WikiAnesthesia - User contributions [en]

Union Memorial (Regional)

2025-10-21T18:42:13Z

Dpavlic1: Added contact info

=== About ===
Union Memorial (MedStar Health) is a regional anesthesia elective available to CA-3s who have completed their initial regional rotation downtown. You will work directly with attendings (some remote Hopkins grads) and interact with experienced CRNAs.

=== Getting Started ===

==== Site coordinators ====

* Joshua Dishon (Chair of Anesthesiology Department at Union Memorial)
* Nicole Allen (Administrator)

==== The Experience ====

* 2 week call-free rotation at major orthopedic surgery center
* Expect to get significant experience with both upper and lower extremity blocks. Arguably, the rotation rounds out blocks we do not perform as often at other sites. Most commonly:
** Total Shoulders: Interscalene (single-shot)
** General Hand: Infraclavicular, often with catheter placement (preferred over supraclavicular per general institutional preference)
** Total Knees: Post-op adductor catheters
** Miscellaneous Knee Procedures: Adductor/IPACK
** AKA/BKA: Fem/Sciatic catheters
**Other (less frequent): PECS catheters, TAP catheters

==== First Day ====

* Union Memorial Hospital is located at the Hopkins Homewood campus (201 E University Parkway)
* You'll park in Garage A first day and park in Garage B once you have your parking associated with your employee badge.
** If there is a parking attendant outside the garage that asks if you are a patient, just say yes otherwise they won't let you into the garage
* You'll confirm your Powerchart access, get scrubs/meal card, and meet with Dr. Dishon (Josh) who will take you around, expect to jump into a block as soon as opportunity arises
*There are three floors of ORs: Ground floor (hand +/- shoulders), 3rd floor (newer, knee/hip +/- shoulders), 4th floor (cardiothoracic and vascular [AKA's, BKA's, AVF's])
*Codes: Block cart (0531), 3rd floor staff lounge (2019)[[File:UMH Campus Map.png|thumb|Union Memorial Hospital Campus - Parking located off Calvert Street (turn onto 34th street).]]

==== Contact Info (please do not distribute) ====

* Nicole Mitchell (Admin Assistant) 410-554-6559
* Josh Dishon MD 443-904-2026
* Mark Jensen MD 585-953-9797
* Kerry Blaha MD 410-258-5758
* Tandi Mohammed MD 443-4447-5946
* Jane Radov MD 443-691-3000
* Rahul Guha MD 734-223-3061
* Marcelo Quezado MD 443-801-8889
* Sumanth Kuppalli MD 443-224-3500
*Bob Andrews MD 410-375-5442
*Nadya Averbach MD 703-728-8346
*Rani Emad MD 410-258-8198
*Denisa Pavlickova MD 917-530-5354
*Alyssa Salisbury MD 713-419-2621
*Jane Anh MD 718-962-5774
*Ming Fang MD 443-928-1604 

==== Block Recipes ====

* By and large, you will be using 0.5% ropivicaine for everything
** General volumes (more than you'll be used to):
*** Interscalene: 20 cc
*** Supraclavicular: 20-40 cc (I'm serious)
*** Infraclavicular: 30 cc
*** Adductor/Saphenous: 20 cc
*** Popliteal/Sciatic: 20 cc
**21G 100 mm block needle (exception: shorter needle for interscalene)
**Fent/Versed sedation universally
* For catheters, supplies include:
** PNC kit
** Vial(s) of 0.5% Ropivicaine
** Chloraprep, large/poptart Tegaderm, CHG Tegaderm dressing, sterile ultrasound probe cover (standard for all blocks, whether sterile or not), ultrasound gel, sterile gloves
*If two catheter sites, each pump is run with '''0.2%''' ropivicaine at 10 cc/hour intermittent bolus (PIB) without demand. Otherwise patients with single PNC (e.g. single adductor PNC) have PIB pumps programmed as 8/4/20/3 --> cc per hr / cc demand bolus / lockout interval in minutes / number of demands per hr.

