathophysiology</big>'''

*During normal embryologic development, the intestinal tract physiologically herniates into the umbilical cord at approximately the sixth week of gestation, with expected return to the abdominal cavity by around the twelfth week.
*In gastroschisis, this process is disrupted, most commonly attributed to an ischemic insult to the developing abdominal wall, which impairs normal closure and results in persistent herniation of the abdominal contents.

 '''<big>Surgical/Medical Management</big>'''

* Infants with gastroschisis are frequently delivered via cesarean section to minimize the risk of additional bowel injury during passage through the vaginal canal, although the mode of delivery may ultimately be individualized based on obstetric considerations.
* The overarching treatment goal is reduction of the herniated intestinal contents into the abdominal cavity, followed by closure of the fascial and skin defects.
* Management strategies are influenced by several factors, including the size and type of the defect, the size and gestational maturity of the infant, and the presence of associated comorbidities.
* Immediately after delivery, the exposed bowel is typically covered with sterile saline-soaked dressings and enclosed in a clear plastic wrap or silo. This approach helps maintain moisture and normothermia while allowing continuous visual assessment of the herniated intestines.
* Management includes either a surgical approach vs staged approach
** In a primary surgical approach, the bowel is carefully evaluated for evidence of atresia, necrosis, or vascular compromise before being reduced into the abdominal cavity. In some cases, the umbilical cord may be utilized as a biologic dressing to facilitate closure.
** In a staged approach, a silo is placed over the herniated viscera, allowing for gradual, serial reduction of the bowel into the abdominal cavity over several days prior to definitive closure.
***A one stage closure is typically ill-advised due to the risk of developing abdominal compartment syndrome.

 '''<big>Anesthetic Considerations</big>'''

'''Preoperative'''

* Obtain a CBC, CMP and T&S
** Blood loss is typically unexpected however there will be lots of evaporative losses than sometimes may be best treated with blood
** Evaluate whether there are any electrolyte issues
* NGT placement to decompress the stomach and decrease the risk of aspiration
* Address any other comorbidities (VACTERL) associated with the pathology

'''Intraoperative'''

* Standard ASA Monitors
** Temperature will be particularly important given the large amount of heat loss from the open abdomen
* Induction
** Position the patient in reverse trendelenberg to minimize the pressure from the abdominal contents on the lungs
** RSI to minimize aspiration risk
* Lines
** PIVs for resuscitation
** Arterial Line
** Central Lines for CVP monitoring and postoperative parenteral nutrition administration
* Maintenance
** Patient can be maintained w/ either volatile or IV anesthetics
** Avoid N2O due to risk of bowel distension
** Maintain paralysis to help with abdominal closure
** When surgical team is closing the abdomen, have close discussion with surgical team as this may cause decreased diaphragmatic excursion, compression of the lungs, increased airway pressures.
*** If at any point there are an increase in the peak inspiratory pressures > 35 or intra-abdominal pressure > 20, there should be an active discussion with the surgical team about reopening and performing a staged repair.

'''Postoperative'''

* Disposition to the NICU
* Anticipate post operative ventilation requirements
* Continue to monitor intra-abdominal pressures
* Early enteral feeding and TPN discontinuation can decrease length of stay and infection risk

'''<big>Resources</big>'''

* Gropper M, et al. ''Miller's Anesthesia.'' Chapter 77: Pediatric Anesthesia. Section: Omphalocele and Gastroschisis. 9th ed.
* Ledbetter DJ. Gastroschisis and Omphalocele. Surg Clin North Am. 2006;86(2):249-60. PubMed

Gastroschisis

2026-01-13T02:10:17Z

Spate215:

'''<big>Definition</big>'''

* Direct abdominal defect that causes a portion of the intestines and other abdominal organs to herniate '''WITHOUT''' a covering membrane/peritoneal sac
* Typically located on the right side of the umbilicus
* Approximately 10–20% of cases are associated with additional congenital anomalies.
**Commonly reported associated abnormalities include undescended testes, Meckel’s diverticulum, and intestinal duplication.

