WikiAnesthesia - User contributions [en]

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T21:48:26Z

Christopher.Deeble:

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

Provides renal support to patients. Usually veno-venous, but arterio-venous exists too (not covered here).

== Properties ==
'''Solute removal mechanisms:'''

* Diffusion
** Accomplished by passive movement of solute across a membrane (due to a solute concentration gradient, movement from high to low)
** Efficient clearance of low-molecular-weight solutes (< 500-1,500 Daltons)
** Clearance decreases with increasing molecular weight of solute
* Convection
** Accomplished by active movement of solute (due to a pressure gradient) across a membrane
** Limited primarily by size of pores in membrane
** Clearance of different size of solute similar until the size of the solute reaches with size of the pores
** Overall CVVH with higher clearance rate than CVVHD for solutes 1,000 to 20,000 Daltons
'''Membrane characteristics:'''

* Geometric: length, mean inner radius, wall thickness, number of pores, number of fibers (determines membrane surface area)
* Membrane ultrafiltration coefficient: water permeability of filter
* Filter ultrafiltration coefficient: membrane ultrafiltration coefficient multiplied by membrane surface area
* Mass transfer area coefficient: overall capacity of membrane to provide diffusive removal of solute
* Membrane sieving coefficient: ratio of specific solute concentration in ultrafiltrate (only removed by convection) divided by mean plasma concentration in filter
* Cutoff: molecular weight of the smallest solute retained by the membrane
'''Fluids:'''

* Can alter pre/post filter replacement fluid compositions to adjust final electrolyte concentrations in blood

== Types of CRRT (see figure 1 for diagrams) ==
[[File:Img 1.png|thumb|Figure 1: Types of CRRT (Recreated based on Tandukar 2019 & Asahi Kasei Medical Co.)]]
'''SCUF (Slow continuous ultrafiltration)'''

* Convection
* Mainly fluid removal

'''CVVH (Continuous venovenous hemofiltration)'''
* Convection
'''CVVHD (Continuous venovenous hemodialysis)'''
* Diffusion
'''CVVHDF (Continuous venovenous hemodiafiltration)'''
* Combination of convection and diffusion

== Anesthetic implications ==

=== Indications ===
Renal replacement for patients with cardiovascular/hemodynamic instability, acute brain injury, cerebral edema, or raised intracranial pressure (for slow electrolyte correction).

Can be used during liver transplant surgery for help with electrolyte management, acid-base status, and fluid balance.

=== Intraoperative management ===
'''Suggested vascular access (in descending order):'''

# Right internal jugular vein
## catheter tip location: SVC/RA
## recommended catheter length: 15 cm
# Femoral vein
## catheter tip location: IVC
## recommended catheter length: 25 cm
# Left internal jugular vein
## catheter tip location: SVC/RA
## recommended catheter length: 20 cm
# Subclavian (dominant arm)
## catheter tip location: SVC/RA
## 14-17 cm from right subclavian, 17 cm from left subclavian
# Subclavian (non-dominant arm)
## catheter tip location: SVC/RA
## 14-17 cm from right subclavian, 17 cm from left subclavian

'''Anticoagulation:'''

* Techniques to reduce clotting risk: intermittent saline flushes, pre-filter dilution, high blood pump speeds, and low filtration fractions
* Common to use regional citrate (infused into blood prior to entering the extra-corporeal circuit); functions by binding calcium; need to monitor ionized calcium

'''Effect on anesthetic drugs:'''

* Mainly affects drugs that are non-protein bound, have a low molecular weight (< 500 Daltons), and possess a low volume of distribution (< 1L/kg)
* Also need to consider solute/drug charge, membrane binding, and hydrophilicity/hydrophobicity
* Common anesthetic drug properties
** Rocuronium: 609 Daltons, Volume of distribution = 0.25 L/kg, protein binding 30%
** Vecuronium: 637 Daltons, Volume of distribution = 0.3-0.4 L/kg, protein binding 60-80%
** Cisatracurium: 1243 Daltons, Volume of distribution = 0.145 L/kg
** Sugammadex: 2178 Daltons, Volume of distribution = 0.15-0.2 L/kg, protein binding 0%
** Propofol: 178 Daltons, Volume of distribution = 0.60 L/kg, protein binding 95%
** Etomidate: 244 Daltons, Volume of distribution = 2.5-4.5 L/kg, protein binding 75%
** Ketamine: 237 Daltons, Volume of distribution = 3.6 L/kg, protein binding 10-30%
** Midazolam: 362 Daltons, Volume of distribution = 1-3.1 L/kg, protein binding 97%
** Dexmedetomidine: 200 Daltons, Volume of distribution = 1.68 L/kg, protein binding 94%
** Fentanyl: 528 Daltons, Volume of distribution = 11 L/kg, protein binding 80-85%
** Remifentanil: 412 Daltons, Volume of distribution = 0.35 L/kg, protein binding 70%

== Pathophysiology==

== References ==
Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019 Mar;155(3):626-638. doi: 10.1016/j.chest.2018.09.004. Epub 2018 Sep 25. PMID: 30266628; PMCID: PMC6435902.

Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C; Nomenclature Standardization Initiative (NSI) alliance. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care. 2016 Oct 10;20(1):318. doi: 10.1186/s13054-016-1489-9. PMID: 27719682; PMCID: PMC5056503.

Continuous Renal Replacement Therapy (CRRT) | Asahi Kasei Medical Co., Ltd. (n.d.). <nowiki>https://www.asahi-kasei.co.jp/medical/en/apheresis/product/crrt/about/cure.html</nowiki>

Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth. 2022 Aug;36(8 Pt A):2656-2668. doi: 10.1053/j.jvca.2021.10.002. Epub 2021 Oct 8. PMID: 34750060.

Bohorquez H, Koyner JL, Jones CR. Intraoperative Renal Replacement Therapy in Orthotopic Liver Transplantation. Adv Kidney Dis Health. 2023 Jul;30(4):378-386. doi: 10.1053/j.akdh.2023.03.003. PMID: 37657884.
[[Category:Comorbidities]]

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T21:48:04Z

Christopher.Deeble:

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

Provides renal support to patients. Usually veno-venous, but arterio-venous exists too (not covered here).

== System properties and mechanisms ==
'''Solute removal mechanisms:'''

* Diffusion
** Accomplished by passive movement of solute across a membrane (due to a solute concentration gradient, movement from high to low)
** Efficient clearance of low-molecular-weight solutes (< 500-1,500 Daltons)
** Clearance decreases with increasing molecular weight of solute
* Convection
** Accomplished by active movement of solute (due to a pressure gradient) across a membrane
** Limited primarily by size of pores in membrane
** Clearance of different size of solute similar until the size of the solute reaches with size of the pores
** Overall CVVH with higher clearance rate than CVVHD for solutes 1,000 to 20,000 Daltons
'''Membrane characteristics:'''

* Geometric: length, mean inner radius, wall thickness, number of pores, number of fibers (determines membrane surface area)
* Membrane ultrafiltration coefficient: water permeability of filter
* Filter ultrafiltration coefficient: membrane ultrafiltration coefficient multiplied by membrane surface area
* Mass transfer area coefficient: overall capacity of membrane to provide diffusive removal of solute
* Membrane sieving coefficient: ratio of specific solute concentration in ultrafiltrate (only removed by convection) divided by mean plasma concentration in filter
* Cutoff: molecular weight of the smallest solute retained by the membrane
'''Fluids:'''

* Can alter pre/post filter replacement fluid compositions to adjust final electrolyte concentrations in blood

== Types of CRRT (see figure 1 for diagrams) ==
[[File:Img 1.png|thumb|Figure 1: Types of CRRT (Recreated based on Tandukar 2019 & Asahi Kasei Medical Co.)]]
'''SCUF (Slow continuous ultrafiltration)'''

* Convection
* Mainly fluid removal

'''CVVH (Continuous venovenous hemofiltration)'''
* Convection
'''CVVHD (Continuous venovenous hemodialysis)'''
* Diffusion
'''CVVHDF (Continuous venovenous hemodiafiltration)'''
* Combination of convection and diffusion

== Anesthetic implications ==

=== Indications ===
Renal replacement for patients with cardiovascular/hemodynamic instability, acute brain injury, cerebral edema, or raised intracranial pressure (for slow electrolyte correction).

Can be used during liver transplant surgery for help with electrolyte management, acid-base status, and fluid balance.

=== Intraoperative management ===
'''Suggested vascular access (in descending order):'''

# Right internal jugular vein
## catheter tip location: SVC/RA
## recommended catheter length: 15 cm
# Femoral vein
## catheter tip location: IVC
## recommended catheter length: 25 cm
# Left internal jugular vein
## catheter tip location: SVC/RA
## recommended catheter length: 20 cm
# Subclavian (dominant arm)
## catheter tip location: SVC/RA
## 14-17 cm from right subclavian, 17 cm from left subclavian
# Subclavian (non-dominant arm)
## catheter tip location: SVC/RA
## 14-17 cm from right subclavian, 17 cm from left subclavian

'''Anticoagulation:'''

* Techniques to reduce clotting risk: intermittent saline flushes, pre-filter dilution, high blood pump speeds, and low filtration fractions
* Common to use regional citrate (infused into blood prior to entering the extra-corporeal circuit); functions by binding calcium; need to monitor ionized calcium

'''Effect on anesthetic drugs:'''

* Mainly affects drugs that are non-protein bound, have a low molecular weight (< 500 Daltons), and possess a low volume of distribution (< 1L/kg)
* Also need to consider solute/drug charge, membrane binding, and hydrophilicity/hydrophobicity
* Common anesthetic drug properties
** Rocuronium: 609 Daltons, Volume of distribution = 0.25 L/kg, protein binding 30%
** Vecuronium: 637 Daltons, Volume of distribution = 0.3-0.4 L/kg, protein binding 60-80%
** Cisatracurium: 1243 Daltons, Volume of distribution = 0.145 L/kg
** Sugammadex: 2178 Daltons, Volume of distribution = 0.15-0.2 L/kg, protein binding 0%
** Propofol: 178 Daltons, Volume of distribution = 0.60 L/kg, protein binding 95%
** Etomidate: 244 Daltons, Volume of distribution = 2.5-4.5 L/kg, protein binding 75%
** Ketamine: 237 Daltons, Volume of distribution = 3.6 L/kg, protein binding 10-30%
** Midazolam: 362 Daltons, Volume of distribution = 1-3.1 L/kg, protein binding 97%
** Dexmedetomidine: 200 Daltons, Volume of distribution = 1.68 L/kg, protein binding 94%
** Fentanyl: 528 Daltons, Volume of distribution = 11 L/kg, protein binding 80-85%
** Remifentanil: 412 Daltons, Volume of distribution = 0.35 L/kg, protein binding 70%

== Pathophysiology==

== References ==
Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019 Mar;155(3):626-638. doi: 10.1016/j.chest.2018.09.004. Epub 2018 Sep 25. PMID: 30266628; PMCID: PMC6435902.

Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C; Nomenclature Standardization Initiative (NSI) alliance. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care. 2016 Oct 10;20(1):318. doi: 10.1186/s13054-016-1489-9. PMID: 27719682; PMCID: PMC5056503.

Continuous Renal Replacement Therapy (CRRT) | Asahi Kasei Medical Co., Ltd. (n.d.). <nowiki>https://www.asahi-kasei.co.jp/medical/en/apheresis/product/crrt/about/cure.html</nowiki>

Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth. 2022 Aug;36(8 Pt A):2656-2668. doi: 10.1053/j.jvca.2021.10.002. Epub 2021 Oct 8. PMID: 34750060.

Bohorquez H, Koyner JL, Jones CR. Intraoperative Renal Replacement Therapy in Orthotopic Liver Transplantation. Adv Kidney Dis Health. 2023 Jul;30(4):378-386. doi: 10.1053/j.akdh.2023.03.003. PMID: 37657884.
[[Category:Comorbidities]]

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T21:31:49Z

Christopher.Deeble:

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

Provides renal support to patients. Usually veno-venous, but arterio-venous exists too (not covered here).