==== Subsequent Days ====

* Arrive by 7:00 AM to catch attendings for any first start blocks (in room by 7:30 AM)
*Anticipate bouncing between floors for 1st case starts -> PACU catheters -> preop blocks
*'''Expect to feel like a medical student''' until you get to know attendings better
*Josh will often help connect you with attendings doing regional cases in the morning, but you will need to hover frequently
*Some attendings will get better about texting you when there is a block
* APS is a good opportunity for blocks/catheters on the floor. Dr. Jensen (Mark) runs APS service and is very good about keeping you in the loop, and proactive with creating block opportunities
*Fridays start with administrative meeting, thus case starts are at 8:30 AM
*Before going home, peek at the list of cases for the following day to figure out the best OR to show up to and when
**The anesthesia schedule is published separately and around 3 pm, so you'll likely have to ask someone if you want to know where specific attendings will be

=== Miscellaneous ===

* There is a full gym (free weights, machines, cardio) adjacent to the anesthesia offices in the 33rd Street Professional Building
* Nearby cafes for studying if preparing for ITE/Advanced:
** Bird in Hand (free wifi, outlets for laptop/phone, good food/beverage selection)

Esophagectomy

2024-10-04T15:06:02Z

Dpavlic1:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = If thoracic approach:
* DLT
* ETT w/Bronchial blocker
If transhiatal:
* ETT
| lines_access = Large bore PIV
NGT
Art Line
| monitors = Standard monitors
ABP
± Flowtrac
| considerations_preoperative =
| considerations_intraoperative = One-lung ventilation (if thoracic approach)
| considerations_postoperative = Aspiration
Vocal cord paresis
Recurrent laryngeal nerve injury
Operative mortality
}}

An '''esophagectomy''' is a surgical procedure to remove part of the esophagus and remains a formidable surgery with high morbidity and mortality.<ref name=":0">{{Cite journal|last=Ng|first=Ju-Mei|date=June 1, 2008|title=Perioperative Anesthetic Management for Esophagectomy|url=https://doi.org/10.1016/j.anclin.2008.01.004|journal=Anesthesiology Clinics|volume=26|issue=2|pages=293–304|doi=10.1016/j.anclin.2008.01.004|issn=1932-2275|via=}}</ref> It is performed for esophageal cancer<ref>{{Cite journal|last=Napier|first=Kyle J|date=2014|title=Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities|url=http://www.wjgnet.com/1948-5204/full/v6/i5/112.htm|journal=World Journal of Gastrointestinal Oncology|language=en|volume=6|issue=5|pages=112|doi=10.4251/wjgo.v6.i5.112|issn=1948-5204|pmc=PMC4021327|pmid=24834141}}</ref> and non-malignant conditions including hiatal hernias, severe GERD refractory to medical management, esophageal strictures and diverticula, and dysmotility disorders such as achalasia.

Anesthetic management depends greatly on the surgical approach. Notably procedures using a thoracic approach typically require one-lung ventilation, while transhiatal procedures do not (see [[#Procedure variants|procedure variants]] for details). The primary anesthetic goals include prevention of tracheal aspiration, lung protective ventilatory strategies, multimodal pain management which may include epidural analgesia, fluid management to optimize tissue oxygen delivery, and adequate perfusion to areas of anastomosis.<ref>{{Cite journal|last=Jaeger|first=J. Michael|last2=Collins|first2=Stephen R.|last3=Blank|first3=Randal S.|date=December 1, 2012|title=Anesthetic Management for Esophageal Resection|url=https://doi.org/10.1016/j.anclin.2012.08.005|journal=Anesthesiology Clinics|volume=30|issue=4|pages=731–747|doi=10.1016/j.anclin.2012.08.005|issn=1932-2275|via=}}</ref>
==Preoperative management ==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|Oxygen consumption increases 50% in the immediate post-op period. Patients need to be able to increase cardiac output and oxygen delivery after surgery.
|-
|Pulmonary
|Evaluate smoking history and underlying pulmonary dysfunction
|-
|Gastrointestinal
| Patients have passive reflux following esophagectomy.
|-
|Hematologic
|Hypercoagulability due to malignancy
|-
|Renal
|Underlying renal insufficiency may be exacerbated
|-
|Other
|
|}

===Labs and studies===

===Operating room setup===

* Double lumen tube with clamp prepared vs. ETT w/ bronchial blocker vs. ETT (depends on procedure variant)
* Fiberoptic scope to evaluate ETT positioning
* Large gauge NGT +/- bridal as patients remain NPO for >5 days postop
* Arterial line setup
* Significant amounts of crystalloid/colloid ready
* Glucagon 1mg IV (institution and surgeon preference)

===Patient preparation and premedication===

===Regional and neuraxial techniques===
Thoracic epidural can be used for intraoperative analgesia, but more importantly can be used for postop pain management with PCEA.