'''<big>Diagnosis</big>'''
* Identified via ultrasound during prenatal screening
* Elevated AFP can help confirm the diagnosis
** Levels of AFP tend to be higher in Gastroschisis compared to Omphalocele

 '''<big>Epidemiology/Prognosis</big>'''

* Occurs in 3-4 out of 10000 births
* Outcomes are variable, but are highly dependent on the amount of organs/intestines that have herniated and the prior level of prenatal care
** Survival rates are > 90%

 '''<big>Embryology/Pathophysiology</big>'''

*During normal embryologic development, the intestinal tract physiologically herniates into the umbilical cord at approximately the sixth week of gestation, with expected return to the abdominal cavity by around the twelfth week.
*In gastroschisis, this process is disrupted, most commonly attributed to an ischemic insult to the developing abdominal wall, which impairs normal closure and results in persistent herniation of the abdominal contents.

 '''<big>Surgical/Medical Management</big>'''

* Infants with gastroschisis are frequently delivered via cesarean section to minimize the risk of additional bowel injury during passage through the vaginal canal, although the mode of delivery may ultimately be individualized based on obstetric considerations.
* The overarching treatment goal is reduction of the herniated intestinal contents into the abdominal cavity, followed by closure of the fascial and skin defects.
* Management strategies are influenced by several factors, including the size and type of the defect, the size and gestational maturity of the infant, and the presence of associated comorbidities.
* Immediately after delivery, the exposed bowel is typically covered with sterile saline-soaked dressings and enclosed in a clear plastic wrap or silo. This approach helps maintain moisture and normothermia while allowing continuous visual assessment of the herniated intestines.
* Management includes either a surgical approach vs staged approach
** In a primary surgical approach, the bowel is carefully evaluated for evidence of atresia, necrosis, or vascular compromise before being reduced into the abdominal cavity. In some cases, the umbilical cord may be utilized as a biologic dressing to facilitate closure.
** In a staged approach, a silo is placed over the herniated viscera, allowing for gradual, serial reduction of the bowel into the abdominal cavity over several days prior to definitive closure.

 '''<big>Anesthetic Considerations</big>'''

'''Preoperative'''

* Obtain a CBC, CMP and T&S
** Blood loss is typically unexpected however there will be lots of evaporative losses than sometimes may be best treated with blood
** Evaluate whether there are any electrolyte issues
* NGT placement to decompress the stomach and decrease the risk of aspiration
* Address any other comorbidities (VACTERL) associated with the pathology

'''Intraoperative'''

* Standard ASA Monitors
** Temperature will be particularly important given the large amount of heat loss from the open abdomen
* Induction
** Position the patient in reverse trendelenberg to minimize the pressure from the abdominal contents on the lungs
** RSI to minimize aspiration risk
* Lines
** PIVs for resuscitation
** Arterial Line
** Central Lines for CVP monitoring and postoperative parenteral nutrition administration
* Maintenance
** Patient can be maintained w/ either volatile or IV anesthetics
** Avoid N2O due to risk of bowel distension
** Maintain paralysis to help with abdominal closure
** When surgical team is closing the abdomen, have close discussion with surgical team as this may cause decreased diaphragmatic excursion, compression of the lungs, increased airway pressures.
*** If at any point there are an increase in the peak inspiratory pressures > 35 or intra-abdominal pressure > 20, there should be an active discussion with the surgical team about reopening and performing a staged repair.

'''Postoperative'''

* Disposition to the NICU
* Anticipate post operative ventilation requirements
* Continue to monitor intra-abdominal pressures
* Early enteral feeding and TPN discontinuation can decrease length of stay and infection risk

'''<big>Resources</big>'''

* Gropper M, et al. ''Miller's Anesthesia.'' Chapter 77: Pediatric Anesthesia. Section: Omphalocele and Gastroschisis. 9th ed.
* Ledbetter DJ. Gastroschisis and Omphalocele. Surg Clin North Am. 2006;86(2):249-60. PubMed

Gastroschisis

2026-01-12T22:41:31Z

Spate215:

'''<big>Definition</big>'''

* Abdominal defect that causes a portion of the intestines and other abdominal organs to herniate '''WITHOUT''' a covering membrane/peritoneal sac
* Typically located on the right side of the umbilicus
* Approximately 10-20% of cases are a conjoining abnormality
** Common abnormalities associated with Gastroschisis include undescended testes, Meckel's Diverticulum, and intestinal duplication