== Mechanisms ==
'''Solute removal mechanisms:'''

* Diffusion
** Accomplished by passive movement of solute across a membrane (due to a solute concentration gradient, movement from high to low)
** Efficient clearance of low-molecular-weight solutes (< 500-1,500 Daltons)
** Clearance decreases with increasing molecular weight of solute
* Convection
** Accomplished by active movement of solute (due to a pressure gradient) across a membrane
** Limited primarily by size of pores in membrane
** Clearance of different size of solute similar until the size of the solute reaches with size of the pores
** Overall CVVH with higher clearance rate than CVVHD for solutes 1,000 to 20,000 Daltons
'''Membrane characteristics:'''

* Geometric: length, mean inner radius, wall thickness, number of pores, number of fibers (determines membrane surface area)
* Membrane ultrafiltration coefficient: water permeability of filter
* Filter ultrafiltration coefficient: membrane ultrafiltration coefficient multiplied by membrane surface area
* Mass transfer area coefficient: overall capacity of membrane to provide diffusive removal of solute
* Membrane sieving coefficient: ratio of specific solute concentration in ultrafiltrate (only removed by convection) divided by mean plasma concentration in filter
* Cutoff: molecular weight of the smallest solute retained by the membrane

== Types of CRRT (see figure 1 for diagrams) ==
[[File:Img 1.png|thumb|Figure 1: Types of CRRT (Recreated based on Tandukar 2019 & Asahi Kasei Medical Co.)]]
'''SCUF (Slow continuous ultrafiltration)'''

* Convection
* Mainly fluid removal

'''CVVH (Continuous venovenous hemofiltration)'''
* Convection
'''CVVHD (Continuous venovenous hemodialysis)'''
* Diffusion
'''CVVHDF (Continuous venovenous hemodiafiltration)'''
* Combination of convection and diffusion

== Anesthetic implications ==

=== Indications ===
Renal replacement for patients with cardiovascular/hemodynamic instability, acute brain injury, cerebral edema, or raised intracranial pressure (for slow electrolyte correction).

=== Intraoperative management ===
'''Suggested vascular access (in descending order):'''

# Right internal jugular vein
## catheter tip location: SVC/RA
## recommended catheter length: 15 cm
# Femoral vein
## catheter tip location: IVC
## recommended catheter length: 25 cm
# Left internal jugular vein
## catheter tip location: SVC/RA
## recommended catheter length: 20 cm
# Subclavian (dominant arm)
## catheter tip location: SVC/RA
## 14-17 cm from right subclavian, 17 cm from left subclavian
# Subclavian (non-dominant arm)
## catheter tip location: SVC/RA
## 14-17 cm from right subclavian, 17 cm from left subclavian

'''Anticoagulation:'''

* Techniques to reduce clotting risk: intermittent saline flushes, pre-filter dilution, high blood pump speeds, and low filtration fractions
* Common to use regional citrate (infused into blood prior to entering the extra-corporeal circuit); functions by binding calcium; need to monitor ionized calcium

'''Effect on anesthetic drugs:'''

* Mainly affects drugs that are non-protein bound, have a low molecular weight (< 500 Daltons), and possess a low volume of distribution (< 1L/kg)
* Also need to consider solute/drug charge, membrane binding, and hydrophilicity/hydrophobicity
* Common anesthetic drug properties
** Rocuronium: 609 Daltons, Volume of distribution = 0.25 L/kg, protein binding 30%
** Vecuronium: 637 Daltons, Volume of distribution = 0.3-0.4 L/kg, protein binding 60-80%
** Cisatracurium: 1243 Daltons, Volume of distribution = 0.145 L/kg
** Sugammadex: 2178 Daltons, Volume of distribution = 0.15-0.2 L/kg, protein binding 0%
** Propofol: 178 Daltons, Volume of distribution = 0.60 L/kg, protein binding 95%
** Etomidate: 244 Daltons, Volume of distribution = 2.5-4.5 L/kg, protein binding 75%
** Ketamine: 237 Daltons, Volume of distribution = 3.6 L/kg, protein binding 10-30%
** Midazolam: 362 Daltons, Volume of distribution = 1-3.1 L/kg, protein binding 97%
** Dexmedetomidine: 200 Daltons, Volume of distribution = 1.68 L/kg, protein binding 94%
** Fentanyl: 528 Daltons, Volume of distribution = 11 L/kg, protein binding 80-85%
** Remifentanil: 412 Daltons, Volume of distribution = 0.35 L/kg, protein binding 70%

== Pathophysiology==

== References ==
Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019 Mar;155(3):626-638. doi: 10.1016/j.chest.2018.09.004. Epub 2018 Sep 25. PMID: 30266628; PMCID: PMC6435902.

Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C; Nomenclature Standardization Initiative (NSI) alliance. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care. 2016 Oct 10;20(1):318. doi: 10.1186/s13054-016-1489-9. PMID: 27719682; PMCID: PMC5056503.

Continuous Renal Replacement Therapy (CRRT) | Asahi Kasei Medical Co., Ltd. (n.d.). <nowiki>https://www.asahi-kasei.co.jp/medical/en/apheresis/product/crrt/about/cure.html</nowiki>

Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth. 2022 Aug;36(8 Pt A):2656-2668. doi: 10.1053/j.jvca.2021.10.002. Epub 2021 Oct 8. PMID: 34750060.
[[Category:Comorbidities]]

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T21:06:29Z

Christopher.Deeble: add

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T20:38:13Z

Christopher.Deeble: image

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T20:37:25Z

Christopher.Deeble: added image

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T20:31:53Z

Christopher.Deeble: added

CRRT (Continuous Renal Replacement Therapy)

2024-05-04T20:27:21Z

Christopher.Deeble: added info

Intraoperative management of Williams Syndrome

2024-05-04T19:36:26Z

Christopher.Deeble: added info

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

Genetic syndrome with associated cardiac abnormalities (namely supravalvar aortic stenosis, pulmonary arterial stenosis, coronary abnormalities), psychomotor retardation, facial dysmorphism. Risk of sudden death 25-100x than general population; many deaths associated with anesthesia/sedation (50% of which associated with cardiac catheterization cases).

== Anesthetic implications ==

=== Preoperative optimization ===
Labs: hypercalcemia common in young patients, hyperglycemia common in older patients; thyroid function tests; renal function

Cardiac evaluation: four extremity blood pressures; assess for carotid or abdominal bruits; ECG to assess for arrhythmias, QTc prolongation, or ventricular hypertrophy; echocardiography to assess structural issues (more details below); consider cardiac catheterization

Minimize NPO time. May require pre-op anxiolysis prior to procedures (additionally to help optimize hemodynamics).

=== Intraoperative management ===
Consider more challenging airway due to craniofacial abnormalities such as micrognathia, mandibular hypoplasia, teeth malocclusion (although some sources indicate no particularly associated difficulty with airway management)

Mostly concerned with uncorrected cardiac abnormalities, namely supravalvar aortic stenosis and pulmonary artery stenosis.

IV induction preferred over inhalational induction. For high-risk patients and procedures, consider invasive blood pressure monitoring. Minimize tachycardia and hypotension. Maintain adequate preload. Maintain NSR, SVR, and avoid increases in pulmonary vascular resistance. Critical for aggressive early cardiac resuscitation. If needed, consider ECMO on sooner side.

Factor in musculoskeletal abnormalities with choice of NMBs.

=== Postoperative management ===
Continuous pulse-ox and telemetry. Usually require longer post-op monitoring.

== Related surgical procedures ==
May have had cardiothoracic surgical repairs, or prior cardiac catheterizations and associated procedures.

== Pathophysiology ==
Genetic: microdeletion of 26-28 genes (1.5 megabases) at chromosome 7q11.23, elastin deficiency.

Supravalvar aortic stenosis in up to 70% of patients, mainly as narrowing located at sinotubular junction. In addition to affecting aortic valve, this can also limit coronary perfusion.

Pulmonary artery stenosis affecting 40-75% of patients, often in branch or peripheral pulmonary arteries. Peripheral pulmonary stenosis tends to improve over time, although in some patients this does not occur. (Hanley)

Coronary artery abnormalities 5-9% of patients, and up to 45% with concurrent supravalvar aortic stenosis.

Associated Kounis syndrome (coronary dysfunction)

Bicuspid aortic valve (present in 5-12% of patient with WS, 25-39% of patients with supravalvar aortic stenosis)

VSD in 4-21%, mitral valve prolapse in 9-27%

Hypertension in 50%

Additionally thoracic aorta stenosis and renal artery stenosis

50% with hypercalcemia (younger patients)

15-30% subclinical hypothyroidism (usually asymptomatic)

Up to 75% glucose intolerance/diabetes (especially in older patients)

== Signs and symptoms ==
Usually noticed by characteristic facial features “elfin facies”, in combination with cardiac abnormalities

Common facial features: full faces with heavy cheeks, wide mouths with full lips, broad foreheads, pointed chins, short nose with bulbous tip, mandibular hypoplasia (possible malocclusion)

May have musculoskeletal involvement such as contractures or muscle weakness.

== Diagnosis ==
Genetic testing

ECG findings: QTc prolongation 15%; LVH 40%, RVH 60%

== Treatment ==

=== Medication ===

=== Surgery ===
May require pulmonary artery reconstruction if persistent pulmonary artery disease causing RV hypertension, RV hypertrophy, or systolic ventricular septal flattening.

=== Prognosis ===
Study of 108 patients undergoing anesthesia, perioperative mortality of 0.9%, cardiac arrest at rate of 1.85%; rate of all cardiac complications of 11.1%, with most common being bradycardia or hypotension.

Another study with 75 patients (who underwent 202 anesthetics), cardiovascular-free complication rate was 96.8% for non-cardiac surgery vs. 85.7% for patients undergoing cardiac procedures.

== Epidemiology ==
1/8,000 live births

== References ==
Staudt GE, Eagle SS. Anesthetic Considerations for Patients With Williams Syndrome. J Cardiothorac Vasc Anesth. 2021 Jan;35(1):176-186. doi: 10.1053/j.jvca.2020.01.022. Epub 2020 Jan 21. PMID: 32127269.

Olsen M, Fahy CJ, Costi DA, Kelly AJ, Burgoyne LL. Anaesthesia-related haemodynamic complications in Williams syndrome patients: a review of one institution's experience. Anaesth Intensive Care. 2014 Sep;42(5):619-24. doi: 10.1177/0310057X1404200512. PMID: 25233176.

Collins RT 2nd, Mainwaring RD, MacMillen KL, Hanley FL. Outcomes of Pulmonary Artery Reconstruction in Williams Syndrome. Ann Thorac Surg. 2019 Jul;108(1):146-153. doi: 10.1016/j.athoracsur.2019.02.013. Epub 2019 Mar 15. PMID: 30885853.

Brown ML, Nasr VG, Toohey R, DiNardo JA. Williams Syndrome and Anesthesia for Non-cardiac Surgery: High Risk Can Be Mitigated with Appropriate Planning. Pediatr Cardiol. 2018 Aug;39(6):1123-1128. doi: 10.1007/s00246-018-1864-1. Epub 2018 Mar 23. PMID: 29572733.

Kounis NG, Tsigkas G, Almpanis G, Mazarakis A, Kounis GN. Kounis syndrome--the killer for Williams syndrome? Ann Card Anaesth. 2010 Sep-Dec;13(3):265-6. doi: 10.4103/0971-9784.69065. PMID: 20826975.
[[Category:Comorbidities]]

Intraoperative management of VAD (ventricular assist device)

2024-05-04T19:32:27Z

Christopher.Deeble: added info

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

Used in setting of heart failure, either as a bridge to transplant or as a destination therapy. Usually two types of continuous flow pumps: centrifugal and axial-flow. Centrifugal pumps more sensitive to preload and afterload. Patients frequently anticoagulated. More likely to encounter HeartMate 3 (centrifugal) or HeartWare HVAD.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==
Clarify type of LVAD. Note baseline LVAD settings. Address anticoagulation, risks of bleeding versus thromboembolic complications. Assess RV function. Check for compatibility of LVAD with defibrillation/cautery. Physical exam focused on sequelae of heart failure. Baseline ECG, Echo, and labs. If applicable, manage pacemaker/AICD.

== Intraoperative management ==
Recommend having staff familiar with LVAD (trained anesthesiologist, VAD nurse, cardiothoracic surgery team, cardiologist)

Switch patient to AC power to save battery. Bipolar cautery preferred. Consider placing external defibrillation pads. Maintain NSR.

For patients with pulmonary hypertension or mod-severe RV dysfunction undergoing higher risk surgeries with blood loss and fluid shifts, consider CVC or PAC. May want to have TEE available for unstable patients.

Monitor LVAD parameters with patient controller or device monitor; usually speed, power, flow, and pulsatility index (PI); speed and power are directly measured, while flow and PI are derived. PI ranges between 1-10, usually 3-6.

