WikiAnesthesia - User contributions [en]

Prostatectomy

2023-02-03T23:09:29Z

Blainesa: Added to the list of symptoms in the setting of various irrigating solutions

{{Infobox surgical case reference
| anesthesia_type = Regional or GA
| airway = ETT
| lines_access = 1-2PIV
| monitors = Standard, 5-lead EKG
| considerations_preoperative = Pts are usually elderly, may have renal impairment from chronic retention
| considerations_intraoperative = Risk for TURP syndrome, bladder perf
| considerations_postoperative = Pain varies based on type of procedure, TURP is relatively mild pain, open procedures are associated with more significant pain
}}

Prostate resection can be performed for benign conditions, such as urinary retention, as well as prostate cancer or other cancers of the pelvis. The procedure can be performed open, laparoscopically, robotically, or through the urethra (TURP).

== Preoperative management ==

=== Patient evaluation ===
Patients are usually elderly, and are more likely to have pre-existing medical conditions
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Cerebrovascular disease and Alzheimer's common in this age group. Assess AMS preop to guide evaluation of postop changes.
|-
|Cardiovascular
|HTN, CAD common in this age group. Assess exercise tolerance.
|-
|Pulmonary
|COPD is more common in this age group, consider preop testing as guided by H&P including smoking history and symptoms.
|-
|Hematologic
|Moderate blood loss expected with large glands, if <80g, no T&C necessary. Preop Hb.
|-
|Renal
|Anticipate renal impairment due to chronic obstruction, consider BUN, Cr, electrolytes. If elevated BUN or Cr, check CrCl
|-
|Endocrine
|Increased incidence of DM
|-
|Other
|
|}

=== Labs and studies ===

* As guided by H&P
* Preop Hb
* T&C for glands >80g

=== Regional and neuraxial techniques ===

* Regional may be used, and may hold some advantage due to earlier detection of TURP syndrome with mental status changes.
** other advantages include lower intraop blood loss, possible lower incidence of postop DVT, faster return of bowel function
* Postdural puncture headache is very low in this age group.
* T9 level is optimal (T8-10 depending on incision site)
* Spinal anesthetic is usually favored over continuous lumbar epidural for TURP as the procedure is relatively short
** Spinal with 0.75% bupi, 12mg in 7.5% dextrose (1.6mL)
* For open or laparoscopic procedures, continuous epidural may also be used

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors

=== Induction and airway management ===

* Standard induction for GA cases
* Regional may also be used

=== Positioning ===

* Lithotomy

=== Maintenance and surgical considerations ===

* Standard maintenance

=== Emergence ===

* Postop pain usually not significant.
* BP may decrease when legs are repositioned to supine from lithotomy. Legs should be simultaneously returned to supine position to avoid stress on L-spine

== Postoperative management ==

=== Disposition ===

* PACU

=== Pain management ===

* In TURP, pain is usually minimal, may use opiates PRN

=== Potential complications ===

* TURP syndrome
** Symptoms: N/V, visual disturbances, AMS, coma, seizures, HTN, cardiovascular collapse
*** Can vary depending on irrigant used:
****Glycine is metabolized to ammonia and can be associated with encephalopathy. It can also be associated with visual disturbances due to the inhibitory effect of glycine on brainstem neurons.
****Sorbitol can lead to hyperglycemia
****Hypotonic fluids can lead fluid overload, HTN, pulmonary edema, hyponatremia and hemolysis
***Sodium <120 is associated with more severe symptoms
** Pathophysiology: Intravascular volume overload due to absorption of irrigant resulting in hyponatremia and hypotonicity
** Risks: increased hydrostatic pressure of irrigant, number of venous sinuses opened, duration of surgery, experience of surgeon, peripheral venous pressure
*** resections should be optimally limited to <1h
** Treat: may use diuresis (e.g., furosemide) and hypertonic saline
* Risks of lithotomy position:
** Peroneal nerve compression at lateral fibular head > foot drop
* Bladder perforation:
** may produce shoulder pain in awake patient
** In asleep patient, increased BP and HR

== Procedure variants ==

{| class="wikitable"
|+
!
!TURP
!Open/Robotic/Laparoscopic
|-
|Unique considerations
|
|
|-
|Position
|Lithotomy
|Supine or Lithotomy
|-
|Surgical time
|1h
|1h for simple, 3h for radical
|-
|EBL
|Blood loss can be large if venous sinuses entered
May be difficult to quantify due to irrigant use
|May be significant (1500cc) in radical retropubic resections
|-
|Postoperative disposition
|PACU
|PACU
Catheter irrigation completed in PACU to clear blood clots and prevent obstruction
|-
|Pain management
|Pain score 1
|Pain score 8, consider PCA or PRN opiates
|-
|Potential complications
|TURP sundrome
Foot drop from lithotomy position
|DVT
Foot drop from lithotomy position

