WikiAnesthesia - User contributions [en]

Langley Gouge

2024-12-24T00:54:01Z

Sremick: Blanked the page

Langley Gouge

2024-12-20T12:48:07Z

Sremick: created

A week or two before, you should be contacted by their anesthesiologist that does the scheduling and trainee coordination (as of Dec 2024 – Lucas Suder (Suder, Lucas V Capt USAF (USA) [[Mailto:lucas.v.suder.mil@health.mil|lucas.v.suder.mil@health.mil]] ) and Tory Garling (Garling, Tory P Maj USAF 633 MDG (USA) [[Mailto:tory.p.garling.mil@health.mil|tory.p.garling.mil@health.mil]])). They’ll ask for your schedule requests (days you need off or need to be somewhere else).

Week before –

* Badge/orientation - you should go to Langley to meet up with one of them to get a quick orientation and more importantly, to get your badge. You’ll need a badge/security memo from one of them to get your badge – Office is on the fist floor, ask for direction.
* Pharmacy/pyxis – you’ll need the pharmacy access memo from Suder or Garling, and then take it to inpatient pharmacy. They’ll add your access to the facility. Same username and fingerprint as NMCP.
* Genesis periop tracker - You’ll also need to see the Genesis Account Coordinator at Langley (Mr Simmons – ask someone at Langley to show you where his office is). He provides the approval/justification to DHA/genesis to add you to the 0120 tracker access. After that happens, be sure you still have 0124 (NMCP), it’s been a trend that when the DHA genesis team adds you to 0120 they remove you from 0124, despite all the requests you’ll submit to not do that. (they “remove the Service Resource Security” for the list and need to add it back )
* -iAccess should work from NMCP, mine did.

Locker room, men's is 4114#. There are scrubs in there, no scrub card. Pick any open locker.

Day 1 – do anesthesia. Workflow is awesome, and quick. Be mindful of things that will delay discharge from PACU (too sedated, too nauseous) The ORs are generally scheduled to end NLT 1530, and you don’t want it to be your patient that needs to be babysat when everyone is trying to leave. You'll do your own blocks right before rolling back.

NMCP Anesthesia Intro Guide (Cole's Don't Panic Guide)

2023-08-29T14:43:58Z

Sremick: delete public

NMCP Anesthesia Intro Guide (Cole's Don't Panic Guide)

2023-08-29T14:42:10Z

Sremick: Created page

=== NMCP Anesthesia Intro Guide (Cole's Don't Panic Guide) - Booklet Print ===
[[File:NMCP Anesthesiology Introductory Guide (rotator manual) Booklet Print.pdf|thumb|Booklet Print]]

=== NMCP Anesthesia Intro Guide (Cole's Don't Panic Guide) ===
[[File:NMCP Anesthesiology Introductory Guide (rotator manual).pdf|thumb]]

ERAS Total Joint

2023-08-14T18:50:06Z

Sremick: transfered to practice group page

ERAS Total Joint

2023-08-14T18:47:47Z

Sremick: added flow chart

'''ENHANCED RECOVERY AFTER SURGERY (ERAS)'''

PRIMARY TOTAL KNEE ARTHROPLASTY AND TOTAL HIP ARTHROPLASTY

Revised: June 14, 2022

'''Goals:''' Use a multidisciplinary plan of care to reduce surgical stress, enhance recovery and improve outcomes. The use of evidence-based enhanced recovery after surgery (ERAS) protocols for hip and knee arthroplasty surgery to improve outcomes. ERAS components include education, nutrition, detection and correction of anemia, active pre-warming, preemptive oral analgesia, intraoperative anesthesia techniques, postoperative analgesia and early postoperative mobilization. Multiple randomized controlled studies have demonstrated the benefits, safety, and cost-effectiveness of these protocols.

'''NMCP Total Joint Management Guidelines'''
[[File:ERAS Total Joint Flow Chart Rev JUL 2022.pdf|thumb|610x610px|NMCP TJ ERAS Guidelines Flow Chart]]

'''Pre-operative Preparation:'''

· Pre-operative Education: Patients will be encouraged to attend a class held once every month that includes presentations by the Total Joint Team addressing anesthesia, physical therapy, occupational therapy, nutrition and discharge planning aspects of surgery.

· In pre-admission testing all medications will be reviewed. Patients will be asked to stop the following medications:

· ACE inhibitors (i.e. Lisinopril) or angiotensin receptor blockers stopped 24 hours prior to surgery.

· Diuretics should not be taken on the day of surgery unless given for heart failure.

· Modifications to oral hypoglycemic and insulin regimens will be specified.

· Assess postoperative nausea and vomiting (PONV) risk. For patients at high risk, suggest totally intravenous anesthetic (TIVA) anesthetic or use of an adjunct propofol infusion.

· All patients will have orders from the Total Joint Team for Profend nasal decolonization swabbing, IV antibiotics, sequential compression devices, and pre-op multimodal analgesia (Pregabalin 75mg (>70yo hold) , Mobic 15mg or Celebrex 200mg, acetaminophen 1000mg, Emend 40mg, Rapaflow 8mg (males >50yo) for administration in pre-operative holding area. A paper Rx to pick up Ensure Pre-Surgery Clear Nutrition Drink at Nutrition Management next to the Galley to be taken at 0500 on DOS.

· Patients will have an order in Essentris identifying them as “ERAS Total Joint Protocol.” An orthopedic ERAS checklist template will be initiated upon admission in Essentris. This will be a multidisciplinary flow sheet for the patient’s stay.

· Patients must have ERAS entered under comments when scheduling in S3. Same spot where “block” or “blood” is seen on S3. Clinic scheduling must be aware so that “ERAS” appears on S3.

'''Pre-operative Hold Area:'''

· Liberal pre-op fasting with solids up to 8 hours and approved clears up to 2 hours. No tobacco or nicotine 6 hours prior. Encourage preoperative clear fluids by mouth (preferably carbohydrate containing fluids) up to 2 hours before surgery. The following are acceptable clear liquids: Water, apple juice, Pedialyte, Gatorade or other sports drinks, Sprite or 7-up, black coffee (NO CREAMER), tea.

· An intravenous line will be started. No bolus will be given (KVO).

· Review consent.

· Verify correct patient, correct procedure and correct side.

· Answer any remaining patient questions.

· Profend nasal decolonization swabbing will be completed by nursing staff.