PI = 10 x (Qmax – Qmin)/Qaverage

'''Low PIs (with stable RPM, or hypotension (MAP < 60)):'''

High flows (power): decreased afterload (vasodilation):

- sepsis

- vasodilating agent (eg anesthetic agent)

Low flows (power): low LV preload; hypovolemic, cardiogenic, mechanical obstructive:

- pulmonary hypertension, arrythmia

- low CVP (hypovolemia, bleeding, reverse Trendelenburg)

- high CVP (consider PAC or echo for further workup): RV dysfunction; tamponade, pulmonary embolus, tension pneumothorax, auto-PEEP, abdominal compartment syndrome

'''High PIs:'''

low flow/power (increased afterload, decreased speed)

high flow/power (increased myocardial contractility from recovery, inotropes or exercise, or greater LV filling resulting in greater Frank-Starling increase of contractility)

Pulse oximetry may be unreliable in setting of decreased pulsatility. Can consider using cerebral oximetry (which doesn’t require a pulse). May need to obtain blood gas.

NIBP cuff successful 53% of time, with 41% of time only showing mean value. Doppler ultrasound may be a reliable method; study with HM II showing 94% success rate.

Intra-operative malignant arrhythmias occurring in 1.2% of patients. 0.1% reported intraoperative device failure.

With regards to cardiac arrest: while chest compressions may dislodge LVAD, overall compressions may be more beneficial.

== Postoperative management ==
Standard PACU unless patient with ICU needs. Avoid hypoventilation and optimize oxygenation (prevent changes in PVR). Address anticoagulation when appropriate. Make sure that LVAD has appropriate power supply. Careful treatment of pain to prevent hypertension, but also need to avoid oversedation leading to hypercarbia or hypoxia.

== Pathophysiology ==
Determinants of flow:

Pressure gradient across pump: inversely proportional to pump flow (amount of cardiac output support); gradient defined as difference between outlet and inlet pressures, which correlate with left ventricular and aortic pressures.

Afterload sensitivity: High MAP increases pressure gradient, thus decreasing flow. Hypotension may increase pump flows but can cause injury to organs if too low. Recommend keeping MAP between 70-90.

Preload dependence: increased LV preload increases LVEDP which decreased the pressure gradient and thus increases flow. Centrifugal LVADs are limited by the available volume in the LV. Adequate RV function is necessary, as well as maintaining normal pulmonary vascular resistance. A suction event (collapse of LV walls toward inflow conduit) can occur when the LVAD flow exceeds available preload; such an event may precipitate ventricular arrythmias.

Speed: RPMs (speed of pump) is proportional to flow. Upper limit of RPM may be limited by underlying LV function (as in most cases the desire is to maintain pulsatility, i.e. ejection out of aortic valve). Diminished pulsatility implicated in long-term sequelae such as arteriovenous malformations (some leading to GI bleeds), aortic valve thrombosis, aortic insufficiency.

Heartmate II patients with development of acquired type 2A von Willebrand disease (likely from shearing forces in LVAD).

== Epidemiology ==
2021 study found that the inpatient utilization of LVADs was 0.93% (1690 out of 184,115) in CHF patients.

== References ==
Roberts, S.M., Hovord, D.G., Kodavatiganti, R. ''et al.'' Ventricular assist devices and non-cardiac surgery. ''BMC Anesthesiol'' '''15''', 185 (2015). <nowiki>https://doi.org/10.1186/s12871-015-0157-y</nowiki>

Nicolosi AC, Pagel PS. Perioperative considerations in the patient with a left ventricular assist device. Anesthesiology. 2003 Feb;98(2):565-70. doi: 10.1097/00000542-200302000-00038. PMID: 12552217.

Chung M. Perioperative Management of the Patient With a Left Ventricular Assist Device for Noncardiac Surgery. Anesth Analg. 2018 Jun;126(6):1839-1850. doi: 10.1213/ANE.0000000000002669. PMID: 29200070.

Modi K, Pannu AK, Modi RJ, Shah SD, Bhandari R, Pereira KN, Kubra KT, Raval MR, Ajibawo T. Utilization of Left Ventricular Assist Device for Congestive Heart Failure: Inputs on Demographic and Hospital Characterization From Nationwide Inpatient Sample. Cureus. 2021 Jul 1;13(7):e16094. doi: 10.7759/cureus.16094. PMID: 34367750; PMCID: PMC8330485.

Manning, Michael. Anesthesia for noncardiac surgery in adults with a durable ventricular assist device. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2023.
[[Category:Surgical procedures]]

Fontan

2024-05-04T19:24:25Z

Christopher.Deeble: added info

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Estimated around 70,000 patients worldwide with Fontan circulation. Performed in patients where biventricular repair not possible; conditions such as tricuspid atresia, pulmonary atresia with intact ventricular septum, double inlet left ventricle, hypoplastic left heart syndrome, double outlet right ventricle, and complete atrioventricular septal defects. Fontan is usually the final of 3 stages of palliative surgery (first being Norwood, second being Glenn); staged approach to allow the body to adapt. Patients tend to demonstrate gradual decline over time.

Fontan circulation dependent on systemic venous pressure, PVR, AV valve function, cardiac rhythm, and ventricular function. Driving force of blood through pulmonary circuit is dependent on the different between the central venous pressure and the atrial pressure (passive process). CVP is mainly determined by intravascular volume, thus hypovolemia is poorly tolerated. Also important to maintain sinus rhythm and competent AV valve for optimal atrial emptying and ventricular filling. Additionally avoid agents that decrease myocardial contractility, as well avoid increases in PVR.

== Anesthetic implications ==

=== Preoperative optimization ===
Detailed history and physical examination

Baseline labs, ECG, Echo.

=== Intraoperative management ===
If undergoing major surgery with fluid shifts, monitor with arterial line and CVP. Young patient with well compensated Fontan physiology with CVP (mPAP) of 12 mmHg, and atrial pressure of 5 mmHg (transpulmonary pressure gradient of 7 mmHg).

Avoid hypotension from anesthetic agents (such as high concentration volatiles, or induction agents that drop SVR). Avoid increased in PVR (such as hypercarbia, acidosis, increased intrathoracic pressure, inadequate analgesia/anesthesia)

Spontaneous ventilation may be beneficial for short procedures if able to avoid hypercarbia. If needing invasive ventilation, need to avoid increased in intrathoracic pressure (which would decrease venous return, and in turn reduce pulmonary blood flow); thus low respiratory rates, short inspiratory times, low PEEP, tidal volumes 5-6 mL/kg. Plan for early extubation.

=== Postoperative management ===
Monitor oxygen saturation, volume status. Address anticoagulation needs. Adequate pain management to facilitate normal breathing patterns.

== Related surgical procedures ==
Norwood (stage 1)

Glenn (stage 2)

Heart transplant (as treatment for failing Fontans)

== Pathophysiology ==
Abnormal cardiorespiratory response to exercise: blunted heart rate response, limited ability to increase stroke volume (impaired ventricular function and difficulty increasing preload)

Restrictive respiratory physiology in up to 89% of patients, due to both extrinsic and intrinsic causes; can also experience recurrent pneumonias, pleural effusions, pulmonary embolisms, and in rare cases plastic bronchitis.

45% of patients with atrial arrhythmias in 10 years following surgery, related to multiple suture lines near sinus node, atrial enlargement, and elevated atrial pressure.

Left to right shunts may be present due to aorto-pulmonary collaterals, or incomplete occlusion of prior artificial shunts; may result in increases in PVR and volume overload of ventricle

Protein losing enteropathy in 13% of patients in a 10 year follow up after surgery. Manifests as edema, ascites, malabsorption of fat, hypercoagulopathy, hypocalcemia, hypomagnesemia, immunodeficiency

In 10-year follow-up studies, about 30% of patients with thromboembolic events. Patients usually with anticoagulation or antiplatelet agents.

Fontan associated liver disease causing congestion, fibrosis, and cirrhosis; usually progressive.

== Signs and symptoms ==

== Diagnosis ==
Assess Fontan function with Echo, CT and MRI.

== Treatment ==

=== Medication ===
Pertaining to complications arising from failing Fontan: heart failure medications, anticoaguation, anti-arrhythmic, pulmonary vasodilators

=== Surgery ===
Fontan final stage usually performed around 1-5 years of age. Blood from IVC is directed to pulmonary circuit via extracardiac conduit (usual), or intra-atrial baffle. Some patients require a small fenestration between right atrium and conduit to limit caval pressures, as well as increase preload to ventricle.

=== Prognosis ===
After Fontan surgery, 30-year survival of >80%. After diagnosis of PLE, 60% 5-year and 20% 10-year survival.

== Epidemiology ==

== References ==
Lei SY. FONTAN PHYSIOLOGY. In: Houck PJ, Haché M, Sun LS. eds. ''Handbook of Pediatric Anesthesia''. McGraw Hill; 2015. Accessed June 04, 2023. <nowiki>https://accesspediatrics.mhmedical.com/content.aspx?bookid=1189&sectionid=70364339</nowiki>

McNamara JR, McMahon A, Griffin M. Perioperative Management of the Fontan Patient for Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth. 2022 Jan;36(1):275-285. doi: 10.1053/j.jvca.2021.04.021. Epub 2021 Apr 20. PMID: 34023201.

Sandeep Nayak, MBBS MD FRCA , P.D. Booker, MBBS MD FRCA, The Fontan circulation, ''Continuing Education in Anaesthesia Critical Care & Pain'', Volume 8, Issue 1, February 2008, Pages 26–30, <nowiki>https://doi.org/10.1093/bjaceaccp/mkm047</nowiki>
[[Category:Comorbidities]]

Tetralogy of Fallot/Pulmonary Atresia/Major Aortopulmonary Collateral Arteries

2024-05-04T19:21:19Z

Christopher.Deeble: added info

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Major aortopulmonary collateral arteries (MAPCAs) are present in 20-25% of patients with Tetralogy of Fallot plus pulmonary atresia. Overall condition of TOF/PA/MAPCAs incidence of 0.7 per 10,000 live births. Associated DiGeorge syndrome (22q11 deletion) in >35% of patients. Oxygenation dependent on ratio of pulmonary to systemic blood flow (Qp/Qs). Often undergo a single complete repair vs. a staged repair.

== Anesthetic implications ==

=== Preoperative optimization ===
Basic laboratory data including CBC with differential, basic metabolic panel, and coagulation studies. ECG, chest X-ray. Recent (within 6 months) transthoracic echocardiography. Cardiac catheterization with angiography with characterization of MAPCAs. Review prior cardiac catheterization anesthetic record for hemodynamic instability or desaturations, which may be an indication of MAPCA spasms (can occur again during surgical dissection).

=== Intraoperative management ===
Most patients can safely undergo inhalational induction with sevoflurane (except those with congestive heart failure or extreme cyanosis). Adjust FiO2 to maintain oxygen saturation 75-85% (balanced Qp/Qs). DiGeorge patients may prove more difficult to intubate.

Patients may have tortuous peripheral veins. Due to large potential blood loss, recommend 2 large peripheral IVs for patients having initial surgery; for patients with prior sternotomies or thoracotomies, recommend single lumen introducer and rapid blood product infuser. Additionally, placement of RIJ CVC for CVP monitoring. Try to save femoral veins for future cardiac catheterization procedure, however, can use if need more access. Arterial access in a radial artery for blood pressure monitoring and obtaining blood gas samples. May consider a femoral artery catheter if concerned about accurate blood pressure waveform; alternatively, can request surgeon connect pressure tubing to arterial bypass cannula to transduce aorta (temporary until recovery of radial waveform).

To avoid drops in systemic blood pressure, avoid inhaled anesthetic agents after induction. Maintenance with TIVA: various combinations of infusions of fentanyl, midazolam, ketamine, or dexmedetomidine with a longer acting nondepolarizing neuromuscular blocker infusion. Tend to avoid propofol due to risk of interfering with cardiopulmonary bypass oxygenator, or concern of metabolic acidosis.

Dissection around MAPCAs with large contributions to pulmonary blood flow may lead to desaturations and metabolic acidosis. Usually done off CPB if tolerated.

=== Postoperative management ===
Transfer to CVICU intubated for continued monitoring and resuscitation/repletion of blood products.

