WikiAnesthesia - User contributions [en]

Cholecystectomy

2021-08-04T00:12:18Z

Svdg:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = Peripheral IV
| monitors = No procedure-specific monitoring requirements
| considerations_preoperative = PONV prophylaxis
| considerations_intraoperative = General considerations for laparoscopic surgery
| considerations_postoperative = PONV, consider TAP block
}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref>.
==Preoperative management==
===Patient evaluation===
Most patients are healthy presenting for elective surgery, though others with acute cholecystitis may be critically unwell (e.g., patients with critical illness who develop acalculous cholecystitis).

=== Labs and studies ===

* No procedure-specific considerations for otherwise healthy patients.

*

===Operating room setup===

* No procedure-specific equipment required.

*

*

=== Patient preparation and premedication ===

* Laparoscopy and cholecystectomy specifically are minor risk factors for PONV<ref>{{Cite journal|last=Apfel|first=C. C.|last2=Heidrich|first2=F. M.|last3=Jukar-Rao|first3=S.|last4=Jalota|first4=L.|last5=Hornuss|first5=C.|last6=Whelan|first6=R. P.|last7=Zhang|first7=K.|last8=Cakmakkaya|first8=O. S.|date=2012-11|title=Evidence-based analysis of risk factors for postoperative nausea and vomiting|url=https://pubmed.ncbi.nlm.nih.gov/23035051|journal=British Journal of Anaesthesia|volume=109|issue=5|pages=742–753|doi=10.1093/bja/aes276|issn=1471-6771|pmid=23035051}}</ref>, consider the need for pre-operative prophylaxis (e.g., scopolamine, aprepitant)
* Anxiolysis as indicated by patient characteristics and local practices.

===Regional and neuraxial techniques===

* Open<ref>{{Cite journal|last=Savas|first=Jeannie F.|last2=Litwack|first2=Robert|last3=Davis|first3=Kevin|last4=Miller|first4=Thomas A.|date=2004-11|title=Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment|url=https://pubmed.ncbi.nlm.nih.gov/15546579|journal=American Journal of Surgery|volume=188|issue=5|pages=603–605|doi=10.1016/j.amjsurg.2004.07.016|issn=0002-9610|pmid=15546579}}</ref> and laparoscopic<ref>{{Cite journal|last=Sinha|first=Rajeev|last2=Gurwara|first2=A. K.|last3=Gupta|first3=S. C.|date=2009-06|title=Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients|url=https://pubmed.ncbi.nlm.nih.gov/19522659|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A|volume=19|issue=3|pages=323–327|doi=10.1089/lap.2008.0393|issn=1092-6429|pmid=19522659}}</ref><ref>{{Cite journal|last=Bessa|first=Samer S.|last2=Katri|first2=Khaled M.|last3=Abdel-Salam|first3=Wael N.|last4=El-Kayal|first4=El-Saed A.|last5=Tawfik|first5=Tarek A.|date=2012-07|title=Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study|url=https://pubmed.ncbi.nlm.nih.gov/22686181|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A|volume=22|issue=6|pages=550–555|doi=10.1089/lap.2012.0110|issn=1557-9034|pmid=22686181}}</ref><ref>{{Cite journal|last=Agrawal|first=Malti|last2=Verma|first2=A. P.|last3=Kang|first3=L. S.|date=2013-01|title=Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study|url=https://pubmed.ncbi.nlm.nih.gov/25885719|journal=Anesthesia, Essays and Researches|volume=7|issue=1|pages=44–48|doi=10.4103/0259-1162.113988|issn=0259-1162|pmc=4173493|pmid=25885719}}</ref><ref>{{Cite journal|last=Das|first=Writuparna|last2=Bhattacharya|first2=Susmita|last3=Ghosh|first3=Sarmila|last4=Saha|first4=Swarnamukul|last5=Mallik|first5=Suchismita|last6=Pal|first6=Saswati|date=2015-04|title=Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial|url=https://pubmed.ncbi.nlm.nih.gov/25829908|journal=Saudi Journal of Anaesthesia|volume=9|issue=2|pages=184–188|doi=10.4103/1658-354X.152881|issn=1658-354X|pmc=4374225|pmid=25829908}}</ref> cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.
* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref name=":0">{{Cite journal|last=Grape|first=Sina|last2=Kirkham|first2=Kyle Robert|last3=Akiki|first3=Liliane|last4=Albrecht|first4=Eric|date=2021-07-06|title=Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis|url=https://pubmed.ncbi.nlm.nih.gov/34243030|journal=Journal of Clinical Anesthesia|volume=75|pages=110450|doi=10.1016/j.jclinane.2021.110450|issn=1873-4529|pmid=34243030}}</ref>.