· Pre-op multimodal analgesia: oral Pregabalin 75 mg (>70yo hold), oral Mobic 15 mg or Celebrex 200 mg, oral acetaminophen 1,000 mg, oral Emend 40mg, oral Rapaflow 8mg (males >50yo) to be administered in pre-op holding area by the pre-operative nurse upon arrival. Mobic and Celebrex will be held for renal impairment (Cr >1.4) or allergy. Acetaminophen will be held if allergy, hepatic impairment, chronic ETOH use. Any medication holds will be pre-determined by the surgery team and ordered in Essentris appropriately.

· Skin: clip hair at operative site prn.

· SCD applied to non-operative extremity. No TEDs.

· Surgeon: Surgical site marking.

· Regional adductor block completed for total knee replacements. Ropivacaine 0.2% with a maximum dosing of 15 mL.

'''Intra-operative:'''

· Expected length of average operation: 2-3 hours.

· Any deviations from flowsheet should be discussed at pre-operative TeamStepps.

· Anesthesia: Spinal vs epidural vs general. Neuraxial preferred. Most cases will be able to be done under single injection spinal anesthesia. Bupivacaine 0.5% 10-12mg or Mepivacaine 1.5% 50-60mg. NO EPINEPHRINE OR NARCOTICS IN SPINAL.

· Antibiotics within 30 minutes prior to made incision. Recommended agent is cefazolin. Alternative agents are vancomycin and clindamycin. Cefazolin 1 gm IV for less than 80 kg, Cefazolin 2 mg IV for 80 kg to 119.9 kg, Cefazolin 3 mg IV for 120 kg+. If true PCN allergy, Vancomycin IV. Will be ordered by surgery team. Any deviation from Cefazolin, needs to be discussed with surgeon.

· Administer Tranexamic acid (TXA) 1 gm IV prior to incision and 1 gm IV on way to PACU. Hold for TXA allergy, history of seizure disorder, or active thrombosis.

· Administer 10 mg IV Dexamethasone.

· PONV prophylaxis options: 5-HT3 receptor antagonist (ondansetron 4 mg IV), Dexamethasone 10 mg IV), Consider TIVA or Propofol infusion in high risk PONV patients.

· Normoglycemia: Monitor finger stick blood glucose hourly in diabetics. Begin insulin administration if blood glucose > 200 mg/dl. Target 140-200 mg/dl. Low dose insulin sliding scale (201-250 = 2 Units; 251-300 = 4 Units; 301-350 = 6 Units; 351-400 = 8 Units).

· Positioning: THA posterior and lateral approach position in lateral decubitus, THA anterior approach supine on Hana table or regular OR bed (surgeon preference). TKA supine position.

· Surgeon preference regarding axillary roll for lateral decubitus position.

· Protect bony prominences using egg crate or jelly padding. Gel pads over pegs for lateral decubitus position.

· Apply bovie pad and chest strap. Place Bair hugger over chest and arms.

· Chloraprep operative site x 2 sticks.

· Inject “Total Joint Cocktail” prior to wound closure: Ropivacaine 0.5% (200 mg) 40 mL + toradol 30 mg/mL (1 mL) + epinephrine 1:1000 (.6 mL) + saline 8.4 mL = 50 mL total volume. No toradol if Cr >1.4 or CKD3.

· Wound closure and dressing. Dressings include, Prineo and Mepilex Ag

· TKA and THA patients: Apply ace wrap from foot to proximal leg.

· Apply ice (ice machine) to operative site over surgical dressing and SCD to operative leg.

'''Post-operative:'''

'''Anesthesia:'''

· Pain control should be ordered utilizing the “ANES PACU Adult” order set and see “ERAS-TJ PACU Med Instructions.”

· Pain should be managed with ICE Man cooling device and Fentanyl for breakthrough pain.

· No ketamine, Demerol, Phenergan, Benadryl, morphine, dilaudid, Ativan, valium, versed.

· Zofran should be the primary agent for PONV.

· Discuss dilaudid or Phenergan with Surgeon prior to ordering as second-line adjuncts.

'''PACU''':

· Radiographs.

· Fluid management as needed.

· Normothermia will be maintained with a temperature of 36°C on arrival to the PACU. Use a Bair hugger.

'''Ward:'''

· Advance diet as tolerated. KVO IV fluids once PO intake has normalized.

· Antibiotic prophylaxis: Dosing to be completed by 24 hours post-op.

· Foley catheter removal if present on POD #1 at 0400.

· Early mobilization: OOB to chair, physical therapy, occupational therapy, ambulation. Patients should ambulate on DOS.

· Incentive spirometer 10 times/hour while awake.

· Ice machine and elevation when at rest.

· Precautions: TKA patients must keep knee straight when in bed. No pillow under knee. THA patients must avoid extremes of motion. Bowel regimen: Surfak 1 cap po QD, Miralax 1 capful QD prn. Milk of Magnesia 30-60 mL po QD prn. Bisacodyl 10 mg QD suppository prn constipation not relieved by Milk of Magnesia.

· PONV: Zofran 4 mg IV Q4h prn.

· VTE prophylaxis: SCDs and TEDS. Aspirin 81 mg vs Eliquis start AM of POD #1.

· Multimodal analgesia:

· Baseline coverage: NSAID - Toradol 15 mg IV q6h x 5 doses post-op. Caution if renal impairment. Oral Mobic 15 mg QD or Celebrex 200 mg QD to start after 5 Toradol doses completed. (Caution if renal impairment and hold for Cr >1.4)

· First Line: Oral acetaminophen scheduled dosing 1,000 mg q8h.

· Second Line: Tramadol 50 mg po q6h prn >5/10 pain not relieved by acetaminophen.

· Third Line: Oxycodone (Roxicodone) IR 5 mg po q4h prn 5-8/10 pain not relieved by acetaminophen or Tramadol. Oxycodone (Roxicodone) IR 10 mg po q4h prn 9-10/10 pain not relieved by acetaminophen or Tramadol.

· Fourth Line: Morphine 2-4 mg IV (2 mg IV for 5-8/10 pain, 4 mg IV for 9-10/10 pain) q4h prn pain not relieved by acetaminophen, Tramadol and Roxicodone or Dilaudid .5-1 mg IV (.5 mg IV for 5-8/10 pain, 1 mg IV for 9-10/10 pain) q4h prn pain not relieved by acetaminophen, Tramadol and Roxicodone.