== Related surgical procedures ==
Cardiac catheterization lab procedures after surgical repairs: branch PA stenosis ballooning, Melody or Harmony valves

== Pathophysiology ==
Oxygenation dependent on ratio of pulmonary to systemic blood flow (Qp/Qs). MAPCA morphology can be a large determinant of this balance of blood flows. Large unobstructed MAPCAs can lead to adequate oxygenation but over-circulation due to unrestricted pulmonary blood flow, which may cause heart failure. Stenotic or tortuous MAPCAs lead to restricted pulmonary blood flow with limited oxygenation, but seldom to cause heart failure.

== Signs and symptoms ==

== Diagnosis ==

===== Neonatal evaluation: =====
Estimate overall pulmonary blood flow, based on systemic oxygen saturation: high pulmonary blood flow >90%, low pulmonary blood flow < 75%, balanced pulmonary blood flow 75-90%. In most cases, newborns are within 75-90% systemic oxygen saturation and there no clinical need for neonatal intervention*.

<nowiki>*</nowiki>Two variants of pulmonary blood supply merit neonatal intervention: 1) unilateral ductus arteriosus (or anomalous PA from ascending aorta) with MAPCAs to other lung. 2) centrally confluent native PAs that arborize to all lung segments, with all dual supply MAPCAs

If systemic oxygen saturation <75% or > 90% (regardless of anatomy of pulmonary blood supply), then neonatal surgery is performed

===== Pre-surgical work-up: =====
Intracardiac anatomy determined by echocardiography.

Computed tomography or angiography used to determine the anatomy of the pulmonary blood supply including presence of central pulmonary arteries and MAPCA supply (single vs dual).

== Treatment ==

=== Medication ===

=== Surgery ===
If stable, elective repair at around 4-7 months old.

Single-staged complete repair: complete unifocalization and intracardiac repair (VSD closure and conduit from right ventricle to unifocalized pulmonary arteries)

Palliation: AP window or unifocalization to a shunt (systemic to PA)

Note that unifocalization refers to incorporation of MAPCAs and PAs into a single central pulmonary artery system, additionally with augmentation/reconstruction of stenotic or hypoplastic branches.

A flow study can be conducted intra-operatively to assess for candidacy for intracardiac repair. Patients with a flow study with low PA pressures (<= 25 mmHg) at physiologic flows will have a intracardiac repair performed. Patients with a flow study with high PA pressures (> 25 mmHg) at slightly supraphysiologic levels of flow will have a systemic-to-PA shunt placed.

=== Prognosis ===

== Epidemiology ==
Overall condition of TOF/PA/MAPCAs incidence of 0.7 per 10,000 live births. Associated DiGeorge syndrome (22q11 deletion) in >35% of patients.

== References ==

[[Category:Comorbidities]]

CRRT (Continuous Renal Replacement Therapy)

2024-05-02T17:21:46Z

Christopher.Deeble:

CRRT (Continuous Renal Replacement Therapy)

2024-05-02T16:21:23Z

Christopher.Deeble: created page

{{Infobox comorbidity
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Provide a brief summary of this comorbidity here.

== Anesthetic implications ==

=== Preoperative optimization ===

=== Intraoperative management ===

=== Postoperative management ===

== Related surgical procedures ==

== Pathophysiology ==

== Signs and symptoms ==

== Diagnosis ==

== Treatment ==

=== Medication ===

=== Surgery ===

=== Prognosis ===

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

Fontan

2023-06-01T21:44:12Z

Christopher.Deeble: Created page with "{{Infobox comorbidity | other_names = | anesthetic_relevance = | specialty = | signs_symptoms = | diagnosis = | treatment = | image = | caption = }} Commonly as the final staged surgical repair of patients with single ventricles. == Anesthetic implications == === Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patient..."

{{Infobox comorbidity
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| caption =
}}

Commonly as the final staged surgical repair of patients with single ventricles.

== Anesthetic implications ==

=== Preoperative optimization ===

=== Intraoperative management ===

=== Postoperative management ===

== Related surgical procedures ==
Norwood

Glenn

== Pathophysiology ==
Single ventricle physiology, with passive filling of pulmonary arteries.

Failing Fontan physiology commonly with following signs and symptoms:

== Signs and symptoms ==

== Diagnosis ==

== Treatment ==

=== Medication ===
Pertaining to complications arising from failing Fontan: heart failure medications, anticoaguation, anti-arrhythmic, pulmonary vasodilators

=== Surgery ===
If Fontan fails, patient may be considered for a heart transplant.

=== Prognosis ===

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

Tetralogy of Fallot/Pulmonary Atresia/Major Aortopulmonary Collateral Arteries

2023-06-01T21:31:27Z

Christopher.Deeble:

Tetralogy of Fallot/Pulmonary Atresia/Major Aortopulmonary Collateral Arteries

2023-06-01T21:25:59Z

Christopher.Deeble: added details

Tetralogy of Fallot/Pulmonary Atresia/Major Aortopulmonary Collateral Arteries

2023-06-01T20:32:05Z

Christopher.Deeble: created page

Brugada syndrome

2022-11-12T06:40:41Z

Christopher.Deeble: Added details to types of drugs that have been described in literature to have been used safely, and those that have been associated with ECG changes. Added some details about incidence and genetics. Added further studies describing different doses of isoproterenol that were able to achieve desired effect.

{{Infobox comorbidity
| other_names =
| anesthetic_relevance = Moderate
| specialty = Cardiology
| signs_symptoms = Syncope, palpitations, sudden cardiac arrest
| diagnosis = "Coved" or "saddleback" ST elevation on right precordial leads on ECG
| treatment = Implantable cardioverter defibrillator, antiarrhythmic medications
| image =
| caption =
| anesthetic_management = Avoid triggers for arrhythmia such as autonomic instability and fever. Do not use propofol drips or medications known to activated Na+ channels. Treat arrhythmic storm with isoproterenol (IV) followed by quinidine (only PO formulation)
}}'''Brugada syndrome''' (BrS) is a genetic disorder associated with an increased risk of ventricular arrhythmias and sudden cardiac arrest. It is defined by characteristic ECG changes that occur spontaneously or with a drug challenge. The heart is otherwise structurally normal. Patients are often asymptomatic but may present with sudden cardiac arrest, syncope, atrial fibrillation, and nocturnal agonal respiration. Brugada pattern refers to ECG changes alone without corresponding symptoms or clinical criteria.

There are two (sometimes three) types of characteristic ECG changes seen in the Brugada pattern:

*Type 1 (“coved type”): Elevated ST segment >2mm in >1 right precordial lead with pronounced J point elevation, followed by an inverted, symmetrical T wave

*Type 2 (“saddleback”): ST segment descends towards baseline followed by an upright or biphasic T wave
*Type 3: > 2 mm J point, positive T wave, saddleback ST-T configuration, ST segement (terminal portion) elevated < 1 mm

Treatment for Brugada syndrome includes anti-arrhythmic medications and implantable cardioverter defibrillator (ICD) placement for those at risk of sudden cardiac death. All patients should avoid factors known to induce ventricular arrhythmias, such as fever and certain medications.

==Anesthetic implications<ref>{{Cite journal|last=Levy|first=D.|last2=Bigham|first2=C.|last3=Tomlinson|first3=D.|date=2018-06|title=Anaesthesia for patients with hereditary arrhythmias part I: Brugada syndrome|url=https://pubmed.ncbi.nlm.nih.gov/33456827|journal=BJA education|volume=18|issue=6|pages=159–165|doi=10.1016/j.bjae.2018.03.004|issn=2058-5357|pmc=7807910|pmid=33456827}}</ref><ref>{{Cite journal|last=Levy|first=D.|last2=Bigham|first2=C.|last3=Tomlinson|first3=D.|date=2018-06-01|title=Anaesthesia for patients with hereditary arrhythmias part I: Brugada syndrome|url=https://www.bjaed.org/article/S2058-5349(18)30038-6/abstract|journal=BJA Education|language=English|volume=18|issue=6|pages=159–165|doi=10.1016/j.bjae.2018.03.004|issn=2058-5349|pmc=PMC7807910|pmid=33456827}}</ref>==
Perioperative management of patients with BrS should focus on avoidance of factors known to precipitate ventricular arrhythmias. Few clinical trials have been conducted on this subject, therefore guidance for avoidance of specific drugs comes primarily from case reports.

Overview of key points for the perioperative management of BrS:

*Local anesthetics should be avoided if possible
*Propofol is safe for induction but prolonged drips should not be used
*Avoid increases in vagal tone or variations in temperature, avoid ischemia
*Ensure adequate depth of anesthesia and avoid variation in autonomic tone
*Avoid medications that are known to precipitate ventricular arrhythmias (primarily class 1A and 1C antiarrhythmics)
*Sugammadex should be used for neuromuscular blockade reversal
*Manage arrhythmic storm with defibrillation, isoprotenerol, and quinidine

===Preoperative optimization===
Check history is patient, such as history of arrhythmias (especially ventricular), and history of sudden cardiac death in family (reports of autosomal dominant inheritance, incomplete penetrance). ICDs should be disabled prior to surgery. Pacemakers should be switched to non-sensing mode. External defibrillator pads should be placed on patient prior to surgery if possible. Electrolytes (especially potassium, calcium, magnesium) should be checked and replenished as needed.

===Intraoperative management===
There is no definitive recommendation for general anesthesia vs regional, however special considerations must be taken into account for both techniques.

====Neuraxial and Regional Anesthesia====
Local anesthetics are class 1b antiarrhythmics and block voltage-gated sodium channels, and therefore should be avoided if possible. If their use is necessary, the dose should be limited and the patient carefully monitored. Lidocaine with epinephrine is preferred over other local anesthetics<ref>{{Cite journal|last=Dendramis|first=Gregory|last2=Paleologo|first2=Claudia|last3=Sgarito|first3=Giuseppe|last4=Giordano|first4=Umberto|last5=Verlato|first5=Roberto|last6=Baranchuk|first6=Adrian|last7=Brugada|first7=Pedro|date=2017-09-15|title=Anesthetic and Perioperative Management of Patients With Brugada Syndrome|url=https://pubmed.ncbi.nlm.nih.gov/28739038|journal=The American Journal of Cardiology|volume=120|issue=6|pages=1031–1036|doi=10.1016/j.amjcard.2017.06.034|issn=1879-1913|pmid=28739038}}</ref>.

For neuraxial anesthesia, caution should be taken to avoid hypotension and bradycardia.

Bupivacaine has been described to cause ECG changes, but also has been given via epidural without issues (Edge 2002, n = 1, epidural bupi 0.25% 10 mL; Dash 2017 n = 1, epidural bupi 0.125% 10 mL over 20 minutes).

====General Anesthesia====

=====Induction=====
Propofol, etomidate, and thiopental have all been shown to be safe induction agents in patients with BrS. Note that Kloesel (2011) described etomidate to cause ST elevations on ECG (without sequelae). Propofol blocks sodium channels in a dose-dependent fashion and has been known to induce the Brugada pattern when administered as a prolonged infusion. Therefore, propofol infusions and drips should be avoided. With regards to induction, two recent prospective studies have found propofol to be a safe induction agent for BrS patients, and may even attenuate the BrS pattern<ref>{{Cite journal|last=Flamée|first=Panagiotis|last2=Varnavas|first2=Varnavas|last3=Dewals|first3=Wendy|last4=Carvalho|first4=Hugo|last5=Cools|first5=Wilfried|last6=Bhutia|first6=Jigme Tshering|last7=Beckers|first7=Stefan|last8=Umbrain|first8=Vincent|last9=Verborgh|first9=Christian|last10=Forget|first10=Patrice|last11=Chierchia|first11=Gian-Battista|date=2020-03-01|title=Electrocardiographic Effects of Propofol versus Etomidate in Patients with Brugada Syndrome|url=https://pubs.asahq.org/anesthesiology/article/132/3/440/108869/Electrocardiographic-Effects-of-Propofol-versus|journal=Anesthesiology|language=en|volume=132|issue=3|pages=440–451|doi=10.1097/ALN.0000000000003030|issn=0003-3022}}</ref><ref>{{Cite journal|last=Ciconte|first=Giuseppe|last2=Santinelli|first2=Vincenzo|last3=Brugada|first3=Josep|last4=Vicedomini|first4=Gabriele|last5=Conti|first5=Manuel|last6=Monasky|first6=Michelle M.|last7=Borrelli|first7=Valeria|last8=Castracane|first8=Walter|last9=Aloisio|first9=Tommaso|last10=Giannelli|first10=Luigi|last11=Di Dedda|first11=Umberto|date=2018-04|title=General Anesthesia Attenuates Brugada Syndrome Phenotype Expression: Clinical Implications From a Prospective Clinical Trial|url=https://pubmed.ncbi.nlm.nih.gov/30067493|journal=JACC. Clinical electrophysiology|volume=4|issue=4|pages=518–530|doi=10.1016/j.jacep.2017.11.013|issn=2405-5018|pmid=30067493}}</ref>.