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

* No procedure-specific considerations for otherwise healthy patients.

===Induction and airway management===

* Rapid-sequence induction and intubation (RSII) may be required for unfasted patients undergoing emergency surgery.
* Endotracheal intubation is most common for laparoscopic surgery, though supraglottic airways (preferrably with an inbuilt drain channel) can be used<ref>{{Cite journal|last=Belena|first=J. M.|last2=Nunez|first2=M.|last3=Vidal|first3=A.|last4=Gasco|first4=C.|last5=Gilsanz|first5=C.|last6=Alcojor|first6=A.|last7=Anta|first7=D.|last8=Lopez|first8=A. E.|date=2016|title=Use of second generation supra-glottic airway devices during laparoscopic cholecystectomy: a prospective, randomized comparison of LMA Proseal™, LMA SupremeTM and igel™|url=https://pubmed.ncbi.nlm.nih.gov/29873467|journal=Acta Anaesthesiologica Belgica|volume=67|issue=3|pages=121–128|issn=0001-5164|pmid=29873467}}</ref>.
* Orogastric or nasogastric tube should be inserted and suction applied shortly after induction and before trocar insertion.

===Positioning===

* Supine (USA) or lithotomy (Europe).
* Reverse Trendelenburg (head up), often steep. Roll ("airplane") to patient's left.
** Ensure patient secured and well padded.
* Both arms or left arm only tucked (primary surgeon on left).

===Maintenance and surgical considerations===

* General considerations for laparoscopic surgery.

===Emergence===

* PONV prophylaxis, otherwise no procedure-specific considerations.

==Postoperative management==
===Disposition===

* PACU, often same-day discharge

===Pain management===

* NSAIDs and acetaminophen often adequate for laparoscopic cases
* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref name=":0" />.

===Potential complications===

* General complications of laparoscopic surgery

==Procedure variants==

{| class="wikitable"
|+
''*PACE: Perioperative Adverse Cardiac Event''
!
!Open Cholecystectomy
!Laparoscopic Cholecystectomy
|-
|
|
|
|-
|Position
|Supine
|Supine
|-
|Surgical time
|2-4 hours
|0.5-2 hours
|-
|EBL
|250mL
|Minimal
|-
|Postoperative disposition
|PACU
|PACU
|-
|Mortality
|
|
|-
|Morbidity
|Elevated PACE vs laparoscopic<ref>{{Cite journal|last=Liu|first=Jason B.|last2=Liu|first2=Yaoming|last3=Cohen|first3=Mark E.|last4=Ko|first4=Clifford Y.|last5=Sweitzer|first5=Bobbie J.|date=2018-02-01|title=Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments|url=https://pubs.asahq.org/anesthesiology/article/128/2/283/17742/Defining-the-Intrinsic-Cardiac-Risks-of-Operations|journal=Anesthesiology|language=en|volume=128|issue=2|pages=283–292|doi=10.1097/ALN.0000000000002024|issn=0003-3022}}</ref>
|
|-
|Pain
|5-7
|3
|}

==References==
<references />

[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Biliary tract surgery]]