Dexamethasone 10 mg IV x 1 dose on POD #1. Hg A1c > 6.9 hold POD#1 dose and will be placed on SSI while inpatient. (Goal 140-200 blood glucose level)

Discharge planning including home PT, OT, home health, durable medical equipment: Rolling walker, 3:1 commode.

· Labs: CBC and BMP x 1 day, then as clinically indicated. Daily INR if on Coumadin.

· All patients will be encouraged to mobilize on DOS with Ward Staff assistance and walker use.

· Physical therapy will evaluate the patient on DOS for same day discharge patients and POD#1 for all overnight stay patients. Surgical team will ensure these are the first case of the day and will contact the physical therapy team to inform them of the need for DOS evaluation in PACU or on Ward.

'''Patient care is based on individual circumstances and no policy or procedure can detail or describe each circumstance. Thus, this policy is not a statement of the standard of care, and should not be interpreted as such. It is meant to be a guideline only and should never be a substitute for the exercise of judgement.'''

'''Evidence:'''

The following goals were considered while developing this pathway:

· Preanesthesia education can significantly relieve anxiety and emotional stress before hip and knee arthroplasty. 1

· Preoperative education contributes to higher patient confidence, greater patient satisfaction, early recovery and discharge. 2

· Preoperative fasting and carbohydrate loading:

· Several systematic reviews found no evidence to support a safety benefit of prolonged fasting.3,4 Enhanced recovery after surgery consensus guidelines now permit intake of clear fluids until 2 h before induction of anesthesia and a 6 h fast for solid foods.5 The safety of a 2 h-clear/6 h-solids fast is also upheld in obese and morbidly obese cohorts,6 and in patients with uncomplicated diabetes mellitus.7 A more conservative fast is recommended for diabetic patients with gastroparesis.8

· There is insufficient data to make a decision for or against preoperative carbohydrate supplementation for joint arthroplasty.

· Postoperative nausea and vomiting (PONV):

· Patients at moderate risk of PONV (i.e. two risk factors) should receive prophylaxis with dexamethasone at induction or a serotonin receptor antagonist at the end of surgery. 9 High-risk individuals (three or more factors) should receive both dexamethasone at the beginning of surgery and a serotonin receptor antagonist at the end of surgery. Forgoing dexamethasone prophylaxis in a diabetic patient should be decided on an individual basis, after balancing the individual risk of PONV with hyperglycemia. 10

· Pain management: Multimodal, opioid-sparing techniques as the basis for postoperative pain control.5 Multimodal pain management is effective in optimizing pain relief while minimizing complications and side effects. 60 Safe and effective analgesia is a prerequisite to encourage postoperative mobilization.11

· Perioperative pregabalin administration reduces the incidence of chronic neuropathic pain after TKA, with less opioid consumption and better range of motion during the first 30 days of rehabilitation. '''61'''

· Local infiltration of anesthesia (LIA): Local infiltration analgesia provides 6–12h of pain relief after knee arthroplasty.12

· Non-steroidal anti-inflammatory (NSAID).

· Peripheral nerve block (PNB): Adductor canal catheters provide equivalent analgesia without quadriceps weakness.13-16 Combination of epidural analgesia and a single-injection nerve block has been advocated as a way to improve analgesia for knee arthroplasty, with reduced pain scores with therapy and improved physical therapy outcomes.17 Adductor canal block combined with epidural analgesia provides analgesia similar to the combination of femoral nerve block plus epidural analgesia but without the quadriceps weakness that can limit rehabilitation and contribute to falls.18

· Early mobilization: Adverse physiological effects of prolonged bed rest include increased insulin resistance, myopathy, reduced pulmonary function, impaired tissue oxygenation, and increased risk of thromboembolism.19 A meta-analysis shows a significant reduction in length of stay (by 1.8 days) when patients ambulate within 24 h of surgery.20 Early mobilization after knee arthroplasty is also associated with improved functional recovery21 and lower incidence of DVT.22,23

· Normothermia: Measures to avoid hypothermia and hypoxemia also decrease surgical stress and the resulting systemic complications.24 Maintaining perioperative normothermia with forced-air heating has been firmly established to reduce infection,25 cardiac complications,26 coagulopathy, and transfusion requirements.27 Aggressive warming reduced intraoperative blood loss during total hip arthroplasty28 and was associated with reduced opioid need and greater satisfaction after total knee arthroplasty.29 Active intraoperative warming before tourniquet deflation prevented subsequent hypothermia in elderly patients undergoing primary knee replacement under general anaesthesia.30 Short-term postoperative cognitive impairment has been associated with warmer temperatures in elderly patients after knee replacement.31

· Antimicrobial prophylaxis: Infection after joint arthroplasty is a serious complication that can be difficult to treat.32 Evidence from a large systematic review and meta-analysis indicated that systemic antibiotic prophylaxis before hip replacement significantly reduced the incidence of infection.33 The Agency for Healthcare Research and Quality-recommended regimen for patients undergoing primary hip and knee arthroplasty is cefazolin.34 Clindamycin and vancomycin should be reserved as alternative agents, if there is a cephalosporin allergy or surveillance data indicating causative organisms. Pre-operative intranasal betadine swabbing is recommended for all patients and specifically with documented ''S. aureus'' colonization.

· Blood conservation: Transfusion and anemia are both associated with increased incidence of infection, increased length of stay, and higher mortality after joint arthroplasty.35-37 Correction of preoperative anemia is particularly important in patients with multiple risk factors.38 Options to increase preoperative hemoglobin include iron supplements39 and erythropoietin.40 Both are associated with a lower requirement for transfusion after hip and knee arthroplasty. Blood salvage techniques minimize the effects of acute blood loss during both total hip41-43 and total knee arthroplasty.44-46 Pharmacological interventions—specifically, the antifibrinolytic tranexamic acid—have supplanted cell salvage techniques in recent years,47 with multiple publications demonstrating both clinical and cost efficacy in hip,48,49 knee,50-52 and bilateral total knee arthroplasty.53 Tranexamic acid reduces blood loss and the risk of transfusion irrespective of the route of administration (i.v.54 or topical55). The benefits afforded by tranexamic acid are achieved without significant increase in side-effects, including DVT, PE, stroke, myocardial infarction, or seizure.50,52,56