Remember to tape the thoracic tube opposite the side of the thoracotomy incision--thus it should be usually taped to the left.

==Intraoperative management==

===Monitoring and access===

*Invasive hemodynamic monitoring
*Large bore IV access

===Induction and airway management===

*May consider RSI if high-aspiration risk due to esophageal tumor obstructing food passage
*Left sided [[double lumen tube]] or single lumen ETT with bronchial blocker for one lung ventilation (R lung down)

===Positioning===

*Ivor-Lewis
**Start supine position for abdominal thorascopic approach
**Reposition to left lateral decubitus for thoracic anastamosis
*Transhiatal
**Supine throughout

===Maintenance and surgical considerations===

* Consider ketamine bolus (0.5 mg/kg) and gtt (0.2-0.5 mg/kg/hr) for pain management intraop
*Surgeons may request glucagon for lower esophageal sphincter relaxation

====Abdominal Dissection====

*Pt is placed supine and peritoneal cavity is examined for metastatic disease
*Lower portion of the stomach is mobilized
*Gastric conduit formed
*A cervical anastomosis is performed and esophagus and stomach returned to mediastinum

===Emergence===

==Postoperative management ==

===Disposition===

*ICU
* Step-down unit for Enhanced-Recovery cases

===Pain management===

*Epidural utilized for patient controlled epidural analgesia (PCEA)

===Potential complications===

# Anastomotic leak
#Vocal cord paresis
#Recurrent laryngeal nerve injury
#Post-operative atrial fibrillation<ref>{{Cite journal|last=Carney|first=Adam|last2=Dickinson|first2=Matt|date=2015-03|title=Anesthesia for esophagectomy|url=https://pubmed.ncbi.nlm.nih.gov/25701933|journal=Anesthesiology Clinics|volume=33|issue=1|pages=143–163|doi=10.1016/j.anclin.2014.11.009|issn=1932-2275|pmid=25701933}}</ref>
#Morbidity requiring re-operation
#Mortality