Cholecystectomy

2021-07-26T02:00:25Z

Svdg: Some changes in progress. Reference is required for the lifetime surgery incidence here from before. Is gastric tube not standard equipment in ORs? Reverse Trendelenberg we should use explanation (head up) as default as lots of resources confuse the two, will add this to style guide

{{Infobox surgical case reference
| anesthesia_type = General
| airway = Endotracheal tube
| lines_access = Peripheral IV
| monitors = Standard ASA 
5-lead EKG
| considerations_preoperative = NG Tube
| considerations_intraoperative = Rapid sequence intubation
| considerations_postoperative = PONV
}}Cholecystectomy is performed to treat symptomatic cholelithiasis and its complications (e.g., cholecystitis, pancreatitis, cholangitis), and other gallbladder conditions (e.g., polyps, porcelain gallbladder). This is one of the most common procedures performed in hospitals in the United States. Of the more than 20 million people in the US with gallstones, about 30% will eventually require cholecystectomy to relieve symptoms or treat complications. Cholecystectomy is most commonly performed laparoscopically, though there are specific indications for open surgery. The rate of conversion to an open operation is 2-3% for elective surgery and ~10% for acute cholecystitis<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref>.
==Preoperative management==
===Patient evaluation===
Most patients are healthy presenting for elective surgery, though others with acute cholecystitis may be critically unwell (e.g., patients with critical illness who develop acalculous cholecystitis).

=== Labs and studies ===

* No procedure-specific considerations for otherwise healthy patients.

*

===Operating room setup===

* No procedure-specific equipment required.

*

*

=== Patient preparation and premedication ===

* Laparoscopy and cholecystectomy specifically are minor risk factors for PONV<ref>{{Cite journal|last=Apfel|first=C. C.|last2=Heidrich|first2=F. M.|last3=Jukar-Rao|first3=S.|last4=Jalota|first4=L.|last5=Hornuss|first5=C.|last6=Whelan|first6=R. P.|last7=Zhang|first7=K.|last8=Cakmakkaya|first8=O. S.|date=2012-11|title=Evidence-based analysis of risk factors for postoperative nausea and vomiting|url=https://pubmed.ncbi.nlm.nih.gov/23035051|journal=British Journal of Anaesthesia|volume=109|issue=5|pages=742–753|doi=10.1093/bja/aes276|issn=1471-6771|pmid=23035051}}</ref>, consider the need for pre-operative prophylaxis (e.g., scopolamine, aprepitant)
* Anxiolysis as indicated by patient characteristics and local practices.