· Venous thromboembolism prevention: Low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism following total joint arthroplasty.57 Current guidelines from the American College of Chest Physicians (ACCP) recommend routine use of anticoagulants to prevent clinical and radiographic DVT and PE after joint arthroplasty.58 Additionally, all-cause mortality is higher in patients taking potent anticoagulants (LMWH or DOAC) than in patients receiving aspirin or warfarin, and clinically significant PE occurred despite the use of anticoagulants.59 Eliquis has been shown to induce fewer wound related complications as compared to other Xa inhibitors.
<references />'''References:'''

1 Bondy LRSims NSchroeder DROfford KPNarr BJ. The effect of anesthetic patient education on preoperative patient anxiety. Reg Anesth Pain Med 1999; 24: 158–64

2 Halaszynski TMJuda RSilverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 2004; 32(Suppl): S76–86

3 Brady MKinn SStuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003; 2003(4): CD004423

4 Ljungqvist OSøreide E. Preoperative fasting. Br J Surg 2003; 90: 400–6

5 Lassen KSoop MNygren J, et al. Consensus review of optimal perioperative care in colorectal surgery. Enhanced Recovery After Surgery (ERAS) Group recommendations. JAMA Surg 2009; 144: 961–9

6 Maltby JRPytka SWatson NCCowan RAFick GH. Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients. Can J Anaesth 2004; 51: 111–5

7 Breuer JPvon Dossow Vvon Heymann C, et al. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Anesth Analg 2006; 103: 1099–108

8 Kong MFHorowitz M. Diabetic gastroparesis. Diabet Med 2005; 22(Suppl 4): 13–8

9 Apfel CCKranke PEberhart LHRoos ARoewer N. Comparison of predictive models for postoperative nausea and vomiting. Br J Anaesth 2002; 88: 234–40

10 Abdelmalak BBBonilla AMYang D, et al. The hyperglycemic response to major noncardiac surgery and the added effect of steroid administration in patients with and without diabetes. Anesth Analg 2013; 116: 1116–22

11 Mudambai SCKim TEHoward SK, et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472: 1377–83

12 Kehlet HAndersen L&Oslash. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011; 55: 778–84

13 Elkassabany NMAntosh SAhmed M, et al. The risk of falls after total knee arthroplasty with the use of a femoral nerve block versus an adductor canal block: a double-blinded randomized controlled study. Anesth Analg 2016; 122: 1696–703

14 Shah NAJain NP. Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty? Effect on ambulation ability, early functional recovery and pain control: a randomized controlled trial. J Arthroplasty 2014; 29: 2224–9

15 Machi ATSztain JFKormylo NJ, et al. Discharge readiness after tricompartment knee arthroplasty: adductor canal versus femoral continuous nerve blocks. A dual-center, randomized trial. Anesthesiology 2015; 123: 444–56

16 Jaeger PZaric DFomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 2013; 38: 526–32

17 YaDeau JTCahill JBZawadsky MW, et al. The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg 2005; 101: 891–5

18 Kim DHLin YGoytizolo EA, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial. Anesthesiology 2014; 120: 540–50

12 Kehlet HAndersen L&Oslash. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011; 55: 778–84

19 Kehlet HWilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630–41

11 Mudambai SCKim TEHoward SK, et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472: 1377–83

20 Guerra MLSingh PJTaylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil 2015; 29: 844–54

21 Pua YHOng PH. Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. Am J Phys Med Rehabil 2014; 93: 962–70

22 Pearse EOCaldwell BFLockwood RJHollard J. Early mobilization after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br 2007; 89: 316–22

23 Chandrasekaran SAriaretnam SKTsung JDickison D. Early mobilization after total knee replacement reduces the incidence of deep venous thrombosis. ANZ J Sug 2009; 79: 526–9

24 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606–17

25 Scott EMBuckland R. A systematic review of intraoperative warming to prevent postoperative complications. AORN J 2006; 83: 1090–104 1107-1113.

26 Frank SMFleisher LABreslow MJ, et al. Perioperative maintenance of norothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA 1997; 277: 1127–34

27 Schmied HKurz ASessler DIKozek SReiter A. A mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 1996; 347: 289–92

28 Winkler MAkça OBirkenberg B, et al. Aggressive warming reduces blood loss during hip arthroplasty. Anesth Analg 2000; 91: 978–84

29 Benson EEMcMillan DEOng B. The effects of active warming on patient temperature and pain after total knee arthroplasty. Am J Nurs 2012; 112: 26–33

30 Kim YSJeon YSLee JA, et al. Intra-operative warming with a forced-air warmer in preventing hypothermia after tourniquet deflation in elderly patients. J Int Med Res 2009; 37: 1457–64

31 Salazar FDoñate MBoget T, et al. Intraoperative warming and post-operative cognitive dysfunction after total knee replacement. Acta Anaesthesiol Scand 2011; 55: 216–22

32 Zimmerli WTrampuz AOchsner PE. Prosthetic-joint infections. N Engl J Med2004; 351:1645–54

33 Voigt JMosier MDarouiche R. Systematic review and meta-analysis of randomized controlled trials of antibiotics and antiseptics for preventing infection in people receiving primary total hip and knee prostheses. Antimicrob Agents Chemother 2015; 59: 6696–707

34 Bratzler DWDellinger EPOlsen KM. Clinical guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70: 195–283

35 Bernard ACDavenport DLChang PKVaughan TBZwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 2009; 208: 931–7

36 Bower WFJin LUnderwood MJLam YHLai PB. Peri-operative blood transfusion increases length of hospital stay and number of postoperative complications in non-cardiac surgical patients. Hong Kong Med J 2010; 16: 116–20

37 Greenky MGandhi KPulido LRestrepo CParvizi J. Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection? Clin Orthop Relat Res 2012; 470: 2695–701

38 Pola EPapaleo PSantoliquido AGasparini GAulisa LDe Santis E. Clinical factors associated with an increased risk of perioperative blood transfusion in nonanemic patients undergoing total hip arthroplasty. J Bone Joint Surg Am 2004; 86: 57–61

39 Cuenca JIGarcía-Erce JAMartínez FCardona RPérez-Serrano LMuñoz M. Preoperative haematinics and transfusion protocol reduce the need for transfusion after total knee replacement. Int J Surg 2007; 5: 89–94

40 Spahn D. Anaemia and patient blood management in hip and knee surgery. Anaesthesiology 2010; 113: 482–95

41 Del Trujillo MMCarrero AMuñoz M. The utility of the perioperative autologous transfusion system OrthoPAT in total hip replacement surgery: a prospective study. Arch Orthop Trauma Surg 2008; 128: 1031–8

