cases and conditions

anesthesia services

General Anesthesia. Definition?

• General anesthesia "is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired." (ASA) Why? Answer. How? Answer.
• Preoperative: Preoperative Evaluation
Preoperative: Basic Room Setup? (EMS MAIDS)
• Emergency
• Ambubag
• Bougie
• Machine
• Machine system/leak test
• E-cylinder pressures
• Patient demographic information
• Inhaled anesthetic levels
• Suction
• Suction catheter attached
• Monitors
• Pulse oximeter
• ETCO2 sampling line
• NIBP
• EKG Leads (5 for EKG, 2 for TM)
• Temperature probe
• +/- BIS or sedline
• Airway
• Mask for breathing circuit
• Intubating blade and handle
• ETT, stylet, and 10cc syringe
• Oral airway
• Tape for tube and eyes
• Soft bite block
• +/- SGA (with lubricating gel)
• IV access and fluids
• IV kit (tourniquet, tegaderm, gauze, alcohol, needles, saline flush primed tubing)
• IV fluids (as bolus line or as carrier attached to manifold)
• Drugs
• Induction: Lidocaine (~1 mg/kg)
• Induction: Propofol (~2 mg/kg)
• Induction: Rocuronium (0.6-1.2 mg/kg) or Succinylcholine (1 mg/kg)
• Induction: Fentanyl (1-2 mcg/kg) or Esmolol
• Maintenance (Early): Antibiotic
• Maintenance (Early): Dexamethasone (4-5 mg)
• Maintenance (Late): Ondansetron (4 mg)
• Maintenance (Late): Analgesics
Intraoperative: Pre-Induction (TMI)
• +/- Start anesthesia button clicked
• +/- Medications accessible
• Transfer patient
• Monitors attached
• Pulse oximeter
• Non-invasive blood pressure (NIBP) cuff
• Electrocardiogram leads
• Capnography
• +/- Temperature probe
• +/- Twitch monitor
• +/- BIS/Sedline
• IV patent
Intraoperative: Induction (PPD VIP)
• Preoxygenate (to EtO2 >80%)
• Position optimally (e.g. sniffing, ramping)
• Drugs for induction
• Ventilate (unless RSI)
• Intubation
• R hand to scissor teeth
• L hand to insert blade on far right of mouth
• Sweep tongue with blade from right to left
• Epiglottis visualized
• Lift laryngoscope in direction of handle (~45 degrees)
• Insert ETT into trachea
• Cuff inflated
• Confirm ETT placement (C's: Chest rise, Condensation, etCO2, Compliance +/- CTAB)
• Protect ETT and eyes
Intraoperative: Post-Induction (2-1-3 ABCDEF)
• 2-Airway: Cuff inflated -> assist ventilation -> volume control
• 2-Anesthesia: Inhaled anesthetic or TIVA initiated
• 1-Access: Post-induction lines
• 3-Antibiotics (within 60 minutes before incision)
• 3-Antiemetics (dexamethasone 4-5mg for PONV prophylaxis)
• 3-Analgesia (peri-incision)
• Bite block (if 180 degrees or prone)
• Bair hugger (turned on after drapes go up)
• Confirm surgeon orders (write checklist)
• Confirm PACU orders (analgesics, antiemetics)
• Draping with optimal patient visibility
• Drains placed (e.g. OGT, NGT)
• Eyes protected
• ETT protected
• Fluid lines patent (and not accidentally bolusing)
• Foley catheter patent (and accessible)
Intraoperative: Maintenance (2 Goals, MAC)
• Goal: Maintain surgical anesthesia and physiologic homeostasis
• Monitor
• Assess
• Chart
Intraoperative: Emergence during Closure (Timing with Anesthesia, Respiratory, Unnecessary Equipment)
• During Closure:
• Anesthesia: Start titrating down anesthetic
• During Fascia Closure: ~0.7 to 0.8 MAC with FGF low and inhaled anesthetic low (TIVA: ~80% of maintenance propofol or transition to inhaled anesthetic)
• During Skin Closure: ~0.5 to 0.6 MAC with FGF low and inhaled anesthetic off, (TIVA: ~40-60% of maintenance propofol or transition to inhaled anesthetic)
• Respiratory: Start preoxygenating and adjusting ventilation
• During Fascia Closure: Start preoxygenating patient
• During Skin Closure: Consider building up PaCO2 (~etCO2 45-50 in adults without respiratory comorbidities), pressure support ventilation (~10/5 to 5/5 before spontaneous ventilation), and NMBA reversal after bite block only if safe
• Equipment: Start removing unnecessary equipment (e.g. temperature probe, unused lines, eye protection only if safe)
Intraoperative: Emergence after Closure (SBP 4 Drugs)
• Suction (while deep usually)
• Bite block (before NMBA reversal)
• Position and preoxygenate for optimal respiratory mechanics
• 4 Drugs
• Anesthesia: Off (e.g. ~0 MAC with FGF high and inhaled anesthetic off, ~0% of case propofol or inhaled anesthetic off)
• Paralysis: 2 mg/kg sugammadex if 2 or more twitches (4 mg/kg sugammadex if 0-1 twitches)
• Analgesia: 0.2-0.6 mg dilaudid, up to 1000 mg acetaminophen, 15-30mg toradol if surgeon agreeable, etc. (titrated to ~10-20 respiratory rate with spontaneous ventilation)
• Antiemetic: 4 mg ondansetron +/- 0.625 mg droperidol