Indigo carmine reaction
|}

== References ==

[[Category:Surgical procedures]]

Cesarean section

2022-09-29T18:08:37Z

Blainesa: added information about regional versus general anesthesia in C section and various techniques

{{Infobox surgical case reference
| anesthesia_type = Neuraxial or general
| airway = ETT if general
| lines_access = Large bore IV x2
| monitors = Standard
Fetal heart rate monitor
| considerations_preoperative = Full stomach precautions
Aspiration prophylaxis
Left lateral tilt
| considerations_intraoperative = Have uterotonics available
| considerations_postoperative =
}}
A '''cesarean section''' (also known as '''C-section''' or '''cesarean delivery''' ) 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. Often women who have had a cesarean delivery will have a subsequent or ''repeat'' cesarean delivery to prevent the possibility of uterine rupture during labor. 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
|
* Seizures or cerebrovascular accident in patients who progress to eclampsia
|-
|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<ref>{{Cite journal|last=Buley|first=R. J.|last2=Downing|first2=4 W.|last3=Brock-Utne|first3=J. G.|last4=Cuerden|first4=C.|date=1977-10|title=Right versus left lateral tilt for Caesarean section|url=https://pubmed.ncbi.nlm.nih.gov/921864/|journal=British Journal of Anaesthesia|volume=49|issue=10|pages=1009–1015|doi=10.1093/bja/49.10.1009|issn=0007-0912|pmid=921864}}</ref>
* Evaluate for pregnancy induced hypertension (PIH)
|-
|Pulmonary
|
* Pregnant patients typically have compensated respiratory alkalosis, increased minute ventilation, decreased FRC, and increased oxygen consumption.
* Decreased FRC and increased O2 consumption 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 inhalation 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.
*Pregnancy is associated with a hypercoagulable state as a way to blunt the blood loss anticipated during delivery, however, this physiologic adaptation predisposes them to DVT/PE formation.
|-
|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 typically employed if the mother has been laboring prior to cesarean section. There is some controversy regarding whether non-laboring parturients (eg, elective C-section) should be considered "full stomachs".
*Nonparticulate oral antacid (e.g. sodium citrate) immediately prior to general or regional anesthesia.
*Intravenous promotility agent (eg. 10 mg metoclopramide given over 5-10 minutes). Patients may experience akathisia if given too rapidly.
*Intravenous antacids (e.g. ranitidine, famotidine). Onset of action 30 minutes.
* Anxiolysis (benzodiazepines or opiates) not typically used unless patient is extremely anxious due to concern for fetal respiratory depression from placental transfer
*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 prior to neuraxial anesthesia
*Post-operative transversus abdominal block (TAP block) or quadratus lumborum block.
* Post-operative elastomeric pain pumps with local anesthetic may be useful for incisional pain

==Intraoperative management==

=== Monitoring and access===

*Standard monitors

===Induction and airway management===

*Neuraxial anesthesia is preferred unless there are strict contraindications (eg, patient refusal, inadequate anesthesia with existing epidural in an emergency situation, thrombocytopenia in the setting of pre-eclampsia or HELLP). General anesthesia with volatile anesthetics exposes the mother to the risk of difficult airway secondary to upper airway edema and increased bleeding due to uterine relaxation.
**Elective C-section
***Spinal anesthesia employed with 10-12.5 mg of hyperbaric bupivacaine (0.75% in dextrose), 15 mcg of fentanyl, and 100-200 mcg of morphine.
***If risk factors for prolonged duration of surgery are present such as obesity, prior C-section, or prior abdominal surgery, 5 mcg of epinephrine can be added to the spinal anesthetic dose to prolong duration of blockade.
**Urgent C-section in laboring parturient
***Existing labor epidural should be utilized and dosed with 2% lidocaine for rapid achievement of surgical anesthesia to the level of T4.
****2 mL of bicarbonate and 5 mcg of epinephrine can be added to the lidocaine to speed the onset of action.
****0.5% bupivacaine can also be utilized if there is adequate time for its onset of action (10-15 minutes).
****100 mcg of epidural fentanyl can be administered to increase the density of the block.
***Spinal anesthesia should be attempted if there is sufficient time (stability of fetal heart rate tracing)
**Emergency C-section
***20 mL of 3% chloroprocaine should be administered through an existing epidural catheter to achieve rapid surgical anesthesia (roughly 8 minutes to peak effect)
***General anesthesia should be employed if surgical anesthesia cannot be obtained with an existing epidural or if there is no epidural in place.
****RSI with propofol and succinylcholine (etomidate if concern for cardiovascular instability).
****Smaller ETT size generally used (6.0-6.5) due to concern for maternal airway edema in the setting of labor.
****Sevoflurane used for maintenance of anesthesia initially and 70% nitrous oxide in 30% oxygen after delivery of the fetus to reduce the amount of sevoflurane (which has a higher tendency to produce tocolysis and increase bleeding). Opiates (eg, hydromorphone) can be administered after delivery of the fetus.
*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 (e.g. hypotension) after starting oxytocin
*Additional uterotonics may be requested by surgeon if uterine tone is not adequate (e.g. [[methylergonovine]], [[carboprost]], misoprostol)