==Procedure variants==
Multiple variations of surgical approach are described in the literature. As opposed to traditional open surgery, surgeons have more recently favored minimally invasive thoracoscopic and laparoscopic approaches including robotic-assisted techniques. Minimally invasive approaches allow for optimal visualization within the thoracic cavity to reduce chances of injury during dissection, have reduced pulmonary complications, and shortened the time to recovery.<ref>{{Cite journal|last=Mariette|first=Christophe|last2=Markar|first2=Sheraz R.|last3=Dabakuyo-Yonli|first3=Tienhan S.|last4=Meunier|first4=Bernard|last5=Pezet|first5=Denis|last6=Collet|first6=Denis|last7=D'Journo|first7=Xavier B.|last8=Brigand|first8=Cécile|last9=Perniceni|first9=Thierry|last10=Carrère|first10=Nicolas|last11=Mabrut|first11=Jean-Yves|date=2019-01-10|title=Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer|url=https://pubmed.ncbi.nlm.nih.gov/30625052|journal=The New England Journal of Medicine|volume=380|issue=2|pages=152–162|doi=10.1056/NEJMoa1805101|issn=1533-4406|pmid=30625052}}</ref> Despite the variations, from the anesthesiologist's point of view there are two basic types of esophagectomy:
#Transhiatal
##Chiefly used for tumors in the lower esophagus and adenocarcinoma of the GE junction.
##Does not require one-lung ventilation. Resection is done entirely through the abdomen.
# Combined abdominal/thoracic resection
## Used for complete esophagectomy and tumors high enough in the esophagus that a thoracic approach is necessary.
## Require one-lung ventilation for the thoracic portion of the case (see also [[Video-assisted thoracoscopic surgery|video-assisted thoracic surgery, or VATS]]).
## Two major procedure techniques
###[[Ivor Lewis esophagectomy|Ivor-Lewis esophagectomy]]<ref>{{Cite journal|last=Lewis|first=I.|date=1946-07|title=The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third|url=https://pubmed.ncbi.nlm.nih.gov/20994128|journal=The British Journal of Surgery|volume=34|pages=18–31|doi=10.1002/bjs.18003413304|issn=0007-1323|pmid=20994128}}</ref> involves a traditional open laparotomy and open thoracotomy.
###[[McKeown esophagectomy]], adds a third incision in the neck for cervical anastomosis in total esophagectomy. Recent reviews have demonstrated a higher incidence of complications with the McKeown approach.<ref>{{Cite journal|last=van Workum|first=Frans|last2=Slaman|first2=Annelijn E.|last3=van Berge Henegouwen|first3=Mark I.|last4=Gisbertz|first4=Suzanne S.|last5=Kouwenhoven|first5=Ewout A.|last6=van Det|first6=Marc J.|last7=van den Wildenberg|first7=Frits J. H.|last8=Polat|first8=Fatih|last9=Luyer|first9=Misha D. P.|last10=Nieuwenhuijzen|first10=Grard A. P.|last11=Rosman|first11=Camiel|date=January 1, 2020|title=Propensity Score–Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy|url=https://journals.lww.com/10.1097/SLA.0000000000002982|journal=Annals of Surgery|language=en|volume=271|issue=1|pages=128–133|doi=10.1097/SLA.0000000000002982|issn=0003-4932|via=}}</ref><ref>{{Cite journal|last=van Workum|first=Frans|last2=Berkelmans|first2=Gijs H.|last3=Klarenbeek|first3=Bastiaan R.|last4=Nieuwenhuijzen|first4=Grard A. P.|last5=Luyer|first5=Misha D. P.|last6=Rosman|first6=Camiel|date=July 1, 2017|title=McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: systematic review and meta-analysis|url=http://jtd.amegroups.com/article/view/13601/11835|journal=Journal of Thoracic Disease|volume=9|issue=S8|pages=S826–S833|doi=10.21037/jtd.2017.03.173|pmc=PMC5538973|pmid=28815080|via=}}</ref>
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Open
!Thoracoscopic
!Robotic
![[Ivor Lewis esophagectomy|Ivor Lewis]]
!McKeown
![[Transhiatal esophagectomy|Transhiatal]]
|-
|Unique considerations
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|Position
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|Surgical time
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|EBL
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|Postoperative disposition
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|Pain management
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|Potential complications
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|}

==References==

[[Category:Surgical procedures]]

<references />

Hepatic resection

2024-09-25T13:43:03Z

Dpavlic1:

{{Infobox surgical procedure
| anesthesia_type = General
± Truncal block or epidural
| airway = ETT
| lines_access = Large bore IV
Arterial line
± Central line
| monitors = Standard
5-lead ECG
Temperature
ABP
± CVP
| considerations_preoperative = Ascites
Coagulopathy
| considerations_intraoperative = CVP <5 to minimize bleeding
| considerations_postoperative = Bleeding
Bile leak
}}

Hepatic resection involves either an open or laparoscopic approach to removal of liver neoplasms, such as adenomas, hemangiomas, FNH, and metastatic disease, although there are other pathologies requiring resection as well. In the past, hepatectomy was associated with up to a 20% mortality rate. However significant improvements in surgical technique and management have resulted in large reductions in mortality and morbidity.