'''<big>Diagnosis</big>'''

* Identified via ultrasound during prenatal screening
* Elevated AFP can help confirm the diagnosis if there are signs on ulrasound
** Levels of AFP tend to be high in Gastroschisis compared to Omphalocele

'''<big>Epidemiology/Prognosis</big>'''

* Occurs in 3-4 out of 10000 births
* Outcomes are variable, but are highly dependent on the amount of organs/intestines that have herniated and the level of prenatal care
** Survival rates are > 90%

'''<big>Embryology/Pathophysiology</big>'''

* At approximately the 6th week gestation, the intestinal tract typically migrates out of the umbilical cavity via the umbilical cord with the expect that it will return around/by the 12th week of gestation
* However, in Gastroschisis, there is thought to be an ischemic insult to the abdominal wall that prevents closure and therefore results in persistent herniation.

'''<big>Surgical/Medical Management</big>'''

* These babies will likely be delivered via cesearean section to reduce the risk of any additional injury to the bowels during the birthing process via the vaginal canal.
* Goal is to ultimately reduce the intestinal contents back into the abdomen and then close the fascia/skin
* Treatment will depend on the size, type of defect, size of baby, and any other comorbidities
* After delivery, the bowels will be wrapped in sterile saline dressing and wrapped in a clear plastic. The goal of the sterile dressing and plastic wrap is to allow the bowels to remain moist and heated, while still being able to see the herniated intestines.
* There is a surgical approach vs a staged approach
** In the surgical approach, the bowels will be evaluated for any signs of atresia, necrosis, or vascular comproise and then be placed back into the abdominal cavity. The umbilical cord can be used as a biologic dressing
** In the stage approach, there is a serial reduction of the plastic covering that will slowly push the bowels back into the abdomen.

'''<big>Anesthetic Considerations</big>'''

Preoperative

Intraoperative

Postoperative

Omphalocele

2026-01-12T02:32:37Z

Spate215: Created page with "'''<big>Definition</big>''' '''<big>Diagnosis</big>''' '''<big>Epidemiology</big>''' '''<big>Embryology</big>''' '''<big>Surgical/Medical Management</big>''' '''<big>Anesthetic Considerations</big>''' Preoperative Intraoperative Postoperative"

'''<big>Definition</big>'''

'''<big>Diagnosis</big>'''

'''<big>Epidemiology</big>'''

'''<big>Embryology</big>'''

'''<big>Surgical/Medical Management</big>'''

'''<big>Anesthetic Considerations</big>'''

Preoperative

Intraoperative

Postoperative

Gastroschisis

2026-01-12T02:31:58Z

Airway fire

2026-01-12T02:11:27Z

Spate215:

'''<big>Introduction</big>'''

Surgical fires are rare yet potentially devastating events in the operating room and are widely regarded as “never events.” In the United States, an estimated 600 surgical fires occur annually. Through heightened awareness and deliberate preventive practices, operating room teams can significantly reduce the risk of these events and improve patient safety.

Procedures that carry a higher risk of surgical fire include tonsillectomies, tracheostomy creation, burr hole surgery, and surgical removal of lesions involving the head, neck, or face.

'''<big>Triangle of Surgical Fires</big>'''

There are 3 basic elements that all contribute equally to the composition of a surgical fire: '''ignition , oxidizer, and fuel source'''. Each one of these is required in the proper proportion and condition in order to have a surgical fire.

'''Ignition Sources:'''

* Electrocautery (Monopolar, Bipolar, Bovie)
* Lasers
* Fiberoptic Light Source (often used for our bronchoscopic procedure)
* High Speed Drills/Burrs
* Defibrillator

'''Oxidizer'''

* Oxygen
** Oxygen Rich Environments are considered ones where the concentration is greater than 21%.
** Fires will burn hotter, more vigorously, and spread more rapidly in oxygen rich environments
* Nitrous Oxide
** Fires with nitrous tend to burn as hot as they do with oxygen enriched environments
* Air

'''Fuel'''

* Alcohol (Flammable) Skin Prep
* Drapes/Gowns
* Gauzes
* Sponges
* Dressings
* Patient hair/skin
* ETT

'''<big>Prevention of Surgical Fires</big>'''

'''Minimize Oxidizers'''

