Line 2: Line 2:
 
| anesthesia_type = General +/- Epidural
 
| anesthesia_type = General +/- Epidural
 
| airway = ETT
 
| airway = ETT
| lines_access = PIV (1 or 2)
+
| lines_access = 1-2 PIV  <br/>
 
| monitors = Standard ASA
 
| monitors = Standard ASA
 
5-Lead EKG
 
5-Lead EKG
Line 8: Line 8:
 
+/- Art line
 
+/- Art line
 
| considerations_preoperative = Full stomach precautions if acute abdomen
 
| considerations_preoperative = Full stomach precautions if acute abdomen
| considerations_intraoperative =  
+
| considerations_intraoperative = Goal directed fluid therapy
| considerations_postoperative =  
+
| considerations_postoperative = Pain control <br/>
 +
PONV
 
}}
 
}}
  
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* Patients often have bowel prep
 
* Patients often have bowel prep
 
** Patients typically dehydrated and may have electrolyte abnormalities
 
** Patients typically dehydrated and may have electrolyte abnormalities
* Presurgical ERAS protocol  
+
* Consider pre-loading patients that are hypovolemic
 +
* Presurgical ERAS protocol
 
* Consider preop acetaminophen / gabapentin / celcoxib
 
* Consider preop acetaminophen / gabapentin / celcoxib
* Consider pre-loading patients that are hypovolemic
 
 
* Evaluate for anemia and consider corrective options, if needed
 
* Evaluate for anemia and consider corrective options, if needed
 
* Verify desired pre-incision antibiotics
 
* Verify desired pre-incision antibiotics
Line 91: Line 92:
 
* Potential for hypotension if patient hypovolemic or septic  
 
* Potential for hypotension if patient hypovolemic or septic  
 
** Consider co-loading fluids
 
** Consider co-loading fluids
** Consider pre-emptive vasopressor administrator with induction
+
** Consider pre-emptive vasopressor administrator with induction (or phenylephrine drip on standby)
  
 
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
 
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
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* Standard maintenance (avoid N<small>2</small>0)
 
* Standard maintenance (avoid N<small>2</small>0)
 
** Run epidural if present  
 
** Run epidural if present  
* Maintain euvolemia
+
* Maintain euvolemia  
** Goal-Directed Fluid Management
+
** Avoid excessive hypovolemia or hypervolemia
** Avoid excessive Intraoperative fluids
+
** Individualized, stroke-volume-guided fluid administration<ref>{{Cite journal|last=Yates|first=David R. A.|last2=Davies|first2=Simon J.|last3=Warnakulasuriya|first3=Samantha R.|last4=Wilson|first4=R. Jonathan T.|date=2014-12-01|title=Volume Management and Resuscitation in Colorectal Surgery|url=https://doi.org/10.1007/s40140-014-0078-1|journal=Current Anesthesiology Reports|language=en|volume=4|issue=4|pages=376–385|doi=10.1007/s40140-014-0078-1|issn=2167-6275}}</ref>
 +
** Administer fluids towards a specified goal
 
** Fluid losses can be significant (particularly for open cases)
 
** Fluid losses can be significant (particularly for open cases)
 
*** Blood loss, third-spacing, insensible losses  
 
*** Blood loss, third-spacing, insensible losses  
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=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
 
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
  
* Extubate - if appropriate based on hemodynamics, fluid status, respiratory status, neurologic status, etc.  
+
* Typically extubate, depending on patient's hemodynamics, fluid status, respiratory status, neurologic status, etc.
 
* PONV prophylaxis  
 
* PONV prophylaxis  
  
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* Hemorrhage  
 
* Hemorrhage  
 
* Visceral injuries
 
* Visceral injuries
 +
* Anastomotic leak
 
* Sepsis / Septic shock
 
* Sepsis / Septic shock
 
** Potential for hemodynamic instability due to evolving sepsis   
 
** Potential for hemodynamic instability due to evolving sepsis   
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|Surgical time
 
|Surgical time
 
|1-3 hours
 
|1-3 hours
|
+
|1-3 hours
 
|-
 
|-
 
|EBL
 
|EBL

Revision as of 15:45, 15 May 2021

Colectomy
Anesthesia type General +/- Epidural
Airway ETT
Lines and access 1-2 PIV
Monitors Standard ASA

5-Lead EKG Urine output

+/- Art line
Primary anesthetic considerations
Preoperative Full stomach precautions if acute abdomen
Intraoperative Goal directed fluid therapy
Postoperative Pain control
PONV