=====Volatile anesthetics=====
Sevoflurane, nitrous oxide, desflurane, and isoflurane have all been used without issue in BrS patients. Sevoflurane may be preferred because it does not affect the QT interval.

=====Neuromuscular blockade=====
The nondepolarizing muscle relaxants rocuronium (Sahinkaya n = 1, dose 50 mg), vecuronium (Edge n = 1, dose 2 mg increments; Dash n = 1; Staikou), and cisatracurium (Staikou) have been used in case studies without issues.

For succinylcholine there have been case studies of its use without issue (Edge n = 1, dose 100 mg; Staikou), additionally has been described to also be associated with ST changes without sequelae (Kloesel 2011).

For reversal, cholinergic agents such as neostigmine and pyridostigmine may increase parasympathetic tone, even when used in conjunction with glycopyrrolate or atropine. Thus, sugammadex is the preferred reversal agent in patients with BrS.

=====Other anesthetic drug considerations=====

*No adverse effects have been seen with benzodiazepines, opioids (caution with tramadol), ketorolac, or antiemetics such as dexamethasone and ondansetron
*Benzodiazepines
**Midazolam and diazepam have been described in case studies without issues (Staikou)
*Opioids
**Note that tramadol is on list of medications to use with caution from www.brugadadrugs.org, although there have been case reports of its use without issues (Dash n = 1, dose 50 mg; Biricik n = 1, dose 2 mg/kg)
**The following have been used without issues in case reports: hydromorphone (Kloesel n = 1), fentanyl (Edge n = 1; Staikou), remifentanil (Sahinkaya n = 1, dose 0.5 mcg/kg/min), sufentanil (bolus per-induction, dose 0.1 – 0.3 mcg/kg; Flamee, n = 80)
*Antibiotics
**The following have been used without issues in case reports: cefuroxime (Edge n = 1, dose 1.5 g), metronidazole (Edge n = 1, dose 500 mg), gentamicin (Edge n = 1, dose 320 mg)
*Alpha-agonists and beta-antagonists may worsen the Brugada ECG pattern, while alpha-antagonists and beta-agonists may improve it
**Case reports of use of phenylephrine without issue; case report of patient receiving oxymetazoline and association with ST changes (Kloesel 2011)
**Case reports of using labetalol and esmolol without issue (Kloesel 2011)

=====Management of intraoperative arrhythmias=====
Ventricular tachycardia or ventricular fibrillation should be managed with immediate defibrillation. The following are pharmacologic options for acute management of recurrent ventricular arrhythmias:

*Isoprotenerol (1st line): 2-10 micrograms/minute IV titrated to clinical response
*Quinidine: enteral administration only
**Quinidine sulfate (immediate release): 200mg PO every 6 hours
**Quinidine gluconate (extended release): 324mg PO every 8 hours
Watanabe (2006) describes for VT storm (>2 episodes of VF or VT in 24 hours) IV isoproterenol bolus 1-2 micrograms followed by infusion of 0.15-0.30 micrograms/min for 1-3 days. Jongman (2007), describes (for n =1) that an isoproterenol infusion at 1 microgram/min was able to suppress the VF (continued up to 1 day, until quinidine was on board).

Check electrolytes intraop and correct if abnormal. Return temperature to normal.

===Postoperative management===
Continuous ECG monitoring for the first 24-36hrs after surgery is recommended

==Related surgical procedures==
Radiofrequency catheter ablation for ventricular arrhythmias

==Pathophysiology<ref name=":0">{{Cite web|last=Wylie|first=John|date=7/31/22|title=Brugada syndrome: Epidemiology and pathogenesis|url=https://www-uptodate-com.dartmouth.idm.oclc.org/contents/brugada-syndrome-epidemiology-and-pathogenesis?search=brugada%20syndrome&source=search_result&selectedTitle=1~77&usage_type=default&display_rank=1|url-status=live|website=Up To Date}}</ref>==
BrS is an autosomal dominant defect in the sodium channels of cardiac myocytes (mutation in SCN5A identified in about 20-30% of patient with Brugada syndrome (Staikou)). This affects the action potentials of cells in the right-ventricular outflow tract, leading to altered repolarization and subsequent ST elevation in the precordial leads. Not all cells are equally affected, creating a discrepancy in refractory periods and subsequent premature ventricular beats. This is called phase 2 reentry and can lead to sustained ventricular arrhythmias.

==Signs and symptoms<ref name=":1">{{Cite web|last=Wylie|first=John|date=7/31/22|title=Brugada syndrome: Clinical presentation, diagnosis, and evaluation|url=https://www.uptodate.com/contents/brugada-syndrome-clinical-presentation-diagnosis-and-evaluation|url-status=live|website=Up To Date}}</ref>==
Patients are often asymptomatic, but may present with palpitations, syncope, chest discomfort, nocturnal agonal respirations, ventricular arrhythmias or sudden cardiac arrest. Not all patients will have the Brugada pattern ECG at baseline. A family history of Brugada syndrome or sudden cardiac death raises suspicion for diagnosis.

==Diagnosis<ref name=":1" />==
The following are diagnostic criteria from the Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA), and the Asian Pacific Heart Rhythm Society (APHRS) 2013 expert consensus<ref>{{Cite journal|last=Priori|first=Silvia G.|last2=Wilde|first2=Arthur A.|last3=Horie|first3=Minoru|last4=Cho|first4=Yongkeun|last5=Behr|first5=Elijah R.|last6=Berul|first6=Charles|last7=Blom|first7=Nico|last8=Brugada|first8=Josep|last9=Chiang|first9=Chern-En|last10=Huikuri|first10=Heikki|last11=Kannankeril|first11=Prince|date=2014-02|title=Executive Summary: HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes|url=http://dx.doi.org/10.1016/j.joa.2013.08.001|journal=Journal of Arrhythmia|volume=30|issue=1|pages=29–47|doi=10.1016/j.joa.2013.08.001|issn=1880-4276}}</ref>:

1. ECG type 1 morphology in at least 1 right precordial lead occurring either spontaneously or after provocative drug test with Class I antiarrhythmic drugs

2. ECG type 2 morphology in at least 1 right precordial lead when a provocative drug test induces a type I ECG morphology

Workup should include evaluation for underlying structural heart disease, which would suggest an alternative diagnosis. Genetic testing may be appropriate if a specific mutation has been identified within a family.

There are many conditions that may mimic the Brugada pattern on ECG, including pericarditis, myocardial infarction, electrolyte abnormalities, as well as ECG abnormalities such as atypical right bundle branch block and left ventricular hypertrophy.

Reports of provocative testing being done if diagnosis unclear (with class 1 antiarrhythmic agent) (Levy 2018).

==Treatment<ref>{{Cite web|last=Wylie|first=John|title=Brugada syndrome: Prognosis, management, and approach to screening|url=https://www.uptodate.com/contents/brugada-syndrome-prognosis-management-and-approach-to-screening?search=brugada&source=search_result&selectedTitle=2~88&usage_type=default&display_rank=2|url-status=live|website=Up To Date}}</ref>==
Treatment for BrS involves antiarrhythmic drugs and/or an ICD. Patients with history of sudden cardiac arrest or ventricular arrhythmias should receive an ICD. Patients who are not candidates for an ICD can receive quinidine or amiodarone. Catheter ablation may be considered for patients with recurring arrhythmias resulting in ICD shocks. The following factors may provoke arrhythmias and should be avoided in all patients:

*Fever
*Class 1A and 1C anti-arrhythmic medications such as flecainide, procainamide, and ajmaline
*Bupivicaine and procaine
*Tricyclic antidepressants
*Lithium
*Acetylcholine

For a complete list of medications to avoid visit [https://www.brugadadrugs.org www.brugadadrugs.org]

===Medication===
Patients who are not candidates for ICD implantation or have frequent shocks with their ICD can receive antiarrhythmic therapy. The two medications used are quinidine and amiodarone. Quinidine is preferred due to long-term side effects of amiodarone.

===Surgery===
Patients who continue to have shocks with an ICD may undergo radiofrequency catheter ablation

===Prognosis<ref name=":0" />===
Patients with a history of ventricular arrhythmias or sudden cardiac arrest are at greatest risk for future events. Asymptomatic patients are at a lower risk for sudden cardiac death. Other factors that may increase risk for future cardiac events include family history of sudden cardiac arrest, atrial fibrillation, and male gender.

==Epidemiology<ref name=":0" />==
The overall prevalence of the Brugada ECG pattern ranges between 0.1 and 1 percent. There is a higher prevalence in the Philippines, Thailand and Japan. The mean age of sudden cardiac death is 41. The youngest patient was diagnosed 2 days of age, the oldest at 84 years; 20% of Brugada syndrome patients may develop supraventricular arrythmias (Antzelevitch). Brugada syndrome has an incidence of 1/5000 to 1/2000, Brugada pattern on ECG 0.12 – 0.8% (Ranucci).

==References==
<references />C. J. Edge, D. J. Blackman, K. Gupta, M. Sainsbury, General anaesthesia in a patient with Brugada syndrome, ''BJA: British Journal of Anaesthesia'', Volume 89, Issue 5, November 2002, Pages 788–791, <nowiki>https://doi.org/10.1093/bja/89.5.788</nowiki>

Dash S, Pragathee S. Anaesthetic Management in Brugada Syndrome - A Case Report. J Clin Diagn Res. 2017 Feb;11(2):UD03-UD04. doi: 10.7860/JCDR/2017/24898.9457. Epub 2017 Feb 1. PMID: 28384965; PMCID: PMC5376781.

Jongman JK, Jepkes-Bruin N, Ramdat Misier AR, Beukema WP, Delnoy PP, Oude Lutttikhuis H, Dambrink JH, Hoorntje JC, Elvan A. Electrical storms in Brugada syndrome successfully treated with isoproterenol infusion and quinidine orally. Neth Heart J. 2007;15(4):151-5. doi: 10.1007/BF03085972. PMID: 17612676; PMCID: PMC1847769.

Kloesel B, Ackerman MJ, Sprung J, Narr BJ, Weingarten TN. Anesthetic management of patients with Brugada syndrome: a case series and literature review. Can J Anaesth. 2011 Sep;58(9):824-36. doi: 10.1007/s12630-011-9546-y. Epub 2011 Jun 23. PMID: 21698509.

Şahinkaya HH, Yaşar E, Tekgül ZT, Horsanalı BÖ, Özeroğlu E. Anaesthetic Management of a Patient with Brugada Syndrome. Turk J Anaesthesiol Reanim. 2016 Apr;44(2):96-8. doi: 10.5152/TJAR.2016.22230. Epub 2016 Apr 1. PMID: 27366566; PMCID: PMC4894205.

Staikou C, Chondrogiannis K, Mani A. Perioperative management of hereditary arrhythmogenic syndromes. Br J Anaesth. 2012 May;108(5):730-44. doi: 10.1093/bja/aes105. PMID: 22499746.

Watanabe A, Fukushima Kusano K, Morita H, Miura D, Sumida W, Hiramatsu S, Banba K, Nishii N, Nagase S, Nakamura K, Sakuragi S, Ohe T. Low-dose isoproterenol for repetitive ventricular arrhythmia in patients with Brugada syndrome. Eur Heart J. 2006 Jul;27(13):1579-83. doi: 10.1093/eurheartj/ehl060. Epub 2006 Jun 7. PMID: 16760208.
[[Category:Comorbidities]]

Intracardiac catheter ablation for the treatment of arrhythmia

2022-11-12T05:21:18Z

Christopher.Deeble: added some details to procedural variants

Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats.<ref>{{Cite web|date=2022-05-17|title=Atrial Fibrillation Ablation|url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation|access-date=2022-08-08|website=www.hopkinsmedicine.org|language=en}}</ref>

In adults, atrial fibrillation is the most commonly encountered cardiac arrythmia, overall around 1% (much increase in adults > 65 years of age). Morbidity associated with heart failure and stroke. Thrombus formation promoted in left atria due to incomplete ejection from abnormal rhythm. Atrial rates up to 300-600 beats per minute, although AV node blocks most (resulting in around 90-170 beats per minute). ECG shows irregular R-R intervals (in absence of complete AV nodal blockade), absence of P waves, variable atrial cycle length (usually < 200 ms) (Malladi).

