WikiAnesthesia - User contributions [en]

Lobectomy

2025-12-24T21:30:27Z

Elee88:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = DLT, ETT with bronchial blocker
| lines_access = PIV, large bore IV, arterial line on dependent side in lateral position,
| monitors = Standard, 5-lead,
| considerations_preoperative = Chronic respirtory disease, chronic smokers and sequelae, coexisting cardiovascular disease.
</br> "three legged stool" to estimate postoperative lung function - most commonly: PFT's to estimate ppoDLCO & ppoFEV1, functional status / echo
| considerations_intraoperative = One lung ventilation, protective lung ventilation, managing hypoxia on one lung ventilation, thoracotomy vs minimally invasive approach
| considerations_postoperative = analgesia: if VATS, regional block or PCA sufficient; if thoracotomy, epidural or PVB preferred
}}

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

== Preoperative management ==

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

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===
Non-opiate post-operative pain management is particularly important in this patient population due to reduced pulmonary reserve and rib pain post-operatively that may prevent effective secretion mobilization and lung expansion.

* Paravertebral Block
* Erector Spinae Block
* Epidural - if thoracotomy

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

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!Variant 1
!Variant 2
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|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]]

Mannitol

2025-12-24T21:22:11Z

Elee88:

{{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
*Diuresis during kidney transplant

== Contraindications==

* Anuric renal failure
* Severe pulmonary edema

===Absolute contraindications===

=== Precautions===

* Congestive Heart Failure

==Pharmacology==

===Pharmacodynamics===

====Mechanism of action====

====Adverse effects====

* Pulmonary edema in patients with heart failure or renal failure
* Hypernatremia from volume depletion
* Hyperkalemia
* Metabolic acidosis
* Acute Kidney Injury

===Pharmacokinetics===

==Chemistry and formulation==

==History==

==References==

[[Category:Drug reference]]

Coronary artery bypass graft

2025-12-13T22:11:39Z

Elee88: Consideration for a-line placement if radial artery grafts are used

{{Infobox surgical case reference
| anesthesia_type = GA
| airway = ETT
| lines_access = PIV x2
Arterial line
Central line [often 2]
Introducer
± PA catheter
| monitors = Standard
5-lead ECG
Temperature
ABP
CVP
TEE
NIRS
± PAP
| considerations_preoperative = beta-blocker
discussion with surgeon regarding any regional anesthesia adjuncts
| considerations_intraoperative = Heparinization for graft harvest
Full heparinization prior to coming on CPB
Hemodyamics and cardiac function coming off CPB
Reversal of heparin with protamine
Discussion with surgeon regarding extubation in OR
| considerations_postoperative = transfusion and vasopressor requirements
inotropic support
}}
'''Coronary Artery Bypass Graft''', also known as '''CABG''', is a common cardiac surgery procedure in which vein or artery is used as a conduit and is either grafted from the aorta (or if using left internal mammary artery, used in situ) to a coronary artery beyond a blockage in the vessel, with goal of improving blood flow to the heart, i.e. surgical coronary re-vascularization. The left internal mammary artery (LIMA) is considered first choice of graft due to high patency rate of > 90% at 10 years, though saphenous vein grafts are often used as well. It is most often indicated for individuals with significant multi-vessel Coronary Artery Disease, in particular those with Diabetes Mellitus or left main coronary vessel disease; it can also be used on a more emergent basis for those with Acute Coronary Syndrome and ST-Elevation Myocardial Infarction cases that are refractory to PCI or maximal medical management. It can be described by the number of vessels to be bypassed (single, double, triple, quadruple) as well as the technique (traditional on-pump, off-pump or minimally invasive direct).

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|cognitive function
Identify any atherosclerotic lesions along carotid vessels
|-
|Cardiovascular
|Identify diseased vessels & any associated collaterals
Evaluate LVEF, wall thickness and valve functionality

All antianginal medications should be given day of surgery
|-
|Pulmonary
|
|-
|Gastrointestinal
|Evaluate for dysphagia, difficulties swallowing and hx of esophageal/gastric surgery (TEE carries a risk of esophageal rupture)
|-
|Hematologic
|Confirm T+S and at least 4 units pRBCs are on hold, as well as FFP
Anticoagulation is common in these patients
|-
|Renal
|Evaluate for any pre-operative renal insufficiency
|-
|Endocrine
|Evaluate HgbA1c and if Insulin-dependent diabetic, note current insulin regimen
|-
|Other
|Redo sternotomies have a greater risk of significant bleeding and complication
|}

=== Labs and studies ===

* CBC, CMP
* PT, PTT
* CXR: to evaluate for abnormalities (cardiomegaly, pleural effusions)
* EKG: check for LBBB. If a PA catheter is planned, occasionally patients with LBBB may develop a third degree block as a consequence of PA catheter placement