Monitored Anesthesia Care. Definition?

• Monitored anesthesia care (MAC) "does not describe the continuum of depth of sedation, rather it describes 'a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure.' Indications for monitored anesthesia care include 'the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic).'" (ASA) Why? Answer. How? Answer.
• "We all know that with a propofol total intravenous anesthetic (TIVA) we can adjust the rate of infusion to go from light sedation to total general anesthesia. In fact, in our experience, when a proceduralist requests “MAC anesthesia,” they are virtually always requesting a propofol general anesthetic (GA) without an endotracheal intubation." ... "The fault with the nomenclature lies with us and the specialty. The introduction of propofol into clinical use greatly expanded the quality and the spectrum of MAC, but we have ended up victims of our own success. We are clinically able to almost always administer a “room air general anesthetic” when anyone asks for a MAC. And we have perpetuated the falsehood that a general anesthetic without intubation and inhalational agent use is MAC." (APSF)
Preoperative: Basic Room Setup? (EMS MAIDS)
• Emergency
• Ambubag
• Machine
• Machine system/leak test
• E-cylinder pressures
• Suction
• Suction catheter attached
• Monitors
• Pulse oximeter
• ETCO2 sampling line
• NIBP
• EKG Leads
• +/- Temperature probe
• +/- BIS or sedline
• Airway
• Simple facemask with EtCO2 attachment
• Oral airway
• Tape for tube and eyes
• Mask for breathing circuit
• (Backup) SGA with lubricating gel
• (Backup) Intubating blade and handle
• (Backup) ETT, stylet, and 10cc syringe
• IV access and fluids
• IV kit (tourniquet, tegaderm, gauze, alcohol, needles, saline flush primed tubing)
• IV fluids (as bolus line or as carrier attached to manifold)
• Drugs
• Induction: Lidocaine (~1 mg/kg)
• Induction: Propofol (~0.5-1 mg/kg)
• Induction: +/- Fentanyl
• Maintenance: Propofol (~100 mcg/kg/min, range 30-150 mcg/kg/min)
• Maintenance (Early): Antibiotic
• Maintenance (Late): Ondansetron (4 mg)
• Maintenance (Late): Analgesics

• regional anesthesia

phases of care

Preoperative Management

• Answer. Why? Answer. How? Answer.
Sub-Question
• Sub-Answer

Intraoperative Management

• Answer. Why? Answer. How? Answer.
Sub-Question
• Sub-Answer

Postoperative

• Answer. Why? Answer. How? Answer.
Sub-Question
• Sub-Answer

types of surgeries

• open surgeries
• minimally invasive surgeries
• laparoscopic surgery
• robot-assisted surgery

neurosurgery

Craniotomy

• "A craniotomy is a surgical procedure in which a part of the skull is temporarily removed to expose the brain and perform an intracranial procedure." ... "The bone flap is temporarily removed, held at the surgical instrument table, and then placed back after the brain surgery has concluded." (StatPearls)
• "If the bone flap is discarded or not placed back into the skull during the same operation, the procedure is called a craniectomy." (StatPearls)
Room Setup? (1 monitor, 1 med to avoid, 2 infusions)
• GETA
• Special Considerations
• (Monitors) Arterial line. Why? Answer. How? Answer. (Link to arterial line procedure)
• (Drugs) If MEP neuromonitoring, avoid long-acting NMBAs and inhaled anesthetics above 0.5 MAC. (UCSF) Why? Answer. How? Generally, TIVA with propofol and remifentanil is an viable alternative.
• (Drugs) If EMG neuromonitoring, avoid long-acting NMBAs and inhaled anesthetics above 0.5 MAC. Why? Answer. How? Answer.
• (Drugs) If SSEP neuromonitoring, avoid inhaled anesthetics above 0.5 MAC. Why? Answer. How? Answer.
Key Events
• Pinning
Contingencies (BP Parameters)
• Generally, SBP below 140 and MAP above 65. How? Propofol boluses (~10-50mg), increasing inhaled anesthetic concentration, nitroglycerin boluses (~50-100mcg)