===Regional and neuraxial techniques===

* Open<ref>{{Cite journal|last=Savas|first=Jeannie F.|last2=Litwack|first2=Robert|last3=Davis|first3=Kevin|last4=Miller|first4=Thomas A.|date=2004-11|title=Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment|url=https://pubmed.ncbi.nlm.nih.gov/15546579|journal=American Journal of Surgery|volume=188|issue=5|pages=603–605|doi=10.1016/j.amjsurg.2004.07.016|issn=0002-9610|pmid=15546579}}</ref> and laparoscopic<ref>{{Cite journal|last=Sinha|first=Rajeev|last2=Gurwara|first2=A. K.|last3=Gupta|first3=S. C.|date=2009-06|title=Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients|url=https://pubmed.ncbi.nlm.nih.gov/19522659|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A|volume=19|issue=3|pages=323–327|doi=10.1089/lap.2008.0393|issn=1092-6429|pmid=19522659}}</ref><ref>{{Cite journal|last=Bessa|first=Samer S.|last2=Katri|first2=Khaled M.|last3=Abdel-Salam|first3=Wael N.|last4=El-Kayal|first4=El-Saed A.|last5=Tawfik|first5=Tarek A.|date=2012-07|title=Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study|url=https://pubmed.ncbi.nlm.nih.gov/22686181|journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A|volume=22|issue=6|pages=550–555|doi=10.1089/lap.2012.0110|issn=1557-9034|pmid=22686181}}</ref><ref>{{Cite journal|last=Agrawal|first=Malti|last2=Verma|first2=A. P.|last3=Kang|first3=L. S.|date=2013-01|title=Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study|url=https://pubmed.ncbi.nlm.nih.gov/25885719|journal=Anesthesia, Essays and Researches|volume=7|issue=1|pages=44–48|doi=10.4103/0259-1162.113988|issn=0259-1162|pmc=4173493|pmid=25885719}}</ref><ref>{{Cite journal|last=Das|first=Writuparna|last2=Bhattacharya|first2=Susmita|last3=Ghosh|first3=Sarmila|last4=Saha|first4=Swarnamukul|last5=Mallik|first5=Suchismita|last6=Pal|first6=Saswati|date=2015-04|title=Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial|url=https://pubmed.ncbi.nlm.nih.gov/25829908|journal=Saudi Journal of Anaesthesia|volume=9|issue=2|pages=184–188|doi=10.4103/1658-354X.152881|issn=1658-354X|pmc=4374225|pmid=25829908}}</ref> cholecystectomy can be performed under neuraxial anesthesia with a sensory level of T4-T6.
* Transversus abdominis plane (TAP) block likely provides improved analgesia compared to local wound infiltration<ref>{{Cite journal|last=Grape|first=Sina|last2=Kirkham|first2=Kyle Robert|last3=Akiki|first3=Liliane|last4=Albrecht|first4=Eric|date=2021-07-06|title=Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis|url=https://pubmed.ncbi.nlm.nih.gov/34243030|journal=Journal of Clinical Anesthesia|volume=75|pages=110450|doi=10.1016/j.jclinane.2021.110450|issn=1873-4529|pmid=34243030}}</ref>.

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

* No procedure-specific considerations for otherwise healthy patients.

===Induction and airway management===

* Rapid-sequence induction and intubation (RSII) may be required for unfasted patients undergoing emergency surgery.
* Endotracheal intubation is most common for laparoscopic surgery, though supraglottic airways (preferrably with an inbuilt drain channel) can be used<ref>{{Cite journal|last=Belena|first=J. M.|last2=Nunez|first2=M.|last3=Vidal|first3=A.|last4=Gasco|first4=C.|last5=Gilsanz|first5=C.|last6=Alcojor|first6=A.|last7=Anta|first7=D.|last8=Lopez|first8=A. E.|date=2016|title=Use of second generation supra-glottic airway devices during laparoscopic cholecystectomy: a prospective, randomized comparison of LMA Proseal™, LMA SupremeTM and igel™|url=https://pubmed.ncbi.nlm.nih.gov/29873467|journal=Acta Anaesthesiologica Belgica|volume=67|issue=3|pages=121–128|issn=0001-5164|pmid=29873467}}</ref>.
* Orogastric or nasogastric tube should be inserted and suction applied shortly after induction and before trocar insertion.

===Positioning===

* Supine (USA) or lithotomy (Europe).
* Reverse Trendelenburg (head up), often steep. Roll ("airplane") to left.
** Ensure patient secured and well padded.
* Both arms or left arm only tucked (primary surgeon on left).

===Maintenance and surgical considerations===

* General considerations for laparoscopic surgery

===Emergence===

* PONV prophylaxis, otherwise no procedure-specific considerations

==Postoperative management==
===Disposition===

===Pain management===

* NSAIDs and acetaminophen for mild pain
* Opioids for breakthrough pain. Consider PCA for open cases

