WikiAnesthesia - User contributions [en]

Transphenoidal resection of pituitary tumor

2022-09-22T17:36:07Z

Ddiaczok: Additional Info regarding GH tumors: preop eval, airway.

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 2
Arterial line
| monitors = Standard ASA
5-lead EKG
Core temp
UOP
± EEG
| considerations_preoperative = Characterize baseline neurologic deficits (i.e., visual field defects)
Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted
| considerations_intraoperative = Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding
Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation
| considerations_postoperative = PONV prophylaxis
Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)
}}

A '''transphenoidal resection of pituitary tumor''' is a neurosurgical procedure performed through an intranasal exposure to remove tissue from the sella turica.

==Overview==

* Most pituitary tumors are benign adenomas<ref>{{Cite web|date=2022-05-23|title=Pituitary Tumors Treatment (PDQ®)–Health Professional Version - NCI|url=https://www.cancer.gov/types/pituitary/hp/pituitary-treatment-pdq|access-date=2022-09-19|website=www.cancer.gov|language=en}}</ref>
** Only 0.1-0.2% malignant carcinomas
* Approximately 35% are invasive into adjacent bony and/or vascular structures
* Approximately 75% of tumors are functional (hormone-secreting)<ref name=":0">{{Cite book|last=Reddy|first=SS|url=https://www.worldcat.org/oclc/234428919|title=The Cleveland Clinic Foundation intensive review of internal medicine|last2=Hamrahian|first2=AH|date=2009|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|others=James K. Stoller, Franklin A. Michota, Brian F. Mandell, Cleveland Clinic Foundation|isbn=978-0-7817-9079-6|edition=5|location=Philadelphia|chapter=Pituitary Disorders and Multiple Endocrine Neoplasia Syndromes|oclc=234428919}}</ref>
* Mass effect of tumor can lead to decreased secretion of one or more pituitary hormones and other neurologic deficiencies

===Indications===
*Resection of pituitary tumor
===Surgical procedure===

* Performed via a transphenoidal approach through the nares

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
*ACTH or GH secreting tumors may lead to airway abnormalities
*GH: macroglossia, enlarged epiglottis, RLN palsy, subglottic stenosis, enlarged nasal turbinates
|-
|Neurologic
|
*Baseline neuro exam
*GH prone to peripheral neuropathies.
|-
|Cardiovascular
|
*Hyperthyroid patients may have ECG abnormalities
*GH pts may have HTN, LVH, diastolic dysfunction, arrhythmias, CAD
|-
|Renal
|
*Preoperative diabetes insipidus
|-
|Endocrine
|
*Identify and treat (if needed) pituitary hormone abnormalities (see below)
|}

====Tumor anatomy====

*Classified based upon size/structural invasion<ref>{{Cite journal|last=Asa|first=S. L.|last2=Ezzat|first2=S.|date=1998|title=The cytogenesis and pathogenesis of pituitary adenomas|url=https://pubmed.ncbi.nlm.nih.gov/9861546|journal=Endocrine Reviews|volume=19|issue=6|pages=798–827|doi=10.1210/edrv.19.6.0350|issn=0163-769X|pmid=9861546}}</ref>
**Stage I: Microadenoma (<1 cm)
**Stage II: Macroadenoma (≥1 cm)
**Stage III: Macroadenoma with invasion
**Stage IV: Destruction of the sella
*Mass effect can directly compress neurologic structures
**Visual field defects (classically bitemporal hemianopsia)
**Eye movement deficits (CN III more common than CN VI)
**Elevated ICP rare (secondary to obstructive hydrocephalus)
*Invasion into adjacent structures
**Bone
***Skull base
***Sphenoid
**Vascular
***Cavernous sinus
***Carotid artery
*Tumor can be hemorrhagic and/or necrotic

====Endocrine abnormalities====

*Pituitary tumors can be classified as functional (hormone-secreting) or nonfunctional (not hormone-secreting)
**Prolactin > GH > ACTH > LH/FSH > TSH<ref name=":0" />
*Endocrine deficiencies from mass effect
**GH > LH/FSH > TSH > ACTH > Prolactin
**Panhypopituitarism possible
**Posterior pituitary deficiencies less common (ADH, oxytocin)

=== Labs and studies===

* Brain MRI
** Review imaging to evaluate structural invasion
*** Invasion into cavernous sinus and/or enveloping carotid artery higher risk for bleeding

===Operating room setup===

===Patient preparation and premedication===

*Versed
*Consider aprepitant 40 mg PO for PONV prophylaxis

==Intraoperative management==

===Monitoring and access===

*PIV x 2 (20g for drips, 18g+ for bolus)
*Arterial line

*If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.

