WikiAnesthesia - User contributions [en]

Double-lumen endotracheal tube

2021-04-19T21:24:10Z

Chetra.Yean: Created page with "{{Infobox surgical case reference | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | consid..."

Transphenoidal resection of pituitary tumor

2021-04-16T19:32:34Z

Chetra.Yean:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 2 Art line
| monitors = Standard ASA 5-lead EKG Core temp UOP EEG (optional)
| 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)
}}

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

== Preoperative management ==

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

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

* Versed

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* PIV x 2 (20g for drips, 18g+ for bolus)
* Art 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.

=== 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 remi 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, labelol) for HTN/stimulation not controlled by remi bolus/gtt. HTN will worsen bleeding during ENT portion.
* Surgeons will ask for Valsava 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., remi 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]]

Tonsillectomy and/or adenoidectomy

Chetra.Yean: Created page with "{{Infobox surgical case reference | anesthesia_type = General | airway = ETT | lines_access = PIV x 2 Art line | monitors = Standard ASA 5-lead EKG Core temp UOP EEG (opt..."

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x 2

Art line
| monitors = Standard ASA

5-lead EKG

Core temp

UOP

EEG (optional)
| 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)
}}

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

== Preoperative management ==

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

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* PIV x 2 (20g for drips, 18g+ for bolus)
* Art 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
** Opioid vs Beta Blocker
** 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.

=== Positioning ===

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

=== Maintenance and surgical considerations ===

* Propofol gtt (if TIVA, consider EEG monitoring device)
* Remifentanil gtt (start with 0.1mcg/kg/min and titrate)
* +/- Volatile
* No steroids; may interfere with AM cortisol measurement the next day
* ENT will inject lidocaine with epinephrine, watch for IV injection → tachycardia, hypertension
* Combined ENT/Neurosurgery case - ENT for exposure, Neurosurgery for tumor resection
* As with many ENT cases in the nose, can be very stimulating, hence the suggested remi gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
* Consider BB for HTN/stimulation not controlled by remi bolus/gtt. HTN will worsen bleeding during ENT portion
* Surgeons will ask for Valsava during the case.
* Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection

=== Emergence ===

* Paralytic reversal
* Spin back to neutral.
* Smooth awake extubation (i.e., remi wake-up: decrease to gtt to 0.03-0.05 mcg/kg/min for extubation).
* Avoid positive pressure masking after extubation

== Postoperative management ==

=== Disposition ===

=== Pain management ===

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

=== Potential complications ===

== Procedure variants ==

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

== References ==

[[Category:Surgical procedures]]