42 Smith LKWilliams DHLangkamer VG. Post-operative blood salvage with autologous retransfusion in primary total hip replacement. J Bone Joint Surg Br 2007; 89: 1092–7

43 Moonen AFKnoors NTvan Os JJVerburg ADPilot P. Retransfusion of filtered shed blood in primary total hip and knee arthroplasty: a prospective randomized clinical trial. Transfusion 2007; 47: 379–84

44 Shenolikar AWareham KNewington DThomas DHughes JDownes M. Cell salvage auto transfusion in total knee replacement surgery. Transfus Med 1997; 7: 277–80

45 Thomas DWareham KCohen DHutchings H. Autologous blood transfusion in total knee replacement surgery. Br J Anaesth 2001; 86: 669–73

46 Muñoz MAriza DGarcerán MJGómez ACampos A. Benefits of postoperative shed blood reinfusion in patients undergoing unilateral total knee replacement. Arch Orthop Trauma Surg 2005; 125: 385–9

47 Oremus KSostaric STrkulja VHaspl M. Influence of tranexamic acid on postoperative autologous blood retransfuion in primary total hip and knee arthroplasty: a randomized controlled trial. Transfusion 2014; 54: 31–41

48 Zhou XDTao LJLi JWu LD. Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis of nineteen randomized controlled trials. Arch Orthop Trauma Surg 2013; 133: 1017–27

49 Sukeik MAlshryda SHaddad FSMason JM. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br 2011; 93: 39–46

50 Wei ZLiu M. The effectiveness and safety of tranexamic acid in total hip or knee arthroplasty: a meta-analysis of 2720 cases. Transfus Med 2015; 25: 151–62

51 Zhang HChen JChen FQue W. The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1742–52

52 Yang ZGChen WPWu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am 2012; 94: 1153–9

53 He PZhang ZLi YXu DWang H. Efficacy and safety of tranexamic acid in bilateral total knee replacement: a meta-analysis and systematic review. Med Sci Monit 2015; 21: 3634–42

54 Fu DJChen CGuo LYang L. Use of intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials. Chin J Traumatol 2013; 16: 67–76

55 Alshryda SSukeik MSarda PBlenkinsopp JHaddad FSMason M. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J 2014; 96-B: 1005–15 Aug

56 Poeran JRasul RSuzuki S, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014; 349: g4829

57 JParvizi RHuang CRestrepo, et al. Low-Dose Aspirin is Effective Chemoprophylaxis Against Clinically Important Venous Thromboembolism Following Total Joint Arthroplasty. J Bone Joint Surg Am 2017; 99:91-8.

58 Falck-Ytter YFrancis CWJohanson NA, et al. Prevention of VTE in Orthopedic Surgery Patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2 Suppl): e278S–325S

59 Sharrock NE Della Valle AGGo GLyman SSalvati EA. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res2008;466:714–21

60 Sah AP Liang K Scalafani JA. Optimal Multimodal Analgesia Treatment Recommendations for Total Joint Arthroplasty: A Critical Analysis Review. J Bone Joint Surg Rev 2018; 6(6):e7

61 Buvanendran, A Kroin JS Della Valle CJ Kari M Moric M Tuman KJ. Perioperative Oral Pregabalin Reduces Chronic Pain After Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. Int Anes Res Soc; Vol 110, No. 1, January 2010: 199-207

ERAS Total Joint

2023-08-14T18:43:01Z

Sremick: Created page

ERAS Breast Cancer

2023-08-04T13:32:26Z

Sremick: should have been practice group article

ERAS Breast Cancer

2023-08-04T13:31:21Z

Sremick: created

'''(15 Jan 2021)'''

'''NAVAL MEDICAL CENTER PORTSMOUTH'''

'''''Department of General Surgery'''''

620 John Paul Jones Circle

Portsmouth, Virginia 23708

'''E'''nhanced '''R'''ecovery '''A'''fter '''S'''urgery ('''ERAS''')

BREAST CANCER SURGERY PROTOCOL
{| class="wikitable"
|'''Weeks prior to surgery'''
| Appointment to discuss operation if applicable

o Book case as “ERAS-BRCA” on S3 to ensure post-op bed

Pre-operative nurse appointment

Appointment with anesthesia

Lab-work and imaging

Smoking cessation

Preoperative marking with wound care if applicable

Walking/Exercise program

Discuss Regional Anesthesia (PVB vs PECS)
|-
|'''Days prior to surgery'''
| Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)

ACE and ARBs to be held the day of surgery

Beta-blockers should be taken day of surgery
|-
|'''Day of Surgery'''
| Chlorhexidine shower the morning of surgery

Bring home medications list and CPAP

Clear glucose containing drink (Gatorade or Ensure Pre-op) up to 2 hours prior to start of surgery.

Gabapentin 600mg PO on arrival to DOS

Celecoxib 400mg PO on arrival to DOS

Acetaminophen 975mg PO on arrival to DOS

Aprepitant 40mg PO if high PONV risk

Prophylactic antibiotics per surgical team

DVT prophylaxis heparin 5,000U SC q8h after block completed. May start lovenox 12h after placement of block due to hematoma risk per ASRA guidelines.
|-
|'''Regional Anesthesia'''
| Primary: Paravertebral Block performed with plain bupivacaine in pre-op holding area

Secondary: If contraindication to PVB including patient refusal for awake block, consider PECS 1 & 2 blocks with 10mL & 20mL plain bupivacaine/liposomal bupivacaine mixture respectively per side performed prior to induction
|-
|'''Intra-operatively'''

| Plan GETA via propofol TIVA

Induction with lidocaine, propofol, rocuronium, & esmolol prn

Maintenance with propofol TIVA

Esmolol gtt at 10-30mcg/kg/min

Breakthrough pain control

o 1st line Esmolol gtt increase to max 50mcg/kg/min

o 2nd line Ketamine bolus (0.2 to 0.5 mg/kg)