* Whenever feasible, reduce the fraction of inspired oxygen (FiO₂) to less than 30% while still maintaining an adequate oxygen saturation. Lowering oxygen concentration is a key strategy in reducing the risk of surgical fire.
* When planning to use a low FiO₂ (<30%), increase fresh gas flows to facilitate washout of excess oxygen from the breathing circuit. This process may take longer than anticipated; therefore, closely monitor both FiO₂ and end-tidal oxygen (EtO₂) on the ventilator. Ongoing communication with the surgical team during this period is essential.
* Coordinate with the surgical team to identify critical portions of the procedure, particularly when electrocautery will be used near potential oxygen sources. Proactive planning and clear communication can significantly reduce fire risk.

'''Manage Ignition Source'''

* During the surgical time-out, communicate with the surgical team to ensure you are notified before electrocautery is used near any oxygen-enriched environment.
* Reinforce that electrocautery should not be used when entering the trachea, as this significantly increases the risk of airway fire.
* When fiberoptic scopes are in use, turn off the light source when the scope is not actively needed, as the tip can continue to heat over time. Additionally, avoid placing fiberoptic scopes on or near potential fuel sources to further reduce fire risks.

'''Managing Fuel'''

* When possible, use non–alcohol-based skin preparation solutions, such as iodine-based agents. If alcohol-based preps are required, use the minimal necessary amount and ensure that no solution has pooled. Allow adequate drying time—at least three minutes—before draping or initiating the procedure.
* Remove dry towels from the surgical field and moisten sponges to reduce the availability of potential fuel sources.
* For cases with elevated fire risk, consider the use of a laser-resistant endotracheal tube (ETT). Metallic ETTs, typically constructed from aluminum, offer increased resistance to ignition from laser energy. In contrast, polyvinyl chloride (PVC), red rubber, and silicone endotracheal tubes are more susceptible to ignition during laser airway surgery.
* Inflating the ETT cuff with saline rather than air can further reduce fire risk. Adding a dye such as methylene blue to the saline may aid in early detection of cuff rupture.

'''<big>Steps to Manage an Airway Fire</big>'''

# Turn off any delivery of O2 to the patient
# Disconnect the breathing circuit and simultaneously remove the ETT
## Remember, leaving the ETT in place can cause melting of the tube in the airway
## If you do not turn off the oxygen prior to removal of the tube, it can cause a blow torch effect which can turn this airway fire into a surgical fire
# Pour saline into the airway
# Remove all additional debris from the airway including (sponges and ETT fragments)
## Best to inspect the ETT to ensure that it is still intact and there is no major fragments
# Once the fire has extinguished, attempt to reestablish ventilation with either the placement of an ETT or Mask Ventilation
## Avoid all O2 at this point because there may still be small embers in the airway that could ignite
# Perform bronchoscopy to assess injury and remove any additional debris that may be lodged deeper in the airway

'''Resources:'''

# ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire- here’s how to keep them safer. Health Devices. 2009; 38:314-32. PubMed
# Apfelbaum JL, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013;118(2): 271-90. PubMed
# Miller R Miller's Anesthesia. 7th Edition. 2010. Pages 2405-2416
# Barash, Clinical Anesthesia, 7th Edition. Pages 210-211.

Airway fire

2026-01-12T02:10:52Z

Spate215:

'''<big>Introduction</big>'''

Surgical fires are rare yet potentially devastating events in the operating room and are widely regarded as “never events.” In the United States, an estimated 600 surgical fires occur annually. Through heightened awareness and deliberate preventive practices, operating room teams can significantly reduce the risk of these events and improve patient safety.

Procedures that carry a higher risk of surgical fire include tonsillectomies, tracheostomy creation, burr hole surgery, and surgical removal of lesions involving the head, neck, or face.

'''<big>Triangle of Surgical Fires</big>'''

There are 3 basic elements that all contribute equally to the composition of a surgical fire: '''ignition , oxidizer, and fuel source'''. Each one of these is required in the proper proportion and condition in order to have a surgical fire.