===Potential complications===

* PONV
* Subcutaneous emphysema (from insufflation)
* Bowel injury

==Procedure variants==

{| class="wikitable"
|+
''*PACE: Perioperative Adverse Cardiac Event''
!
!Open Cholecystectomy
!Laparoscopic Cholecystectomy
|-
|Unique considerations
|
|
|-
|Position
|Supine
|Supine
|-
|Surgical time
|2-4 hours
|0.5-2 hours
|-
|EBL
|250mL
|Minimal
|-
|Postoperative disposition
|PACU
|PACU
|-
|Mortality
|
|
|-
|Morbidity
|Elevated PACE vs laparoscopic<ref>{{Cite journal|last=Liu|first=Jason B.|last2=Liu|first2=Yaoming|last3=Cohen|first3=Mark E.|last4=Ko|first4=Clifford Y.|last5=Sweitzer|first5=Bobbie J.|date=2018-02-01|title=Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments|url=https://pubs.asahq.org/anesthesiology/article/128/2/283/17742/Defining-the-Intrinsic-Cardiac-Risks-of-Operations|journal=Anesthesiology|language=en|volume=128|issue=2|pages=283–292|doi=10.1097/ALN.0000000000002024|issn=0003-3022}}</ref>
|
|-
|Pain
|5-7
|3
|}

==References==
<references />

[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Biliary tract surgery]]

Cholecystectomy

2021-07-26T00:55:54Z

Svdg:

Cesarean section

2021-05-27T13:02:49Z

Svdg: Added an updated reference for 2019 USA cesarean rates, and added most recent global rate that I could find. More edits later...

{{Infobox surgical case reference
| anesthesia_type = Neuraxial or general
| airway = ETT if general
| lines_access = 2 large bore PIV
| monitors = Standard ASA 
Fetal heart rate monitor
| considerations_preoperative = Full stomach precautions 
Aspiration prophylaxis 
Left lateral tilt
| considerations_intraoperative =
| considerations_postoperative =
}}
A '''Cesarean section''', also known as '''C-section''', is a surgical procedure where the baby is delivered through an incision in the uterus. C-sections are typically performed when a vaginal delivery would put the mother or baby at risk. In the USA, about 32% of deliveries are via Cesarean section<ref>{{Cite web|date=2021-03-24|title=FastStats|url=https://www.cdc.gov/nchs/fastats/delivery.htm|access-date=2021-05-27|website=www.cdc.gov|language=en-us}}</ref>, and worldwide the figure is approximately 21%<ref>{{Cite journal|last=Boerma|first=Ties|last2=Ronsmans|first2=Carine|last3=Melesse|first3=Dessalegn Y.|last4=Barros|first4=Aluisio J. D.|last5=Barros|first5=Fernando C.|last6=Juan|first6=Liang|last7=Moller|first7=Ann-Beth|last8=Say|first8=Lale|last9=Hosseinpoor|first9=Ahmad Reza|last10=Yi|first10=Mu|last11=Neto|first11=Dácio de Lyra Rabello|date=2018-10-13|title=Global epidemiology of use of and disparities in caesarean sections|url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31928-7/abstract|journal=The Lancet|language=English|volume=392|issue=10155|pages=1341–1348|doi=10.1016/S0140-6736(18)31928-7|issn=0140-6736|pmid=30322584}}</ref>.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
* Pregnant patients typically have decreased systemic vascular resistance, decreased diastolic pressure, decreased MAP, increased HR, and increased CO.
* Left uterine tilt to minimize aortocaval compression
* Evaluate for pregnancy induced hypertension (PIH)
|-
|Respiratory
|
* Pregnant patients typically have compensated respiratory alkalosis, increased minute ventilation, decreased FRC, and increased oxygen consumption.
* Decreased FRC results in rapid desaturation if ventilation is compromised.
* Atelectasis can occur secondary to an elevated diaphragm, thereby causing V/Q mismatch and decreased PaO2.
* Increased MV and decreased FRC increase uptake of inhalational agents.
* Mucosal capillary engorgement in upper airway may necessitate smaller endotracheal tube.
|-
|Gastrointestinal / Hepatic
|
* Increased gastric pressure
* Decreased esophageal sphincter tone
* Decreased gastric motility
* Full stomach precautions

* Risk for aspiration
* Liver enzymes may be mildly elevated
** Check for HELLP
|-
|Hematologic
|
* Increased RBC mass, plasma volume, and blood volume
* Leukocytosis
* Iron deficiency anemia + dilutional anemia of pregnancy
* Excessive blood loss possible with uterine atony, multiple gestation, previous C-section, placental pregnancy, placental abruption, pregnancy induced hypertension, or prolonged labor.