===Emergence===

==Postoperative management==

===Disposition===

*L&D PACU
*Operating room PACU

===Pain management===

*Epidural [[morphine]] 1-3mg for long acting post-partum pain relief<ref>{{Cite journal|last=Fuller|first=John G.|last2=McMorland|first2=Graham H.|last3=Douglas|first3=M. Joanne|last4=Palmer|first4=Lynne|date=1990-09|title=Epidural morphine for analgesia after Caesarean section: a report of 4880 patients|url=http://link.springer.com/10.1007/BF03006481|journal=Canadian Journal of Anaesthesia|language=en|volume=37|issue=6|pages=636–640|doi=10.1007/BF03006481|issn=0832-610X}}</ref><ref>{{Cite journal|last=Bollag|first=Laurent|last2=Lim|first2=Grace|last3=Sultan|first3=Pervez|last4=Habib|first4=Ashraf S.|last5=Landau|first5=Ruth|last6=Zakowski|first6=Mark|last7=Tiouririne|first7=Mohamed|last8=Bhambhani|first8=Sumita|last9=Carvalho|first9=Brendan|date=2021-05|title=Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean|url=https://journals.lww.com/10.1213/ANE.0000000000005257|journal=Anesthesia & Analgesia|language=en|volume=132|issue=5|pages=1362–1377|doi=10.1213/ANE.0000000000005257|issn=0003-2999}}</ref>
*IT morphine 50-150mcg for long acting post-partum pain relief if spinal performed<ref>{{Cite journal|last=Bollag|first=Laurent|last2=Lim|first2=Grace|last3=Sultan|first3=Pervez|last4=Habib|first4=Ashraf S.|last5=Landau|first5=Ruth|last6=Zakowski|first6=Mark|last7=Tiouririne|first7=Mohamed|last8=Bhambhani|first8=Sumita|last9=Carvalho|first9=Brendan|date=2021-05|title=Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean|url=https://journals.lww.com/10.1213/ANE.0000000000005257|journal=Anesthesia & Analgesia|language=en|volume=132|issue=5|pages=1362–1377|doi=10.1213/ANE.0000000000005257|issn=0003-2999}}</ref>
*IV [[acetaminophen]]
*[[Ibuprofen]] PO post-op
*± [[Ketorolac]] (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 of
*vasopressors as needed
|
*GA normally used when neuraxial 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]]

<references />

Mannitol

2022-07-11T10:58:13Z

Blainesa: Added information on on the uses and adverse effects of mannitol. Changed formatting.

{{Infobox drug reference
| trade_names =
| drug_class = Osmotic diuretic
| drug_class_color =
| uses = Reduction of intracranial pressure, Treatment of cerebral edema
| contraindications =
| routes = Intravenous
| dosage =
| dosage_calculation = mannitol
| mechanism = Osmotic diuresis
| adverse_effects =
| time_onset =
| duration =
| metabolism =
| halflife_redistribution =
| halflife_elimination =
| clearance =
| protein_binding =
}}

'''Mannitol''' is an osmotic diuretic that is often used to reduce cerebral edema and therefore reduce intracranial pressure.

==Uses==

* Reduction of intracranial pressure
* Treatment of cerebral edema

== Contraindications==
Anuric renal failure, severe pulmonary edema

===Absolute contraindications===

=== Precautions===

==Pharmacology==

===Pharmacodynamics===

====Mechanism of action====

====Adverse effects====
Pulmonary edema in patients with heart failure or renal failure, hypernatremia from volume depletion, hyperkalemia, metabolic acidosis, and AKI

===Pharmacokinetics===

==Chemistry and formulation==

==History==

==References==

[[Category:Drug reference]]