'''Ignition Sources:'''

* Electrocautery (Monopolar, Bipolar, Bovie)
* Lasers
* Fiberoptic Light Source (often used for our bronchoscopic procedure)
* High Speed Drills/Burrs
* Defibrillator
'''Oxidizer'''

'''Oxidizer'''

* Oxygen
** Oxygen Rich Environments are considered ones where the concentration is greater than 21%.
** Fires will burn hotter, more vigorously, and spread more rapidly in oxygen rich environments
* Nitrous Oxide
** Fires with nitrous tend to burn as hot as they do with oxygen enriched environments
* Air
'''Fuel'''

'''Fuel'''

* Alcohol (Flammable) Skin Prep
* Drapes/Gowns
* Gauzes
* Sponges
* Dressings
* Patient hair/skin
* ETT

'''<big>Prevention of Surgical Fires</big>'''

'''Minimize Oxidizers'''

* Whenever feasible, reduce the fraction of inspired oxygen (FiO₂) to less than 30% while still maintaining an adequate oxygen saturation. Lowering oxygen concentration is a key strategy in reducing the risk of surgical fire.
* When planning to use a low FiO₂ (<30%), increase fresh gas flows to facilitate washout of excess oxygen from the breathing circuit. This process may take longer than anticipated; therefore, closely monitor both FiO₂ and end-tidal oxygen (EtO₂) on the ventilator. Ongoing communication with the surgical team during this period is essential.
* Coordinate with the surgical team to identify critical portions of the procedure, particularly when electrocautery will be used near potential oxygen sources. Proactive planning and clear communication can significantly reduce fire risk.
'''Manage Ignition Source'''

'''Manage Ignition Source'''

* During the surgical time-out, communicate with the surgical team to ensure you are notified before electrocautery is used near any oxygen-enriched environment.
* Reinforce that electrocautery should not be used when entering the trachea, as this significantly increases the risk of airway fire.
* When fiberoptic scopes are in use, turn off the light source when the scope is not actively needed, as the tip can continue to heat over time. Additionally, avoid placing fiberoptic scopes on or near potential fuel sources to further reduce fire risks.
'''Managing Fuel'''

'''Managing Fuel'''

* When possible, use non–alcohol-based skin preparation solutions, such as iodine-based agents. If alcohol-based preps are required, use the minimal necessary amount and ensure that no solution has pooled. Allow adequate drying time—at least three minutes—before draping or initiating the procedure.
* Remove dry towels from the surgical field and moisten sponges to reduce the availability of potential fuel sources.
* For cases with elevated fire risk, consider the use of a laser-resistant endotracheal tube (ETT). Metallic ETTs, typically constructed from aluminum, offer increased resistance to ignition from laser energy. In contrast, polyvinyl chloride (PVC), red rubber, and silicone endotracheal tubes are more susceptible to ignition during laser airway surgery.
* Inflating the ETT cuff with saline rather than air can further reduce fire risk. Adding a dye such as methylene blue to the saline may aid in early detection of cuff rupture.
'''<big>Steps to Manage an Airway Fire</big>'''

'''<big>Steps to Manage an Airway Fire</big>'''

# Turn off any delivery of O2 to the patient
# Disconnect the breathing circuit and simultaneously remove the ETT
## Remember, leaving the ETT in place can cause melting of the tube in the airway
## If you do not turn off the oxygen prior to removal of the tube, it can cause a blow torch effect which can turn this airway fire into a surgical fire
# Pour saline into the airway
# Remove all additional debris from the airway including (sponges and ETT fragments)
## Best to inspect the ETT to ensure that it is still intact and there is no major fragments
# Once the fire has extinguished, attempt to reestablish ventilation with either the placement of an ETT or Mask Ventilation
## Avoid all O2 at this point because there may still be small embers in the airway that could ignite
# Perform bronchoscopy to assess injury and remove any additional debris that may be lodged deeper in the airway
'''Resources:'''

'''Resources:'''

# ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire- here’s how to keep them safer. Health Devices. 2009; 38:314-32. PubMed
# Apfelbaum JL, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013;118(2): 271-90. PubMed
# Miller R Miller's Anesthesia. 7th Edition. 2010. Pages 2405-2416
# Barash, Clinical Anesthesia, 7th Edition. Pages 210-211.

Airway fire

2026-01-12T02:10:09Z

Spate215:

Airway fire

2026-01-12T02:09:13Z

Spate215: Created the page