=== Induction and airway management===

* Standard induction
**Propofol
**Short acting opioid vs beta blocker
***Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
**Rocuronium
***Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
*ETT with straight connector
**Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.
**GH: glottic opening may be very distal, traditional ETT may not be long enough, consider MLT 6.0mm

===Positioning===

*180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
*Supine
*Arms tucked
** Additional IV access site options: saphenous veins

===Maintenance and surgical considerations===

*Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)
* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
*± Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
*No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
*Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.
* ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension
*Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection
*As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested remifentanil gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
*Consider short-to-intermediate acting BB (i.e, esmolol, labetalol) for HTN/stimulation not controlled by remifentanil bolus/gtt. HTN will worsen bleeding during ENT portion.
*Surgeons will ask for Valsalva during the case.
*Note down when throat pack is placed in and taken out during case.
*Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection

=== Emergence===

*Pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
* Paralytic reversal (if used).
*Spin back to neutral (particularly, if solo).
*Smooth awake extubation (i.e., remifentanil wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.
*Avoid positive pressure masking after extubation.

==Postoperative management ==

===Disposition===

*PACU

===Pain management===

* Tylenol IV
*Fentanyl (be judicious) as surgeons will likely want a good neuro exam post-op.

===Potential complications===

*Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
**Important to monitor intraop and post-op urinary output.

==Procedure variants==

{| class="wikitable"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]
[[Category:Neurosurgery]]

<references />

Anterior cervical spine surgery

2022-09-22T17:42:03Z

Ddiaczok: monitoring and access

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, possible arterial line
| monitors = Standard, possible invasive BP monitoring, possible neuromonitoring
| considerations_preoperative = Neck ROM, preoperative neurologic exam
| considerations_intraoperative = TIVA for neuromonitoring
| considerations_postoperative =
}}

Provide a brief summary here.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Potentially limited neck ROM related to pain, trauma, or mechanical stabilization devices leading to more challenging airway. Potential unstable cervical spine, instrumentation could cause permanent paralysis. Consider awake intubation if high concern for unstable spine or difficult airway.
|-
|Neurologic
|Possible preexisting motor and/or sensory deficits, particularly in the upper extremities. These symptoms may be exacerbated by head/neck positioning. May have chronic pain.
|-
|Cardiovascular
|Intraoperative bradycardia related to traction on the carotid bulb.
|-
|Pulmonary
|Limited neck ROM related to pain or structural changes can cause difficult laryngoscopy. Recurrent laryngeal nerve potentially at risk of damage intraop.
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitors. Neuromonitoring per surgeon request. PIV 18-20g usually sufficient. Arterial line based on patient comorbidities.

=== Induction and airway management ===
Potentially limited neck ROM related to pain, trauma, or mechanical stabilization devices leading to more challenging airway. Potential unstable cervical spine, instrumentation could cause permanent paralysis. Consider awake intubation if high concern for unstable spine or difficult airway. Consider neuro exam following awake intubation if concern for cervical spine injury.

=== Positioning ===
Positioned supine, typically with shoulder roll for exposure and head on a doughnut gel pillow to facilitate neck positioning.

=== Maintenance and surgical considerations ===

* Neuromonitoring may be used to detect potential nerve/spinal cord injury. In these cases, surgical teams typically require no paralytic and frequently request TIVA techniques to minimize the affect of anesthetic on neuromonitoring.

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Majority of patients appropriate for floor, some surgeons request ICU for monitoring.

=== Pain management ===

=== Potential complications ===

* Neck hematoma
* Airway edema
* Injury to cranial nerves, recurrent laryngeal nerve, and/or superior laryngeal nerve
* Dural tear

== Procedure variants ==

{| class="wikitable"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Posterior cervical spine surgery

2022-09-22T17:54:50Z

Ddiaczok: IVF recs

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===
Limit IV fluids to 40cc/kg to minimize facial and airway edema.

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Anorectal surgery

2022-09-20T15:00:16Z

Ddiaczok: Pain management techniques

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Natural airway or LMA or ETT
| lines_access = 1 PIV
| monitors = Standard ASA, 5 lead EKG
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative = Very painful procedure
}}

Provide a brief summary of this surgical procedure and its indications here.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===
Generally prone or lithotomy. Many surgeons prefer prone as it gives them more anterior visualization of the field, though it is surgeon-dependent. If prone, consider ETT more strongly if concern for inability to maintain airway. Have stretcher readily available in case flipping supine is necessary emergently.

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]