Risk factors for atrial fibrillation (Malladi):

* Hypertension
* Congestive heart failure
* Diabetes mellitus
* Men > women
* Caucasians > African Americans
* Heavy alcohol consumption
* Coronary artery disease/acute myocardial infarction
* Valvular heart disease
* Obesity
* Thyroid dysfunction
* Cardiac surgery
* Electrolyte abnormalities
* Family history
{{Infobox surgical procedure
| anesthesia_type = General (sometimes MAC/sedation)
| airway = ETT
| lines_access = 2 PIVs (Usually one larger gauge 16/18). +/- arterial line
| monitors = Standard, Esophageal Temperature Probe
| considerations_preoperative = These patients are usually already on anticoagulants. If they are not, expect a TEE to be performed before the start of the procedure to rule out any thrombus in the LAA.
| considerations_intraoperative = Before ablation, the proceduralist will often ask you to reposition the esophageal temperature probe to ensure that the esophagus is not damaged during ablation. Monitor closely and frequently inform proceduralists of esophageal temperature.

Serial ACTs will be drawn throughout the procedure. Patients will receive IV heparin throughout the case as instructed by proceduralists.

Paralytic is often contraindicated during maintenance as the proceduralist will pace the phrenic nerve during the ablation to ensure it remains intact. An excellent alternative is to run a remifentanil infusion during the case.
| considerations_postoperative = PACU then usually home (or short stay), patient to remain flat for several hours, watch for late complications of procedure
}}

==Overview==

===Indications===

===Surgical procedure===

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Paroxysmal or chronic atrial fibrillation, CHADS2 scoring, history (cardiac history, risk factors for atrial fibrillation), review if patient has valvular abnormalities
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Review anticoagulation status
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===

* CBC, metabolic panel (electrolytes, renal function), ECG

===Operating room setup===

* Usually in cath lab or hybrid room
* Standard setup
* Arterial line transducer
* Esophageal temperature probe (may have specific one supplied by procedural team)
* Defib/cardioversion pads
* Lead/radiation shielding for providers

===Patient preparation and premedication===

==Intraoperative management==

===Monitoring and access===
Standard Monitors. Establish two PIVs (one large bore in case of myocardial perforation). +/- arterial line (consider EF). +/- OG tube.

===Induction and airway management===
Standard GETA, occasionally performed under MAC (Kottkamp) (although general preferred to help keep patient immobile for arrhythmia mapping, additionally procedure may take many hours, and general anesthesia associated with higher cure rate with single procedure compared to conscious sedation (Di Biase)).

===Positioning===
Supine. Arms will be tucked. Ensure all lines are neatly tucked and off of the floor to ensure they are not caught by the swinging C-arm.

===Maintenance and surgical considerations===

* Maintenance of anesthesia with inhalation agent at 0.7 - 1 MAC with a remifentanil infusion (0.05 - 0.5 mcg/kg/min). Consider addition of phenylephrine infusion as well. Proceduralists like to know if any vasopressors are added during the case as they monitor for cardiac tamponade/atrial perforation. I have found it helpful to start a low dose phenylephrine infusion at the beginning of case to maintain hemodynamics.
* Use of heparin if crossing into left side of heart, monitoring ACT if on heparin (300 seconds, Anderson)
* Consider avoid redosing NMB to help with phrenic nerve monitoring (if being employed) (Yildiz)
* Procedure team may administer isoproterenol to induce arrhythmias, additionally adenosine may be requested to help with eliciting pathways
* May need to reverse heparin with protamine at the end

===Emergence===
Standard emergence. Closure of access site in groin often requires pressure to be held for 15- 30 min. Consider timing emergence to include this. Today, a closure device may be used at access site which negates this additional time. Some proceduralists may request antibiotics if closure device is being used.

==Postoperative management==

===Disposition===

* PACU, then usually home (or short stay)
* Will likely need to remain flat for a few hours due to vascular access sites

===Pain management===

* Usually minimal pain, post-op pain for radiofrequency > post-op pain for cryoablation; acetaminophen or NSAIDs (if no contraindications) (Ashley)

===Potential complications===

* Arrhythmia
* Perforation of aorta or heart
* Phrenic nerve injury, stroke
* Retroperitoneal hemorrhage
* Air embolism (atrial ablation)
* Esophageal injury
* Vascular access-related complications encountered 3-4% of time (Anderson)

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!atrial flutter ablation
!VT ablation
!SVT ablation
|-
|Unique considerations
|similar approach as atrial fibrillation ablation
|minimal/no sedation during mapping, then can convert to GA for ablation
|usually under light/moderate sedation (since GA can suppress arrhythmia)
|-
|Position
|
|Supine
|Supine
|-
|Surgical time
|
|can be > 6 hours
|
|-
|EBL
|usually minimal (just losses from access site)
|usually minimal (just losses from access site)
|usually minimal (just losses from access site)
|-
|Postoperative disposition
|
|
|
|-
|Pain management
|
|usually minimal pain
|usually minimal pain
|-
|Potential complications
|
|Higher chance of needing to defibrillate patient during procedure
|
|}

==References==

[[Category:Surgical procedures]]
<references />Anderson R, Harukuni I, Sera V. Anesthetic considerations for electrophysiologic procedures. Anesthesiol Clin. 2013 Jun;31(2):479-89. doi: 10.1016/j.anclin.2013.01.005. Epub 2013 Feb 23. PMID: 23711654.

Ashley, Elizabeth MC, BSc MB ChB FRCA FFICM, Anaesthesia for electrophysiology procedures in the cardiac catheter laboratory, ''Continuing Education in Anaesthesia Critical Care & Pain'', Volume 12, Issue 5, October 2012, Pages 230–236, <nowiki>https://doi.org/10.1093/bjaceaccp/mks032</nowiki>

Di Biase L, Conti S, Mohanty P, Bai R, Sanchez J, Walton D, John A, Santangeli P, Elayi CS, Beheiry S, Gallinghouse GJ, Mohanty S, Horton R, Bailey S, Burkhardt JD, Natale A. General anesthesia reduces the prevalence of pulmonary vein reconnection during repeat ablation when compared with conscious sedation: results from a randomized study. Heart Rhythm. 2011 Mar;8(3):368-72. doi: 10.1016/j.hrthm.2010.10.043. Epub 2010 Nov 2. PMID: 21055479.

Kottkamp H, Hindricks G, Eitel C, Müller K, Siedziako A, Koch J, Anastasiou-Nana M, Varounis C, Arya A, Sommer P, Gaspar T, Piorkowski C, Dagres N. Deep sedation for catheter ablation of atrial fibrillation: a prospective study in 650 consecutive patients. J Cardiovasc Electrophysiol. 2011 Dec;22(12):1339-43. doi: 10.1111/j.1540-8167.2011.02120.x. Epub 2011 Jun 21. PMID: 21692895.

Malladi V, Naeini PS, Razavi M, Collard CD, Anton JM, Tolpin DA. Endovascular ablation of atrial fibrillation. Anesthesiology. 2014 Jun;120(6):1513-9. doi: 10.1097/ALN.0000000000000261. PMID: 24714120.

Yildiz M, Yilmaz Ak H, Oksen D, Oral S. Anesthetic Management In Electrophysiology Laboratory: A Multidisciplinary Review. J Atr Fibrillation. 2018 Feb 28;10(5):1775. doi: 10.4022/jafib.1775. PMID: 29988243; PMCID: PMC6006978.

Intracardiac catheter ablation for the treatment of arrhythmia

2022-11-12T05:12:03Z

Christopher.Deeble: added to introduction, patient evaluation, operating room setup, surgical considerations, potential complications, post-op management, references

Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats.<ref>{{Cite web|date=2022-05-17|title=Atrial Fibrillation Ablation|url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation|access-date=2022-08-08|website=www.hopkinsmedicine.org|language=en}}</ref>

In adults, atrial fibrillation is the most commonly encountered cardiac arrythmia, overall around 1% (much increase in adults > 65 years of age). Morbidity associated with heart failure and stroke. Thrombus formation promoted in left atria due to incomplete ejection from abnormal rhythm. Atrial rates up to 300-600 beats per minute, although AV node blocks most (resulting in around 90-170 beats per minute). ECG shows irregular R-R intervals (in absence of complete AV nodal blockade), absence of P waves, variable atrial cycle length (usually < 200 ms) (Malladi).

Risk factors for atrial fibrillation (Malladi):

* Hypertension
* Congestive heart failure
* Diabetes mellitus
* Men > women
* Caucasians > African Americans
* Heavy alcohol consumption
* Coronary artery disease/acute myocardial infarction
* Valvular heart disease
* Obesity
* Thyroid dysfunction
* Cardiac surgery
* Electrolyte abnormalities
* Family history
{{Infobox surgical procedure
| anesthesia_type = General (sometimes MAC/sedation)
| airway = ETT
| lines_access = 2 PIVs (Usually one larger gauge 16/18). +/- arterial line
| monitors = Standard, Esophageal Temperature Probe
| considerations_preoperative = These patients are usually already on anticoagulants. If they are not, expect a TEE to be performed before the start of the procedure to rule out any thrombus in the LAA.
| considerations_intraoperative = Before ablation, the proceduralist will often ask you to reposition the esophageal temperature probe to ensure that the esophagus is not damaged during ablation. Monitor closely and frequently inform proceduralists of esophageal temperature.

Serial ACTs will be drawn throughout the procedure. Patients will receive IV heparin throughout the case as instructed by proceduralists.

Paralytic is often contraindicated during maintenance as the proceduralist will pace the phrenic nerve during the ablation to ensure it remains intact. An excellent alternative is to run a remifentanil infusion during the case.
| considerations_postoperative = PACU then usually home (or short stay), patient to remain flat for several hours, watch for late complications of procedure
}}

==Overview==

===Indications===

===Surgical procedure===

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Paroxysmal or chronic atrial fibrillation, CHADS2 scoring, history (cardiac history, risk factors for atrial fibrillation), review if patient has valvular abnormalities
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Review anticoagulation status
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===

* CBC, metabolic panel (electrolytes, renal function), ECG

===Operating room setup===

* Usually in cath lab or hybrid room
* Standard setup
* Arterial line transducer
* Esophageal temperature probe (may have specific one supplied by procedural team)
* Defib/cardioversion pads
* Lead/radiation shielding for providers

===Patient preparation and premedication===

==Intraoperative management==

===Monitoring and access===
Standard Monitors. Establish two PIVs (one large bore in case of myocardial perforation). +/- arterial line (consider EF). +/- OG tube.

===Induction and airway management===
Standard GETA, occasionally performed under MAC (Kottkamp) (although general preferred to help keep patient immobile for arrhythmia mapping, additionally procedure may take many hours, and general anesthesia associated with higher cure rate with single procedure compared to conscious sedation (Di Biase))

===Positioning===
Supine. Arms will be tucked. Ensure all lines are neatly tucked and off of the floor to ensure they are not caught by the swinging C-arm.

===Maintenance and surgical considerations===

* Maintenance of anesthesia with inhalation agent at 0.7 - 1 MAC with a remifentanil infusion (0.05 - 0.5 mcg/kg/min). Consider addition of phenylephrine infusion as well. Proceduralists like to know if any vasopressors are added during the case as they monitor for cardiac tamponade/atrial perforation. I have found it helpful to start a low dose phenylephrine infusion at the beginning of case to maintain hemodynamics.
* Use of heparin if crossing into left side of heart, monitoring ACT if on heparin (300 seconds, Anderson)
* Consider avoid redosing NMB to help with phrenic nerve monitoring (if being employed) (Yildiz)
* Procedure team may administer isoproterenol to induce arrhythmias, additionally adenosine may be requested to help with eliciting pathways
* May need to reverse heparin with protamine at the end

===Emergence===
Standard emergence. Closure of access site in groin often requires pressure to be held for 15- 30 min. Consider timing emergence to include this. Today, a closure device may be used at access site which negates this additional time. Some proceduralists may request antibiotics if closure device is being used.