PONV Prophy

o Dexamethasone 8mg at beginning of case

o Ondansetron 4mg prior to skin closure

PECS plane infiltration with liposomal bupivacaine in normal saline by surgeons

If no regional technique performed, plan for Ketamine gtt 5-10mcg/kg/min with lidocaine 40mcg/kg/min
|-
|'''Post-operatively/PACU'''
| Scheduled

o Gabapentin 300mg PO qHS x10 days

o Acetaminophen 1000mg PO q8h times from pre-op dose x6 total doses then BID for 2 weeks, then PRN

o Celecoxib 200mg PO qDay for 1 month

Breakthrough

o 1st line Acetaminophen 1000mg PO q8h prn if not receiving as scheduled

o 2nd line Tramadol 50mg PO q4h prn

o 3rd line Oxycodone 5mg PO q4h prn
|}

ERAS Lite

2023-01-23T19:58:05Z

Sremick: Replaced content with "thumb''' '''"

[[File:ERAS-LITE updated Aug 2022.docx|thumb]]''' '''

CHKD Gouge

2022-09-01T13:51:41Z

Sremick: Blanked the page

CHKD Gouge

2022-09-01T13:50:49Z

Sremick:

"FYI - for CHKD Becky Cropp needs your paperwork 1 month before. Today is my first day and I was in the OR by 0715. You have to have current BLS and ACLS. Here is her email Rebecca.Cropp@chkd.org|Rebecca.Cropp@chkd.org

CHKD Gouge

2022-09-01T13:48:24Z

Sremick: Created page with ""FYI - for CHKD Becky Cropp needs your paperwork 1 month before. Today is my first day and I was in the OR by 0715. You have to have current BLS and ACLS. Here is her email Rebecca.Cropp@chkd.org""

"FYI - for CHKD Becky Cropp needs your paperwork 1 month before. Today is my first day and I was in the OR by 0715. You have to have current BLS and ACLS. Here is her email [[Mailto:Rebecca.Cropp@chkd.org|Rebecca.Cropp@chkd.org"]]

ERAS Lite

2022-09-01T13:31:03Z

Sremick:

[[File:ERAS-LITE updated Aug 2022.docx|thumb]]
{| class="wikitable"
|'''Weeks prior to surgery'''
|    '''Appointment to discuss operation if applicable '''

o '''Book case as “ERAS-LITE” on S3'''

   '''Pre-operative nurse appointment'''

   '''Appointment with anesthesia if otherwise indicated'''

   '''Lab-work and imaging'''

   '''Smoking cessation'''

   '''Nutrition appointment'''

   '''Preoperative marking with wound care if applicable'''

   '''Walking/Exercise program'''
|-
|'''Days prior to surgery'''
|    '''Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)'''

   '''Blood thinner: Surgeons’s discretion'''

   '''ACE and ARBs to be held the day of surgery'''

   '''Diuretics to be held the day of surgery (unless CHF)'''

   '''Beta-blockers should be taken day of surgery'''

   '''For patients without type 2 dependent diabetes: ENSURE pre-surgery drink: 2 bottles the night before surgery and 1 bottle at 0400 the day of surgery'''

   '''For patients with type 2 diabetes not requiring insulin: Ensure pre-surgery drink: 2 bottles the night before surgery and 1 bottle at 0400 the day of surgery. Check blood sugar on day of surgery and use sliding scale insulin as needed to adjust glycemic levels preoperatively'''

   '''For patients with type 2 diabetes requiring insulin: No ensure presurgery drinks. Drink 16-20 ounces of water or other sugar free/calorie free liquid the night before surgery and 8-10 ounces of water or other sugar free/calorie free liquid 4 hours before scheduled surgery start.'''

|-
|'''Day of Surgery'''
|

   '''Chlorhexidine shower the morning of surgery'''

   '''Bring home medications list and CPAP'''

   '''Bring Sugarless Chewing Gum'''
|-
|'''Pre-operatively'''
|    '''Premedications'''

o '''PO Celecoxib 200mg x 1'''

o '''PO Pregabalin 75 mg x1'''

o '''PO Tylenol 975mg x 1'''

o '''IV Versed 2mg x1 Prior to OR'''

   '''History of PONV'''

o '''Consider PO Emend 40mg'''

o '''Consider Scopalamine Patch'''

   '''Antibiotics: Per surgeon'''

   '''IV in non-operative limb'''

o '''LR at KVO'''

   '''Hair removal done in pre-op holding area'''

   '''Regional Anesthesia as indicated'''

o '''Hold Heparin/Lovenox SQ until after neuraxial/regional'''
|-
|'''Intra-operatively'''

|    '''Positioning Devices as Indicated'''

   '''Normothermia/Bair Hugger'''

   '''Targeted fluid therapy'''

   '''Induction'''

o '''Ketamine 0.2-0.3 mg/kg'''

o '''Lidocaine 1-1.5 mg/kg'''

o '''Propofol as indicated'''

o '''Sympathtic blunting agent;'''

▪ '''Esmolol 0.3-0.5 mg/kg'''

▪ '''Fentanyl 0.5-2 mcg/kg'''

o '''NMBA as indicated'''

o '''Dexamethasone 0.1mg/kg'''

▪ '''Max dose 8 mg'''

   '''Maintenance'''

o '''Volatile Anesthetics as indicated'''

o '''Pain Adjuncts as indicated'''

▪ '''Propofol gtt'''

▪ '''Lidocaine gtt'''

▪ '''Magnesium bolus/gtt'''

▪ '''Dexmedetomidine bolus/gtt'''

o '''Opioids as indicated'''

   '''Ondansetron 4mg IV'''

   '''Surgeon administered long acting local anesthetic wound infiltration'''
|-
|'''Post-operatively/PACU'''
|    '''PACU Medications'''

o '''Ketamine 20mg IV q15min PRN First line for pain if not tolerating PO'''

o '''Tramadol 50-100mg PO x1 PRN First line for pain if tolerating PO'''

o '''Ondansetron 4mg IV x1 PRN'''

o '''Midazolam 2mg IV x1 PRN Anxiety'''

o '''Hydromorphone 0.2-0.4 mg IV PRN Second line for pain'''

   '''LR at 75 mL/hr'''

   '''Clear liquids when awake if no aspiration risk'''

   '''PACU X-Ray as indicated'''
|-
|'''POD#0 (Inpatient)'''
|    '''Pain Meds:'''

o '''PO Acetaminophen 975mg q8h timed from preop dose'''

o '''PO Celecoxib 200mg 12 hours following preop dose'''

o '''PO Tramadol 50-100 mg PO q6h prn pain'''

o '''PO Oxycodone 5-10mg q4h PRN Breakthrough Pain (first line)'''

o '''IV Hydromorphone 0.4mg x1 PRN Breakthrough Pain (second line)'''