*
|-
|Renal
|
* Increased renal blood flow, GFR, and creatinine clearance
* Decreased serum creatinine and BUN
* Dependent edema secondary to increased water and sodium retention
|-
|Other
|
|}

=== Labs and studies ===

* T&S
* T&C only if significant blood loss anticipated
* Coagulation panel
* Chemistry panel
* Complete Blood Count (CBC)
* Other tests as indicated by H&P

=== Operating room setup ===

=== Patient preparation and premedication ===

* Full stomach precautions
* Nonparticulate oral antacid (e.g. sodium citrate) immediately prior to general or regional anesthesia
* Intravenous promotility agent (eg. metoclopramide)
* Intravenous antacids (e.g. ranitidine, famotidine)
* Anxiolysis not typically used unless patient is extremely anxious
* Elevate the right hip to provide left uterine displacement
* Adjunctive azithromycin 500mg IV to standard beta-lactam antibiotics shown to reduce the incidence in endometriosis and wound infection occurring in the first 6 weeks after Cesarean Section<ref>{{Cite journal|last=Tita|first=Alan T.N.|last2=Szychowski|first2=Jeff M.|last3=Boggess|first3=Kim|last4=Saade|first4=George|last5=Longo|first5=Sherri|last6=Clark|first6=Erin|last7=Esplin|first7=Sean|last8=Cleary|first8=Kirsten|last9=Wapner|first9=Ron|last10=Letson|first10=Kellett|last11=Owens|first11=Michelle|date=2016-09-29|title=Adjunctive Azithromycin Prophylaxis for Cesarean Delivery|url=http://www.nejm.org/doi/10.1056/NEJMoa1602044|journal=New England Journal of Medicine|language=en|volume=375|issue=13|pages=1231–1241|doi=10.1056/NEJMoa1602044|issn=0028-4793|pmc=PMC5131636|pmid=27682034}}</ref>.

=== Regional and neuraxial techniques ===

* Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed
** Check coagulation and platelets panel prior to neuraxial anesthesia
* Post-operative transversus abdominal block (TAP block) or quadratus lumborum block.

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitors

=== Induction and airway management ===

* Avoid nasal airways due to potential for mucosal capillary engorgement in upper airway

=== Positioning ===

* Left lateral tilt (15o) to avoid aortocaval compression and supine hypotension.

=== Maintenance and surgical considerations ===

* Anticipate EBL of 700-1000 mL
** Be prepared for excessive blood loss if underlying risk factors
* Immediately post-partum, ~600-800 mL of blood will enter the central circulation (placental autotransfusion), which will increase cardiac output
* Tranexamic acid 1g administered over 30-60 seconds during the first 3 minutes after birth, and after the uterotonic agent has been administered (e.g. oxytocin) is shown to reduce the incidence of post-operative blood loss > 1000 mL by POD #2 or RBC transfusion<ref>{{Cite journal|last=Sentilhes|first=Loïc|last2=Sénat|first2=Marie V.|last3=Le Lous|first3=Maëla|last4=Winer|first4=Norbert|last5=Rozenberg|first5=Patrick|last6=Kayem|first6=Gilles|last7=Verspyck|first7=Eric|last8=Fuchs|first8=Florent|last9=Azria|first9=Elie|last10=Gallot|first10=Denis|last11=Korb|first11=Diane|date=2021-04-29|title=Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery|url=http://www.nejm.org/doi/10.1056/NEJMoa2028788|journal=New England Journal of Medicine|language=en|volume=384|issue=17|pages=1623–1634|doi=10.1056/NEJMoa2028788|issn=0028-4793}}</ref>.
* Start oxytocin 30U in 500mL fluid over 3 hours after clamping of umbilical cord
* Monitor for hemodynamic variance after starting oxytocin
* Additional uterotonics may be requested by surgeon if uterine tone is not adequate