==Postoperative management==

===Disposition===

* PACU, then usually home (or short stay)
* Will likely need to remain flat for a few hours due to vascular access sites

===Pain management===

* Usually minimal pain, post-op pain for radiofrequency > post-op pain for cryoablation; acetaminophen or NSAIDs (if no contraindications) (Ashley)

===Potential complications===

* Arrhythmia
* Perforation of aorta or heart
* Phrenic nerve injury, stroke
* Retroperitoneal hemorrhage
* Air embolism (atrial ablation)
* Esophageal injury
* Vascular access-related complications encountered 3-4% of time (Anderson)

==Procedure variants==

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

==References==

[[Category:Surgical procedures]]
<references />Anderson R, Harukuni I, Sera V. Anesthetic considerations for electrophysiologic procedures. Anesthesiol Clin. 2013 Jun;31(2):479-89. doi: 10.1016/j.anclin.2013.01.005. Epub 2013 Feb 23. PMID: 23711654.

Ashley, Elizabeth MC, BSc MB ChB FRCA FFICM, Anaesthesia for electrophysiology procedures in the cardiac catheter laboratory, ''Continuing Education in Anaesthesia Critical Care & Pain'', Volume 12, Issue 5, October 2012, Pages 230–236, <nowiki>https://doi.org/10.1093/bjaceaccp/mks032</nowiki>

Di Biase L, Conti S, Mohanty P, Bai R, Sanchez J, Walton D, John A, Santangeli P, Elayi CS, Beheiry S, Gallinghouse GJ, Mohanty S, Horton R, Bailey S, Burkhardt JD, Natale A. General anesthesia reduces the prevalence of pulmonary vein reconnection during repeat ablation when compared with conscious sedation: results from a randomized study. Heart Rhythm. 2011 Mar;8(3):368-72. doi: 10.1016/j.hrthm.2010.10.043. Epub 2010 Nov 2. PMID: 21055479.

Kottkamp H, Hindricks G, Eitel C, Müller K, Siedziako A, Koch J, Anastasiou-Nana M, Varounis C, Arya A, Sommer P, Gaspar T, Piorkowski C, Dagres N. Deep sedation for catheter ablation of atrial fibrillation: a prospective study in 650 consecutive patients. J Cardiovasc Electrophysiol. 2011 Dec;22(12):1339-43. doi: 10.1111/j.1540-8167.2011.02120.x. Epub 2011 Jun 21. PMID: 21692895.

Malladi V, Naeini PS, Razavi M, Collard CD, Anton JM, Tolpin DA. Endovascular ablation of atrial fibrillation. Anesthesiology. 2014 Jun;120(6):1513-9. doi: 10.1097/ALN.0000000000000261. PMID: 24714120.

Yildiz M, Yilmaz Ak H, Oksen D, Oral S. Anesthetic Management In Electrophysiology Laboratory: A Multidisciplinary Review. J Atr Fibrillation. 2018 Feb 28;10(5):1775. doi: 10.4022/jafib.1775. PMID: 29988243; PMCID: PMC6006978.

Maxillary and mandibular osteotomy

2022-11-12T04:53:39Z

Christopher.Deeble: added some details to introduction, patient evaluation, potential complications

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Nasal ETT (RAE or MLT)
| lines_access = PIV x2 (Large bore IV x1-2)
± Arterial line
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities (comorbidities such as OSA)
| considerations_intraoperative = Highly stimulating, painful surgery, bed 90-180, consider TIVA to help with PONV, controlled hypotension (to help minimize bleeding), minimize nausea and coughing during extubation
| considerations_postoperative = PONV
Monitor airway patency
Pain -- multimodal pain control, minimize IV opioids
Surgical mouth closure with heavy elastic vs wires (consider having cutting device nearby if needing to urgently open mouth)
}}

== Overview ==

=== Indications ===
Class II-III malocclusion is one of the most common reasons for performing a maxillary and mandibular osteotomies. Severe malocclusion is typically caused by maxillary hypoplasia and is commonly found in patients with orofacial clefts, obstructive sleep apnea (OSA), and maxillary atrophy. Maxillary surgery is required in up to 25% of cleft lip and palate patients.<ref>{{Cite journal|last=Buchanan|first=Edward P.|last2=Hyman|first2=Charles H.|date=2013|title=LeFort I Osteotomy|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805729/|journal=Seminars in Plastic Surgery|volume=27|issue=3|pages=149–154|doi=10.1055/s-0033-1357112|issn=1535-2188|pmc=3805729|pmid=24872761}}</ref><ref>{{Cite journal|last=Scolozzi|first=Paolo|date=2008|title=Distraction Osteogenesis in the Management of Severe Maxillary Hypoplasia in Cleft Lip and Palate Patients|url=http://dx.doi.org/10.1097/scs.0b013e318184365d|journal=Journal of Craniofacial Surgery|volume=19|issue=5|pages=1199–1214|doi=10.1097/scs.0b013e318184365d|issn=1049-2275}}</ref>

=== Surgical Procedure ===
Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal|last=Mercuri|first=L.G.|date=2006|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018|journal=International Journal of Oral and Maxillofacial Surgery|volume=35|issue=3|pages=284–286|doi=10.1016/j.ijom.2005.07.018|issn=0901-5027}}</ref><ref>{{Cite journal|last=Beck|first=James I.|last2=Johnston|first2=Kevin D.|date=2014-02-01|title=Anaesthesia for cosmetic and functional maxillofacial surgery|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X|journal=Continuing Education in Anaesthesia Critical Care & Pain|language=en|volume=14|issue=1|pages=38–42|doi=10.1093/bjaceaccp/mkt027|issn=1743-1816}}</ref>

=== Other Associated Pathologies ===
20% of adult population affected by sleep-disordered breathing, with 7-8% with moderate-to-severe OSA. OSA correlated with obesity, metabolic syndrome, systemic and pulmonary hypertension, congestive heart failure, arrhythmias, heart attacks, stroke. STOP-BANG to screen for OSA.

Other ENT pathology may be present in OSA patients (eg septal deviation, laryngotracheomalacia, tonsil and adenoid hypertrophy). OSA patient may show increased sensitivity to opioids and benzodiazepines.

===== STOP-BANG: =====
'''S'''nore loudly?

'''T'''ired during the day?

'''O'''bserved cessation of breathing during sleep?

'''P'''ressure (high blood pressure)?

'''B'''MI > 35 kg/m^2?

'''A'''ge > 50 years?

'''N'''eck circumference > 40 cm?

'''G'''ender male?

(yes to 0-2 low risk, yes to 3-4 intermediate risk, yes to 5-8 high risk)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw
Check for predicators of difficult mask ventilation
|-
|Neurologic
|
|-
|Cardiovascular
|Check for cardiovascular comorbidities, such as systemic and pulmonary hypertension, CHF, cardiac arrhythmias, MI, stroke
|-
|Pulmonary
|
|-
|Gastrointestinal
|Higher incidence of GERD
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* CBC, T&S with blood type verification
* ± PT/PTT
* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)
*Further studies as indicated from H&P and comorbidities
**If pulmonary issues, may need CXR, ABG, PFTs
**If cardiac issues, may need ECG or ECHO

=== Operating room setup ===

* Airway
** Nasal ETT
** Accordion and/or straight connector
** ± Nasal trumpet
** ± Fiberscope or VL device
* Bolus line ± fluid warmer connected to largest PIV
* Lower body forced-air warmer
* 2 infusion channels and 2 syringe pumps on a manifold
* Maintenance/Carrier line with flushed octopus connecter

=== Patient preparation and premedication ===

* Pretreatment of both nares with Oxymetazoline (Afrin)
* Tylenol PO 15mg/kg (Max: 1g)
* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
* Aprepitant or scopolamine patch as needed
* Consider antisialagogue dose of glycopyrrolate prior to induction
** Adult
*** PO Dose: 1-2 mg PO; Parenteral Dose: 0.1-0.2 mg SC/IM/IV (Max: 1-2 mg/dose, 8mg/day)
** Pediatric
*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)
=== Regional and neuraxial techniques ===

* Mandibular and maxillary nerve blocks performed by the surgeons can be utilized to aid postoperative pain relief

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
** Core temperature monitoring likely only available via bladder or rectal given oral or nasal probes are likely to interfere with surgical exposure
* PIV x2 , at least 1 large-bore PIV for resuscitation
* ± Arterial line as needed based on patient-specific factors
* ± BIS, PSI, or raw EEG monitoring

=== Induction and airway management ===

* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)

* Nasal Intubation
** Consider fiberscopic placement vs DL or VL ± oral manipulation with MaGill forceps
** Consider dilation with lubricated nasal trumpet (one-size greater than the desired ETT) - this will additionally aid in confirming which nare is most likely to easily accommodate the ETT and allow for change in ETT sizing prior to intubation attempt if there is difficulty
** Airway typically secured by surgical team with suture before wrapping the patient's head

* Dexamethasone 4-10mg, typically at least (0.1mg/kg with Max: 10mg for post operative pain/swelling)
* ± Tranexamic Acid (TXA) bolus, typically 1 gram or 30mg/kg over 10-15 minutes
* Ancef, weight-based dosing

=== Positioning ===

* Supine with neck extended, on foam donut
* Careful eye protection and padding
* One or two arms tucked
* Table is usually turned 90-180 degrees

=== Maintenance and surgical considerations ===

* Check ETT to make sure no pressure on nasal ala
*Maintain anesthetic depth with volatile anesthetic ± IV infusions
** Example setup:
*** Sevoflurane (MAC of ~ 0.5)
*** Dexmedetomidine (0.2-0.4 mcg/kg/min)
*** Short-acting opiate (eg. Sufentanil/Alfentanil) or Ultra-short-acting opiate (Remifentanil)
*** ± Tranexamic Acid (TXA)
*** ± Phenylephrine
*** ± Background propofol for PONV

* Consider higher volume hydration (if tolerated) to prevent PONV
* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal|last=Shepherd|first=Jonathan|date=2004|title=Hypotensive anaesthesia and blood loss in orthognathic surgery|url=http://dx.doi.org/10.1038/sj.ebd.6400238|journal=Evidence-Based Dentistry|volume=5|issue=1|pages=16–16|doi=10.1038/sj.ebd.6400238|issn=1462-0049}}</ref>
**if not controlled with a similar IV anesthetic plan as above you may consider other hypotensive agents for as needed example agent listed below:
***Sodium Nitroprusside or SNP (Infusion), Glyceryl trinitrate or GTN (Infusion), Clonidine (Infusion or bolus), β-blockers (Infusion or bolus), Magnesium (Bolus)
* Redose Acetaminophen as able
* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal|last=Lang|first=Scott|last2=Lanigan|first2=Dennis T.|last3=van der Wal|first3=Mike|date=1991-09-01|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex|url=https://doi.org/10.1007/BF03008454|journal=Canadian Journal of Anaesthesia|language=en|volume=38|issue=6|pages=757|doi=10.1007/BF03008454|issn=1496-8975}}</ref><ref>{{Cite journal|last=Campbell|first=R.|last2=Rodrigo|first2=D.|last3=Cheung|first3=L.|date=1994|title=Asystole and bradycardia during maxillofacial surgery.|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/|journal=Anesthesia Progress|volume=41|issue=1|pages=13–16|issn=0003-3006|pmc=2148710|pmid=8629742}}</ref>

=== Emergence ===

* Toradol 0.5 mg/kg, Max: 30 mg
* Zofran
* Reversal with sugammadex
* Ensure removal of all throat packing
* OGT for gastric decompression/removal of surgical bleeding
* Extubate awake and following commands (swallowing in particular)
* Head up or reverse trendelenburg positioning
* Do not suction in the mouth after OGT has been removed
** Consider instead using a soft suction catheter through contralateral nare

* Expect significant postoperative facial swelling
* Removal of the nasal ETT after Le Fort I osteotomy should be done gently because the sectioned nasal septum may easily be displaced

== Postoperative management ==

=== Disposition ===

* PACU -> observation/overnight admission

=== Pain management ===

* Tylenol q6h (liquid PO), NSAID (liquid PO), and IV narcotics all used in perioperative setting, continued after discharge
** Some patients may be excellent candidates for PCAs post-PACU discharge as nursing ratios change and may be recommended for if their pain is particularly difficult to control

* Maxillofacial surgeons typically advise patients to prepare for a prolonged, painful recovery (~six-weeks off) with additional jaw-healing takings up to 2-3 months