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epi, norepi, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider ketamine, precedex, ancef
* Drugs:
**Emergency medications (bolus):
***Epi, atropine
***Other bolus vasopressors (e.g. vaso, phenylephrine, NE)
***+/- Esmolol, nicardinpine, and nitroprusside
** Heparin, protamine, calcium
**+/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* All cardiac medications should be continued on day of surgery except ACE inhibitors which should be stopped 24h prior to surgery

=== Regional and neuraxial techniques ===

*Pre-Op: Erector Spinae Plane Block -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology
*Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* 2 large bore PIVs
* Arterial line - often these are placed awake, especially if there are athersclerotic lesions along Left Main artery or concern for Right ventricle failure
**''Radial artery grafts for CABG are infrequently used but are typically taken from the non-dominant hand''
* CVP
* Cordis
* +/- Pulmonary artery catheter

=== Induction and airway management ===

*Cardio-protective induction with etomidate vs standard induction with propofol depending on patient's cardiac function and pathology

=== Positioning ===

*Supine position

=== Maintenance and surgical considerations ===

* Redo sternotomies have higher risk of significant bleeding
**type and cross with anticipation of early blood loss
**consider having a cooler of blood in the room
*Patients that have been on heparin leading up to the procedure may have developed resistance to heparin via ATIII depletion. If the max dosage of heparin has been given and ACT is still below goal at time of full heparinization, you may need to give ATIII concentrate
*If procedure uses bypass, have a plan for what drips to use coming off of pump.
**Tailor medications based on hemodynamic needs. (e.g. if there is need for inc afterload, inotropy, both, ect.)
**Have other agents readily available such as - Milrinone, dobutamine, Vasopressin, angiotensin II

=== Emergence ===

*Consider parasternal intercostal blocks pre-emergence/prior to transport to CVICU
*Patients will usually remain intubated and sedated through transit to cardiac ICU, though in certain cases & institutions, emergence and extubation may be considered
**Sedation during ICU transfer with gtt - use what is safest for the patient while providing amnesia
**Consider utilizing gtt that will be used by ICU staff after handoff

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

*Can consider regional anesthesia with parasternal intercostal plane blocks [completed pre-emergence] , or Erector Spinae block (pre-induction)

=== Potential complications ===

* MI 6%
* CVA 5%
* Mild neuropsychatric effects 90%
* Death 1-3% (preop-risk dependent)
* Transfusion 40-90%
* Delirium 8%-15%
* Atrial fibrillation Up to 35%
* Renal failure 1%
* Mediastinitis 1-2%

== Procedure variants ==

{| class="wikitable"
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!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:Cardiac surgery]]
[[Category:Cardiac revascularization procedures]]

Bone marrow procurement

2025-12-13T22:06:20Z

Elee88:

{{Infobox surgical procedure
| anesthesia_type = GA vs spinal
| airway = ETT (if GA) vs natural airway (if spinal)
| lines_access = 1 PIV
| monitors = Standard ASA monitors
| considerations_preoperative =
| considerations_intraoperative = Very aggressive fluids.
| considerations_postoperative = PONV and postop pain are common
}}Bone marrow procurement is performed on generally healthy patients who are donating to someone with leukemia. Procurement is typically done on the hip bones (e.g. iliac crest).

==Overview==
===Indications===
Bone marrow donation

===Surgical procedure===
Long ports are inserted into bone marrow and syringes are used to aspirate. Typically done on hip bones in the prone position.

==Preoperative management==
===Patient evaluation===
Donors are typically relatively healthy.
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
Avoid pre-op Tylenol, can give at the end of the case. Everything (Tylenol, steroids) transfers from bone marrow donor to recipient.

===Regional and neuraxial techniques===
Can be done with spinal, though because of prone positioning, lots of movement, and occasionally lengthy procedure, this is relatively uncomfortable for the patient. Using GA with ETT is generally preferred for this reason.

Alternatively, patients are good candidates for deep QL (truncal) block. This is more easily accomplished after patient proned.

==Intraoperative management==
===Monitoring and access===
PIV x1-2 (at least one good IV for resuscitation). Avoid antecubital due to patient positioning.

===Induction and airway management===
Standard induction as patients are generally healthy.

===Positioning===
Prone. Arms Superman/above head and accessible.

===Maintenance and surgical considerations===

* Generally no antibiotics needed
* Avoid nitrous oxide (myelosuppression)
* Avoid steroids (immunosuppression)
* Aggressive fluid repletion, generally ~3:1 repletion with crystalloid. Albumin is often used as well.
** Can do the case with 1 20G PIV, but easier to keep up with fluid repletion if it is 18G or greater or if have a second IV
**Consider fluid warmer given high volume of fluid repletion
* Procedure can be quite painful, consider Dilaudid for postop
*Alternatively consider methadone 0.15 mg/kg (Ideal Body Weight) on induction
* Pretty emetogenic, consider TIVA, scopolamine patch, etc

* Usually harvest 850cc to 1.5L (depends on cell count)

===Emergence===

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

===Pain management===
Long acting opioids as above.

===Potential complications===

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]