The surgical course includes four main phases: assessment, mobilization, parenchymal transection, and closure. One crucial aspect of hepatectomy management includes keeping central venous pressure (CVP) low through the first 3 phases of surgery. A low CVP makes the dissection phase easier (less distended hepatic outflow) and it significantly minimizes venous back bleeding. Following parenchymal transection patients can be appropriately resuscitated.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Consider RSI for patients with ascites
|-
|Neurologic
|Patients with liver disease are at risk for encephalopathy 2/2 ammonia.
Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
|-
|Cardiovascular
|Significant liver dysfunction can result in systemic vasodilation from circulation of vasoactive mediators and vasodilators, as well as low grade endotoxin, which are not cleared by the compromised liver.
|-
|Pulmonary
|Restrictive lung disease from the presence of ascites and pleural effusions
|-
|Gastrointestinal
|Portal hypertension may manifest as GI bleeding, gastric and esophageal varices, ascites, and portosystemic shunts.

Liver dysfunction can change drug metabolism
|-
|Hematologic
|Anemia, thrombocytopenia, coagulopathy
|-
|Renal
|End-stage liver disease can have associated renal insufficiency or renal failure.
|-
|Endocrine
|Hypoglycemia is common in patients with advanced disease, due to impairment in gluconeogenesis.
|-
|Other
|
|}

=== Labs and studies ===

* CBC for hemoglobin and platelets
* CMP for sodium, potassium, creatinine, glucose, bilirubin
* Coagulation panel
* Type and cross PRBCs x2

=== Operating room setup ===

=== Patient preparation and premedication ===

* Some protocols encourage use of clear carbohydrate beverage up to 2 hours prior to surgery.
* Avoid preoperative acetaminophen or gabapentin
* Consider Celebrex for multimodal pain control
* Consider scopolamine patch for PONV

=== Regional and neuraxial techniques ===

* Consider truncal blocks such as transverse abdominis plane (TAP) or quadratus lumborum for post operative pain control.
* Can consider epidural for analgesia adjunct requiring a T6-8.
** Careful attention on the potential for coagulopathy (the extent of the coagulopathy is correlated with degree of resection)

== Intraoperative management ==

=== Monitoring and access ===

* 2 or more large bore peripheral IVs
* Arterial line
* Central line generally not needed to monitor CVP, limited fluid administration often sufficient
** Some surgeons may require central line for CVP monitoring

=== Induction and airway management ===

* Standard IV induction for most patients. Adjust if other comorbid conditions.
* Consider RSI if large volume ascities.
* ETT

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Have a vasoconstrictor available such as phenylephrine or norepinephrine.
* Keep central venous pressure (CVP) low through the first 3 phases of surgery
** Typically around 1L of fluids for most patients
** Once completed patients can be resuscitated with fluids, typically requiring 2-3L of fluids

* There is a known risk of air embolism from open hepatic veins and this risk is exacerbated given an intentionally low CVP.

=== Emergence ===

* Extubation in OR for most patients

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

=== Hepatectomy for living donor liver transplant ===
Despite an increase in patients awaiting liver transplantation, donor organs remain limited. Live donor transplantation has emerged/evolved as a safe surgical practice, and allows for an increase in the donor pool in appropriately selected candidates with reduced waiting time, optimal recipient preparation, adequate surgical planning and marked reduction of cold ischemic time. In general, these transplant surgeries are planned months in advance. As a result, both donor and recipient candidates are thoroughly medically evaluated; cardiac studies, routine laboratory data, and functional testing is available for review. Patients will be admitted from home, and recipients are often well compensated with relatively low biologic MELD scores. Donor right (more common) or left hepatectomy is performed, and partial liver transplant occurs simultaneously in the recipient. Small-for-size syndrome has been described after split-liver transplantation, with clinical manifestations of cholestasis, coagulopathy, ascites, and GI bleed. Required graft-to-recipient body weight ratio is 0.8% to achieve graft and patient survival rates of 90% (Kiuchi et al, 1999), with ideal graft-to-body-weight of 1.5% (Heaton, 2003). Biliary complications are more common in live donor liver transplants.

Exquisite attention to detail focused on adverse event prevention and safety given the altruistic and elective nature of this procedure.

Donor partial hepatectomy is similar to standard liver resections.

* Patients receive IV sedation with midazolam followed by a thoracic epidural for postoperative pain control (assuming no contraindications).
* Induction of anesthesia commences, followed by placement of large bore peripheral venous (14g/16g) and arterial catheter for BP monitoring.
* Central access is generally not required.
* Norepinephrine or phenylephrine can be utilized to maintain MAPs given the low volume/low CVP strategy during the dissection phase to minimize blood loss during dissection.
* Transfusion is rare.