A colectomy is a surgical procedure to remove all or part of the colon. A partial colectomy (also known a segmental or hemi-colectomy) involves removing a portion of the colon, followed by the creation of an anastomosis or stoma. With more advanced disease, the entire large intestine is removed (total colectomy). Colectomies are often done laparoscopically. Common indications for the procedure include cancer, bowel obstruction, colitis, or diverticulitis.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular Bowel rupture can cause sepsis or septic shock and hemodynamic instability.
Respiratory If bowel obstruction and abdominal dissension, there may be impaired diaphragmatic excursion, which could negatively impact FRC and result in more rapid desaturations. Ensure adequate preoxygenation
Gastrointestinal Bowel obstruction increases risk for aspiration. Consider NG tube to decompress stomach.
Hematologic Anemia can result from cancer, chronic inflammation and GI blood loss. Dehydration can cause hemoconcentration and mask anemia. GI malabsorption can impair coagulation system.
Renal If oral intake reduced or there's been vomiting, there may be electrolyte abnormalities. Potential for metabolic acidosis in patients with diarrhea or having a bowel prep.
Endocrine
Other

Labs and studies

  • CBC
  • BMP / Electrolytes
  • Coags
  • Consider T&S or T&C

Operating room setup

  • NGT/OGT
  • Warming blanket

Patient preparation and premedication

  • Patients often have bowel prep
    • Patients typically dehydrated and may have electrolyte abnormalities
  • Consider pre-loading patients that are hypovolemic
  • Presurgical ERAS protocol
  • Consider preop acetaminophen / gabapentin / celcoxib
  • Evaluate for anemia and consider corrective options, if needed
  • Verify desired pre-incision antibiotics

Regional and neuraxial techniques

  • Consider thoracic epidural (for open procedures)[1]
    • Improved post-op pain, earlier return of bowel function, faster ambulation, improved dietary tolerance

Intraoperative management

Monitoring and access

  • Typically only 1 PIV for laparoscopic and 2 for open cases
    • Upgrade IV access if anticipate more significant blood loss or fluid shifts
    • Confirm IVs still good after tucking arms

Induction and airway management

  • RSI if bowel obstruction, distended abdomen, urgent/emergent, or non-NPO cases
    • +/- cricoid pressure
    • +/- removal of a pre-existing NG tube prior to induction
  • Potential for hypotension if patient hypovolemic or septic
    • Consider co-loading fluids
    • Consider pre-emptive vasopressor administrator with induction (or phenylephrine drip on standby)

Positioning

  • Supine
  • May need steep Trendelenburg or Reverse Trendelenburg
  • Possible lithotomy

Maintenance and surgical considerations

  • General endotracheal anesthesia +/- epidural (for open cases)
  • Standard maintenance (avoid N20)
    • Run epidural if present
  • Maintain euvolemia
    • Avoid excessive hypovolemia or hypervolemia
    • Individualized, stroke-volume-guided fluid administration[2]
    • Administer fluids towards a specified goal
    • Fluid losses can be significant (particularly for open cases)
      • Blood loss, third-spacing, insensible losses
  • Maintain normothermia
    • Be particularly vigilant in open cases, where heat losses are greater
  • Place OG tube (or NG if going to be left in post-operatively)
  • Consider opiate-sparing analgesia

Emergence

  • Typically extubate, depending on patient's hemodynamics, fluid status, respiratory status, neurologic status, etc.
  • PONV prophylaxis

Postoperative management

Disposition

  • Typically go to PACU
  • May require ICU, depending on magnitude of surgery and/or patient condition

Pain management

  • Multi-modal pain management
  • Epidural / PCA
  • Consider non-opiate adjuncts

Potential complications

  • Hemorrhage
  • Visceral injuries
  • Anastomotic leak
  • Sepsis / Septic shock
    • Potential for hemodynamic instability due to evolving sepsis
  • Aspiration
  • VTE
  • PONV

Procedure variants

Open colectomy Laparoscopic colectomy
Unique considerations More fluid shifts, more insensible fluid loss, higher bleeding risk, more pain
Position Supine Supine
Surgical time 1-3 hours 1-3 hours
EBL 100-200 mL (although can be much higher, depending on degree of pathology, technical complexity, and patient factors) <100
Postoperative disposition PACU PACU
Pain management Pain typically high. Consider multi-modal pain regimen, epidural anesthesia, PCA Pain typically moderate
Potential complications

References

  1. Nimmo, Susan M; Harrington, Lorraine S (2014-10-01). "What is the role of epidural analgesia in abdominal surgery?". Continuing Education in Anaesthesia Critical Care & Pain. 14 (5): 224–229. doi:10.1093/bjaceaccp/mkt062. ISSN 1743-1816.
  2. Yates, David R. A.; Davies, Simon J.; Warnakulasuriya, Samantha R.; Wilson, R. Jonathan T. (2014-12-01). "Volume Management and Resuscitation in Colorectal Surgery". Current Anesthesiology Reports. 4 (4): 376–385. doi:10.1007/s40140-014-0078-1. ISSN 2167-6275.