=== Emergence ===

== Postoperative management ==

=== Disposition ===

* L&D PACU
* Operating room PACU

=== Pain management ===

* 3-4mg morphine administered via epidural at closure
* IV acetaminophen
* Ibuprofen PO post-op
* ± ketoralac (dependent upon surgeon preference and total blood loss)
* ± Wound infiltration
* ± Transversus abdominal block (TAP block) or quadratus lumborum block (for patients undergoing general anesthesia or neuroaxial without intrathecal opioid administration)
* ± Continuous local anesthetic pain pump

=== Potential complications ===

* Ureteral injury
* Post-partum hemorrhage

== Procedure variants ==

{| class="wikitable"
|+
!
!Neuraxial
!General
|-
|Unique considerations
|
* Decreased BP common with spinal anesthesia
* Given fluid pre-load or co-load
* Be prepared to provide bolus as vasopressors as needed
|
* GA normally used with regional technique contraindicated or when there is not enough time to perform a block due to obstetric emergency

* Rapid sequence induction (RSI)
|-
|Position
|Left lateral tilt
|Left lateral tilt
|-
|Surgical time
|45-90min
|30-45min (given emergency delivery indications)
|-
|EBL
|500-1000mL
|500-1000mL
|-
|Postoperative disposition
|L&D PACU
|L&D or OR PACU
|-
|Pain management
|4
|6
|-
|Potential complications
|[[Post-dural-puncture headache]]
|
* Aspiration
* Difficult Airway
|}

== References ==

[[Category:Surgical procedures]]
[[Category:Obstetric and gynecologic surgery]]

Ketamine

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Ketamine

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Svdg: Created page with "Ketamine is a dissociative anesthetic agent used for induction and maintenance of general anesthesia, sedation, and analgesia. Ketamine stimulates sympathetic tone and typic..."

Ketamine is a dissociative anesthetic agent used for induction and maintenance of general anesthesia, sedation, and analgesia.

Ketamine stimulates sympathetic tone and typically increases heart rate, blood pressure, and cardiac output.

==Uses, Dosing, & Administration==
Give the drug's indications and the doses for each indication. When the drug can be given my mutltiple routes be sure to specify the route of administration. When dosing is by weight be sure to specify total, adjusted, or ideal body weight.

When there are a range of doses it can be helpful to describe how the dose is chosen and/or give a 'typical' dose. When doses are repeated or a drug is given by infusion it can be helpful to describe titration intervals and increments.

======Indication:======

*Route/Administration Dose Unit (weight qualifier) timing

======Induction of anesthesia:======

*IV over 30 to 60 seconds '''0.5 to 2 mg/kg''' (LBW)
**0.5 to 1 mg/kg in patients with shock
*IM '''4 to 6 mg/kg'''

======Maintenance of anesthesia (adjunct to TIVA or inhalational anesthesia)======

*'''0.25 to 0.35 mg/kg''' at incision, followed by continuous infusion '''up to 1 mg/kg/hour'''

===Special Populations===

====Pediatrics====

====Elderly====

====Renal Impairment====

====Hepatic Impairment====
==Contraindications, Warnings, & Interactions==

===Absolute contraindications===

===Precautions===

===Pregnancy & Breastfeeding===

===Drug Interactions===

===Disease-Specific Concerns===

==Adverse Effects==

==Pharmacology==

===Mechanism of action===

===Pharmacodynamics===

===Pharmacokinetics===
==Further Resources==
You can use this section to provide sources that offer further information that may be of interest to users. Present them as a bulleted list and give a brief description of the resource.
==References==

[[Category:Drug reference]]

About WikiAnesthesia

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