=== Potential complications ===

* The reported incidence of PONV after orthognathic surgery varies from 7<ref>{{Cite journal|last=Ichinohe|first=Tatsuya|last2=Kaneko|first2=Yuzuru|date=2007|title=Nitrous Oxide Does Not Aggravate Postoperative Emesis After Orthognathic Surgery in Female and Nonsmoking Patients|url=http://dx.doi.org/10.1016/j.joms.2006.06.283|journal=Journal of Oral and Maxillofacial Surgery|volume=65|issue=5|pages=936–939|doi=10.1016/j.joms.2006.06.283|issn=0278-2391}}</ref> to 40%<ref>{{Cite journal|last=Silva|first=Alessandro C.|last2=O’Ryan|first2=Felice|last3=Poor|first3=David B.|date=2006|title=Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review|url=http://dx.doi.org/10.1016/j.joms.2006.05.024|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=9|pages=1385–1397|doi=10.1016/j.joms.2006.05.024|issn=0278-2391}}</ref>, with steroid prophylaxis and up to 83%<ref>{{Cite journal|last=Piper|first=Swen N.|last2=Röhm|first2=Kerstin|last3=Boldt|first3=Joachim|last4=Kranke|first4=Peter|last5=Maleck|first5=Wolfgang|last6=Seifert|first6=Rudolf|last7=Suttner|first7=Stefan|date=2008|title=Postoperative nausea and vomiting after surgery for prognathism: Not only a question of patients' comfort. A placebo-controlled comparison of dolasetron and droperidol|url=http://dx.doi.org/10.1016/j.jcms.2007.07.011|journal=Journal of Cranio-Maxillofacial Surgery|volume=36|issue=3|pages=173–179|doi=10.1016/j.jcms.2007.07.011|issn=1010-5182}}</ref> with no antiemetic prophylaxis
* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding
** Have closure removal devices at bedside at all time
*Hypertension, and risk of associated bleeding
*Damage to ETT during surgery

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
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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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|}

== References ==

[[Category:Surgical procedures]]
[[Category:Orthognathic surgery]]
[[Category:Maxillofacial surgery]]

Anterior cervical spine surgery

2022-11-12T04:23:59Z

Christopher.Deeble: added details to patient evaluation, positioning, maintenance, emergence, pain management, potential complications; additionally added study that describes performing procedure under cervical plexus block

{{Infobox surgical case reference
| anesthesia_type = General (note that there are reports of cervical plexus block, Wang 2017)
| airway = ETT
| lines_access = PIV, possible arterial line
| monitors = Standard, possible invasive BP monitoring, possible neuromonitoring, consider level of consciousness monitor
| considerations_preoperative = Neck ROM, preoperative neurologic exam, may need CBC and type & screen if expecting blood loss; consider PO aprepitant if PONV concerns
| considerations_intraoperative = minimize neck movement during intubation, maintain MAP for spinal cord perfusion, maintenance anesthesia based on local neuromonitoring standards (TIVA vs. lower dose volatile + 50% nitrous + remifentanil infusion)
| considerations_postoperative = PACU then inpatient, multimodal pain control
}}

Fusion after discectomy usually needed for stability. Patients may have cervical radiculopathy, cervical myelopathy (spinal stenosis), disc disease, cervical instability.

== 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
|If trauma, assess for respiratory depression, decreased sympathetic tone (decreased BP and HR), presence of other injuries (pulmonary contusion, pneumo- or hemothorax, tracheal injuries, facial injuries)
|}

=== Labs and studies ===

* May need CBC and T&S if expecting blood loss

=== Operating room setup ===

=== Patient preparation and premedication ===

* Standard premeds (eg PONV prophylaxis, anxiolytics), if chronic disease and elective cases
* Caution with premeds for trauma patients

=== Regional and neuraxial techniques ===

* Reports of cervical plexus anesthesia; general anesthesia (compared to cervical plexus block) showed increased of the following: intraoperative hemodynamic stability, intraoperative pain control, patient satisfaction, post-op pain medications given, time for surgery, time for recovery (Wang 2017)

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitors. Neuromonitoring per surgeon request. PIV 18-20g usually sufficient. Arterial line based on patient comorbidities. If utilizing arterial line, usually align transducer to level of head.

=== 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. If MEP monitoring, consider succinylcholine or lower dose rocuronium.

=== Positioning ===
Positioned supine, typically with shoulder roll for exposure and head on a doughnut gel pillow to facilitate neck positioning. Sometimes will have cervical traction. Surgeons may prefer left side approach to minimize injury to recurrent laryngeal nerve.

=== 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. If local neuromonitoring group allows, consider 50% nitrous oxide with 0.6% isoflurane (or 0.5 MAC sevoflurane) with remifentanil infusion.
*May need to increase MAP goals (eg > 80) to maintain spinal cord perfusion.

=== Emergence ===

* If patient has a halo device or body jacket, consider waiting until patient is fully awake before removing ETT (as it may be more difficult to re-intubate)
* Airway obstruction from soft tissue occlusion or superior laryngeal nerve damage may occur on extubation; consider testing airway patency by removing air from ETT cuff and observing if patient able to still breath around tube
* If concern for airway issues, consider inserting airway exchange catheter prior to extubation
* If using remifentanil during case, likely will need a longer-acting opioid for pain control after extubation

== Postoperative management ==

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

=== Pain management ===

* Intraop with remifentanil
* Postop with IV acetaminophen, IV hydromorphone, fentanyl pushes as needed, consider PCA; consult with surgeon about use of ketorolac or celecoxib

=== Potential complications ===

* Neck hematoma
* Airway edema
* Injury to cranial nerves, recurrent laryngeal nerve, and/or superior laryngeal nerve
* Dural tear
*Notes on bone non-union:
**Smoking increases risk of non-union (Reuben)
**NSAIDs (celecoxib, rofecoxib, low dose ketorolac < 110 mg/day) for short term (5-days) post-op paoin control without significant difference in non-union assessed at 1 year (Reuben, retrospective)
**Perioperative steroid (dexamethasone 0.2 mg/kg intraop; 4 post op doses 0.06 mg/kg Q6H for 24 hours) reported to improve short term swallowing function and airway edema, and shorten length of stay, with lower 6-month fusion rates but not at 12 months (Jeyamohan)
*Tension pneumothorax
*Hypotension (could be due to venous pooling, acute drop may be due to vascular injury)
*If in sitting position, risk of venous air embolism
*Esophageal perforation

== Procedure variants ==

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

== References ==
Anesthesiologist's manual of surgical procedures [[ISBN (identifier)|ISBN]][[Special:BookSources/978-1-4963-0594-7|978-1-4963-0594-7]][[OCLC (identifier)|OCLC]]888551588

Jeyamohan SB, Kenning TJ, Petronis KA, Feustel PJ, Drazin D, DiRisio DJ. Effect of steroid use in anterior cervical discectomy and fusion: a randomized controlled trial. J Neurosurg Spine. 2015 Aug;23(2):137-43. doi: 10.3171/2014.12.SPINE14477. Epub 2015 May 1. PMID: 25932600.

Pardo, Manuel, Ronald D Miller (2020). Basics of Anesthesia 9th Edition. Print. p. 2096.

Reuben SS, Ablett D, Kaye R. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth. 2005 May;52(5):506-12. doi: 10.1007/BF03016531. PMID: 15872130.

Wang H, Ma L, Yang D, Wang T, Wang Q, Zhang L, Ding W. Cervical plexus anesthesia versus general anesthesia for anterior cervical discectomy and fusion surgery: A randomized clinical trial. Medicine (Baltimore). 2017 Feb;96(7):e6119. doi: 10.1097/MD.0000000000006119. PMID: 28207536; PMCID: PMC5319525.
[[Category:Surgical procedures]]

Open reduction and interal fixation of the tibial plateau fracture

2022-11-12T04:05:15Z

Christopher.Deeble: added article

{{Infobox surgical procedure
| anesthesia_type = General
| airway = standard ETT, or specific to situation (if trauma)
| lines_access = standard PIV, more if indicated based on trauma or comorbidities
| monitors = Standard ASA Monitors, more if indicated based on trauma or comorbidities
| considerations_preoperative = unlikely to be candidate for nerve block/catheter (although literature equivocal about risks); if trauma watch for fat embolism, myoglobinuria, hyperkalemia
| considerations_intraoperative = if trauma, likely will need RSI; standard maintenance, fluid management; X-rays, may need NMB to facilitate surgical manipulation
| considerations_postoperative = PACU, possibly ICU if trauma patient; pain control may be more difficult; compartment syndrome
}}

Tibial plateau fracture account for about 1% of all fractures, often associated with high energy mechanisms. Associated with injury to nearby soft tissue and ligaments (Cunningham). With age, increased incidence of osteoporotic fracture. Fracture pattern described by Schatzker types 1-6 (with 1-3 being on the simpler side) (Wang).

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|Bone fractures may lead to fat embolism, assess oxygenation
|-
|Gastrointestinal
|
|-
|Hematologic
|Assess bleeding and hypovolemia
|-
|Renal
|Myoglobinemia and hyperkalemia from crush injuries
|-
|Endocrine
|
|-
|Other
|Likely trauma as cause, need to assess other organs that may be involved (eg neck, thorax)
|}

=== Labs and studies ===

* CBC, BMP, consider checking CPK, urine drug screen
* ECG and/or ECHO as indicated

=== Operating room setup ===

* Standard setup
* If trauma, may need additional equipment for airway and infusion of blood products
* Arterial line and CVC setup as indicated

=== Patient preparation and premedication ===

* For elective cases, consider PO acetaminophen and/or PONV prophylaxis

=== Regional and neuraxial techniques ===

* Usually not offered due to concern for post-op missed compartment syndrome (Hyder, Dwyer; although there are case reports of missed compartment syndrome with regional anesthesia, there are also case reports of diagnosing compartment syndrome with regional anesthesia onboard)
* Study examining single shot RA in patients with tibial plateau fracture without evidence of compartment syndrome (Cunningham n = 60)
* Ask surgical team about consideration

== Intraoperative management ==

=== Monitoring and access ===

* 1-2x 14-16G PIV
* Consider arterial line, or CVC (large blood loss, continued need for mechanical ventilation post-op)

=== Induction and airway management ===

* Elective cases, standard induction
* If trauma, RSI to prevent aspiration; may need specific airway equipment if patient with limited neck mobility (eg in C-collar)

=== Positioning ===

* Supine, or slightly lateral

=== Maintenance and surgical considerations ===

* Standard anesthesia maintenance
* Maintain euvolemia -> goal directed fluid management with crystalloids and blood products as needed
* Active warming especially for trauma patients, including convection blanket, active humidifier, warm fluids
* If use of tourniquet, MAP may drop with release of tourniquet
* TXA IV or topical may decrease blood loss with overall minimal side effects (Wang)

=== Emergence ===

* PONV prophylaxis
* Especially for trauma patients, wait until full return of protective airway reflexes before extubation

== Postoperative management ==

=== Disposition ===

* PACU, or ICU if trauma patient

=== Pain management ===

* Multimodal PO and IV medications

=== Potential complications ===

* Compartment syndrome (usually clinical diagnosis), may lead to hyperkalemia and myoglobinuria/emia
* Fat embolism (symptoms of hypoxemia, increased heart rate, tachypnea, respiratory alkalosis, mental status changes, petechiae)
* Wound infection
* DVT
* Peripheral nerve damage

=== ERAS ===

* For elective cases, standard guidelines; consider PO acetaminophen for pain control and PO aprepitant for PONV prophylaxis

== Procedure variants ==

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

== References ==
Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg. 2022 May 1;134(5):1072-1081. doi: 10.1213/ANE.0000000000005980. PMID: 35313323.

Dwyer T, Burns D, Nauth A, Kawam K, Brull R. Regional anesthesia and acute compartment syndrome: principles for practice. Reg Anesth Pain Med. 2021 Dec;46(12):1091-1099. doi: 10.1136/rapm-2021-102735. Epub 2021 Jun 29. PMID: 34187911.

Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996 May;78(3):499-500. PMID: 8636198.

Anesthesiologist's manual of surgical procedures [[ISBN (identifier)|ISBN]][[Special:BookSources/978-1-4963-0594-7|978-1-4963-0594-7]][[OCLC (identifier)|OCLC]]888551588

Wang Z, Lu Y, Wang Q, Song L, Ma T, Ren C, Li Z, Yang J, Zhang K, Zhang B. Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study. BMC Musculoskelet Disord. 2020 Nov 12;21(1):739. doi: 10.1186/s12891-020-03772-7. PMID: 33183258; PMCID: PMC7659088.
[[Category:Surgical procedures]]