   '''Bowel Regimen'''

o '''Colace 100mg BID PRN'''

   '''Antiemetic'''

o '''Ondansetron 4mg q4h PRN'''

   '''Advance diet as tolerated'''

   '''Ambulating 2-3 times/day outside of room'''

   '''PT/OT consult if Required'''

   '''Wound Care consult if required'''

   '''Consider foley removal'''

|-
|'''Ward POD#1 (Inpatient)'''
|    '''POD 1 labs: CBC and BMP/Mag/Phos'''

   '''Start VTE prophylaxis after first CBC'''

o '''Lovenox 40 mg SQ daily'''

o '''Heparin 5000 U TID if bleeding concerns or renal insufficiency'''

o '''Heparin 5000 U BID if older than 75 year of age'''

   '''Pain Meds'''

o '''If needed, add PO Pregabalin 150mg qDay'''

o '''If needed, add oral Valium 5 mg q8h prn muscle spasm'''

   '''Consider removal of foley if in situ'''

   '''Continue to advance diet'''

   '''Discontinue IVF once tolerating > 500 mL orally'''

   '''Ambulate TID'''

   '''ICS 10x/hr'''

   '''Discharge Planner to See'''
|-
|'''Ward POD #2 & Onward (Inpatient'''
|    '''Out of bed 8 hours'''

   '''Consider discharge once meets criteria'''

   '''Discharge Medications as below:'''
|-
|'''POD#0 (Outpatient)'''
|    '''Discharge Meds'''

o '''Acetaminophen 975mg q8h'''

▪ '''63 Tabs (7 days)'''

o '''Naproxen 500mg q12h'''

▪ '''14 Tabs (7 days)'''

o '''Oxycodone 5mg q4h PRN'''

▪ '''5-15 Tabs (1-2 days)'''

o '''Colace 100mg BID PRN'''

▪ '''14 tabs (7 days)'''

o '''Zofran 4mg q4h PRN'''

▪ '''30 tabs (5 days)'''

|}

''' '''

ERAS Lite

2022-09-01T13:27:57Z

Sremick: created page

{| class="wikitable"
|'''Weeks prior to surgery'''
|    '''Appointment to discuss operation if applicable '''

o '''Book case as “ERAS-LITE” on S3'''

   '''Pre-operative nurse appointment'''

   '''Appointment with anesthesia if otherwise indicated'''

   '''Lab-work and imaging'''

   '''Smoking cessation'''

   '''Nutrition appointment'''

   '''Preoperative marking with wound care if applicable'''

   '''Walking/Exercise program'''
|-
|'''Days prior to surgery'''
|    '''Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)'''

   '''Blood thinner: Surgeons’s discretion'''

   '''ACE and ARBs to be held the day of surgery'''

   '''Diuretics to be held the day of surgery (unless CHF)'''

   '''Beta-blockers should be taken day of surgery'''

   '''For patients without type 2 dependent diabetes: ENSURE pre-surgery drink: 2 bottles the night before surgery and 1 bottle at 0400 the day of surgery'''

   '''For patients with type 2 diabetes not requiring insulin: Ensure pre-surgery drink: 2 bottles the night before surgery and 1 bottle at 0400 the day of surgery. Check blood sugar on day of surgery and use sliding scale insulin as needed to adjust glycemic levels preoperatively'''

   '''For patients with type 2 diabetes requiring insulin: No ensure presurgery drinks. Drink 16-20 ounces of water or other sugar free/calorie free liquid the night before surgery and 8-10 ounces of water or other sugar free/calorie free liquid 4 hours before scheduled surgery start.'''

|-
|'''Day of Surgery'''
|

   '''Chlorhexidine shower the morning of surgery'''

   '''Bring home medications list and CPAP'''

   '''Bring Sugarless Chewing Gum'''
|-
|'''Pre-operatively'''
|    '''Premedications'''

o '''PO Celecoxib 200mg x 1'''

o '''PO Pregabalin 75 mg x1'''

o '''PO Tylenol 975mg x 1'''

o '''IV Versed 2mg x1 Prior to OR'''

   '''History of PONV'''

o '''Consider PO Emend 40mg'''

o '''Consider Scopalamine Patch'''

   '''Antibiotics: Per surgeon'''

   '''IV in non-operative limb'''

o '''LR at KVO'''

   '''Hair removal done in pre-op holding area'''

   '''Regional Anesthesia as indicated'''

o '''Hold Heparin/Lovenox SQ until after neuraxial/regional'''
|-
|'''Intra-operatively'''

|    '''Positioning Devices as Indicated'''

   '''Normothermia/Bair Hugger'''

   '''Targeted fluid therapy'''

   '''Induction'''

o '''Ketamine 0.2-0.3 mg/kg'''

o '''Lidocaine 1-1.5 mg/kg'''

o '''Propofol as indicated'''

o '''Sympathtic blunting agent;'''

▪ '''Esmolol 0.3-0.5 mg/kg'''

▪ '''Fentanyl 0.5-2 mcg/kg'''

o '''NMBA as indicated'''

o '''Dexamethasone 0.1mg/kg'''

▪ '''Max dose 8 mg'''

   '''Maintenance'''

o '''Volatile Anesthetics as indicated'''

o '''Pain Adjuncts as indicated'''

▪ '''Propofol gtt'''

▪ '''Lidocaine gtt'''

▪ '''Magnesium bolus/gtt'''

▪ '''Dexmedetomidine bolus/gtt'''

o '''Opioids as indicated'''

   '''Ondansetron 4mg IV'''

   '''Surgeon administered long acting local anesthetic wound infiltration'''
|-
|'''Post-operatively/PACU'''
|    '''PACU Medications'''

o '''Ketamine 20mg IV q15min PRN First line for pain if not tolerating PO'''

o '''Tramadol 50-100mg PO x1 PRN First line for pain if tolerating PO'''

o '''Ondansetron 4mg IV x1 PRN'''

o '''Midazolam 2mg IV x1 PRN Anxiety'''

o '''Hydromorphone 0.2-0.4 mg IV PRN Second line for pain'''

   '''LR at 75 mL/hr'''

   '''Clear liquids when awake if no aspiration risk'''