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

== References ==

[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Hepatic surgery]]

Circumcision

2024-08-02T18:10:40Z

Dpavlic1:

{{Infobox surgical procedure
| anesthesia_type = General, Caudal Epidural
| airway = ETT vs LMA
| lines_access = PIV x 1
| monitors = Standard, Temperature
| considerations_preoperative = OR and table pre-warmed
| considerations_intraoperative = Temperature
| considerations_postoperative = Emergence delirium
}}

'''Circumcision''' is a procedure involving the foreskin removal of the penis exposing the glans penis. Indication includes family reasons, phimosis or recurrent balanitis <ref name=":0">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref><ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117280100|title=A guide to pediatric anesthesia|date=2020|others=Craig Sims, Dana Weber, Chris Johnson|isbn=978-3-030-19246-4|edition=2nd ed|location=Cham|oclc=1117280100}}</ref>. Most circumcisions occur in the newborn nursery performed by pediatrician or obstetrician with different clamps when patients are neonates<ref name=":0" /><ref name=":2">{{Cite book|url=https://www.worldcat.org/oclc/1137179895|title=Gregory's pediatric anesthesia|date=2020|others=Dean B. Andropoulos, George A. Gregory|isbn=978-1-119-37151-9|edition=Sixth edition|location=Hoboken, NJ|oclc=1137179895}}</ref>. However, if circumcision is performed in the operating room, the procedure begins with two incisions to remove the penile skin surrounding and covering the glans penis which is the most common method in the operating room<ref name=":2" />.

== Preoperative management ==

=== Operating room setup ===

* Set OR temperature to 70o to 75o
* Underbody bear hugger preheated

=== Patient preparation and premedication ===

* PO midazolam for anxiety in children experiencing separation anxiety
* PO acetaminophen for pain

=== Regional and neuraxial techniques ===

* Caudal epidural, penile block, pudendal nerve block, or dorsal ring block for analgesia supplemented with general <ref name=":0" /><ref name=":1" /><ref>{{Cite journal|last=Boisvert-Moreau|first=Frédérique|last2=Turcotte|first2=Bruno|last3=Albert|first3=Natalie|last4=Singbo|first4=Narcisse|last5=Moore|first5=Katherine|last6=Boivin|first6=Ariane|date=2022-11-17|title=Randomized controlled trial (RCT) comparing ultrasound-guided pudendal nerve block with ultrasound-guided penile nerve block for analgesia during pediatric circumcision|url=https://rapm.bmj.com/content/early/2022/11/16/rapm-2022-103785|journal=Regional Anesthesia & Pain Medicine|language=en|doi=10.1136/rapm-2022-103785|issn=1098-7339|pmid=36396298}}</ref>'
*Caudal: 0.25% Bupivacaine 1cc/kg OR 0.2% ropivacaine

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* Temperature
* PIV x 1

=== Induction and airway management ===

* Mask induction with sevoflurane +/- N2O
** ETT vs LMA
* IV induction for patients > 10 years old

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Maintenance with volatile anesthetics, IV anesthetic or a combination
* Monitor temperature and ensure large surface areas are covered with warm blankets

=== Emergence ===

* Emergence delirium

== Postoperative management ==

=== Disposition ===

* PACU
* Usually discharged home

=== Pain management ===

* Pain is mild
** Multimodal
*** PO/PR/IV acetaminophen
*** IV/PO NSAIDs
*** IV/PO opioids
*** Topical local anesthetic
*** Regional block (penile block, can be performed by surgeon or anesthesia)
*** Caudal epidural

=== Potential complications ===

* Infection
* Hematoma

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Circumcision
|-
|Position
|Supine
|-
|Surgical time
|30 minutes
|-
|EBL
|Minimal
|-
|Postoperative disposition
|Home
|-
|Pain management
|Mild , multimodal
|-
|Potential complications
|Infection, hematoma
|}

== References ==

[[Category:Surgical procedures]]