   '''PACU X-Ray as indicated'''
|-
|'''POD#0 (Inpatient)'''
|    '''Pain Meds:'''

o '''PO Acetaminophen 975mg q8h timed from preop dose'''

o '''PO Celecoxib 200mg 12 hours following preop dose'''

o '''PO Tramadol 50-100 mg PO q6h prn pain'''

o '''PO Oxycodone 5-10mg q4h PRN Breakthrough Pain (first line)'''

o '''IV Hydromorphone 0.4mg x1 PRN Breakthrough Pain (second line)'''

   '''Bowel Regimen'''

o '''Colace 100mg BID PRN'''

   '''Antiemetic'''

o '''Ondansetron 4mg q4h PRN'''

   '''Advance diet as tolerated'''

   '''Ambulating 2-3 times/day outside of room'''

   '''PT/OT consult if Required'''

   '''Wound Care consult if required'''

   '''Consider foley removal'''

|-
|'''Ward POD#1 (Inpatient)'''
|    '''POD 1 labs: CBC and BMP/Mag/Phos'''

   '''Start VTE prophylaxis after first CBC'''

o '''Lovenox 40 mg SQ daily'''

o '''Heparin 5000 U TID if bleeding concerns or renal insufficiency'''

o '''Heparin 5000 U BID if older than 75 year of age'''

   '''Pain Meds'''

o '''If needed, add PO Pregabalin 150mg qDay'''

o '''If needed, add oral Valium 5 mg q8h prn muscle spasm'''

   '''Consider removal of foley if in situ'''

   '''Continue to advance diet'''

   '''Discontinue IVF once tolerating > 500 mL orally'''

   '''Ambulate TID'''

   '''ICS 10x/hr'''

   '''Discharge Planner to See'''
|-
|'''Ward POD #2 & Onward (Inpatient'''
|    '''Out of bed 8 hours'''

   '''Consider discharge once meets criteria'''

   '''Discharge Medications as below:'''
|-
|'''POD#0 (Outpatient)'''
|    '''Discharge Meds'''

o '''Acetaminophen 975mg q8h'''

▪ '''63 Tabs (7 days)'''

o '''Naproxen 500mg q12h'''

▪ '''14 Tabs (7 days)'''

o '''Oxycodone 5mg q4h PRN'''

▪ '''5-15 Tabs (1-2 days)'''

o '''Colace 100mg BID PRN'''

▪ '''14 tabs (7 days)'''

o '''Zofran 4mg q4h PRN'''

▪ '''30 tabs (5 days)'''

|}

''' '''

Nasal intubation

2022-08-17T13:49:24Z

Sremick: added reference for possible increased complications without benefit of serial dilation

'''Nasal intubation''' is an approach to [[endotracheal intubation]] often used to increase intraoral exposure during head & neck surgery.

== Indications==
*Transoral robotic surgery
*Maxillofacial surgery
*Dental surgery
* Restricted mouth opening
*Cervical spine instability
*Lower facial trauma
*Structural abnormalities that preclude oral intubation

==Contraindications==

* Severe bleeding diathesis
*Anticoagulation
* Basilar skull fractures
**Advancing a nasal tube in a patient with a basilar skull fracture risks penetration into the brain.<ref name=":0">{{Cite journal|last=Hall|first=C. E. J.|last2=Shutt|first2=L. E.|date=2003|title=Nasotracheal intubation for head and neck surgery|url=https://pubmed.ncbi.nlm.nih.gov/12603455|journal=Anaesthesia|volume=58|issue=3|pages=249–256|doi=10.1046/j.1365-2044.2003.03034.x|issn=0003-2409|pmid=12603455|via=}}</ref>

==Patient evaluation==
A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />

==Preparation of Nasal Mucosa==

===Topical anesthesia and vasoconstriction===
Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%. If topical anesthesia is also desirable, lidocaine 3-4% (with phenylephrine 0.25-1%) or cocaine 4-10% may also be used.<ref name=":0" /> Prepare for any potential hemodynamic effects from systemic absorption of the drugs and/or additives used.

===Mechanical dilation===
Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal|last=Adamson|first=D. N.|last2=Theisen|first2=F. C.|last3=Barrett|first3=K. C.|date=1988|title=Effect of mechanical dilation on nasotracheal intubation|url=https://pubmed.ncbi.nlm.nih.gov/3163370|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons|volume=46|issue=5|pages=372–375|doi=10.1016/0278-2391(88)90220-0|issn=0278-2391|pmid=3163370|via=}}</ref> <ref>{{Citation|last=Folino|first=Thomas B.|title=Nasotracheal Intubation|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK499967/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29763142|access-date=2022-08-17|last2=Mckean|first2=George|last3=Parks|first3=Lance J.}}</ref>

==Selection of Endotracheal Tube==

Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation.

*[[Ring-Adair-Elwyn endotracheal tube|Nasal RAE tubes]] have a preformed bend at a set depth depending on the internal diameter of the tube
** Must be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth
**Most patients require a size 7.0 mm internal diameter nasal RAE or larger
*[[Microlaryngeal endotracheal tube|Microlaryngeal tubes]] may be used if a smaller diameter is desirable
**Typically 5.0 mm and 6.0 mm internal diameter are sufficiently long to be used for nasotracheal intubation

==Complications ==

=== Epistaxis ===

* Most common complication of nasal intubation epistaxis from nasal trauma
* Causes include<ref name=":0" />
** Inadequate vasoconstriction
** Larger diameter endotracheal tubes
** Excessive force
** Repeated insertion attempts.
* Softening the endotracheal tube in hot water may reduce risk<ref>{{Cite journal|last=Lu|first=P. P.|last2=Liu|first2=H. P.|last3=Shyr|first3=M. H.|last4=Ho|first4=A. C.|last5=Wang|first5=Y. L.|last6=Tan|first6=P. P.|last7=Yang|first7=C. H.|date=1998|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation|url=https://pubmed.ncbi.nlm.nih.gov/10399514|journal=Acta Anaesthesiologica Sinica|volume=36|issue=4|pages=193–197|issn=0254-1319|pmid=10399514|via=}}</ref>
* If bleeding occurs, intubation should be completed quickly if possible.
** If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated to tamponade bleeding<ref name=":0" />

=== Alar necrosis ===

* Occurs due to pressure from the nasal tube
* May occur quickly
** Has been reported in nasal intubations of even short duration.<ref name=":0" />
* Prevented by securing the tube such that pressure is avoided on the nasal ala

=== Other complications ===
Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.

== References ==
<references />