Laser interstitial thermal therapy (LITT)

• Answer. Why? Answer. How? Answer.
Sub-Question
• Sub-Answer

Complex spinal fusion

• Preoperative (normal consent + POCD if >65 years old + prone blindness considerations + nerve compression)
Room Setup?
• GETA
• Special Considerations
• Monitor: BIS or sedline
• Monitor: Arterial line kit with pressure transducer
• +/- Monitor: Central line kit with CVP transducer
• Airway: Accordion extender for ETT
• +/- IV Access: Rapid infusion catheter kit
• IV Fluids: Fluids connected to hotline
• IV Fluids: Fluid carrier connected to manifold
• Drugs: Propofol infusion (if SSEPs, avoid inhaled anesthetics)
• Drugs: Remifentanil infusion (if MEPs, avoid paralytics)
• Drugs: Tranexaminc acid infusion
• +/- Drugs: Phenylephrine infusion
Key Events
• If prone positioning onto Jackson table, make sure bite block is in
• If performing MEPs, make sure bite block is in
Contingencies (BP Parameters, Electromechanical dissociation)
• Generally, MAP above 85.

orthopedic surgery

Total hip arthroplasty

• Case explained in general terms. Why? Answer. How? Answer.
Room setup?
• GETA or Spinal
• Special Considerations
• Medications (Preop): Tylenol PO
• Medications (Preop): Scopolamine patch (if no CI and under age 70)
• Medications (Preop): Famotidine IV
• Medications (Preop): Vancomycin (over 60 minutes, started before incision)
• Medications (Intraop): Cefazolin (started before incision)
• Medications (Intraop): Tranexaminic acid (at the start and end of the case)
• Medications (Intraop): 20-30mL/kg (IBW) crystalloid
• Medications (Intraop): Dexamethasone 0.1 mg/kg (up to 10mg)
• Medications (Intraop): Ondansetron 4mg
• Medications (Intraop): Ketorolac 15mg (unless Cr >1.4 AND older than 65 OR has a diagnosis of renal insufficiency)
• Medications (Intraop): 20-30mL/kg (IBW) crystalloid
• Special: Spinal
• Special: Adductor canal block
Key Events
• Chronological key events. Why? Answer. How? Answer.
Contingencies
• Common complication. Why? Answer. How? Answer.

Total knee arthroplasty

• Case explained in general terms. Why? Answer. How? Answer.
Room setup?
• GETA or Spinal + Adductor Canal Block
• Special Considerations
• Medications (Preop): Tylenol PO
• Medications (Preop): Scopolamine patch (if no CI and under age 70)
• Medications (Preop): Famotidine IV
• Medications (Preop): Vancomycin (over 60 minutes, started before incision)
• Medications (Intraop): Cefazolin (started before incision)
• Medications (Intraop): Tranexaminic acid (at the start and end of the case)
• Medications (Intraop): 20-30mL/kg (IBW) crystalloid
• Medications (Intraop): Dexamethasone 0.1 mg/kg (up to 10mg)
• Medications (Intraop): Ondansetron 4mg
• Medications (Intraop): Ketorolac 15mg (unless Cr >1.4 AND older than 65 OR has a diagnosis of renal insufficiency)
• Medications (Intraop): 20-30mL/kg (IBW) crystalloid
• Special: Spinal
• Special: Adductor canal block
Key Events
• Chronological key events. Why? Answer. How? Answer.
Contingencies
• Common complication. Why? Answer. How? Answer.

transplant surgery

Liver transplant

• 3 Phase Surgery.
Room setup?
• GETA RSI
• Special Considerations
• (Machine) Isoflurane anesthetic
• (Suction) 18Fr NG tube
• (Monitors) Arterial line
• (Monitors) MAC Cordis 2-lumen with introducer port
• (Monitors) PA Catheter
• (Monitors) TEE machine and probe
• (IV) Ultrasound for lines
• (IV) 75mL/hr basic carrier with 6-8gang manifold
• (IV) Hotline for bolus line
• (Drugs, Induction) Propofol
• (Drugs, Induction) Rocuronium
• (Drugs, Emergency) Norepinephrine 8mcg/mL
• (Drugs, Emergency) Vasopressin 1U/mL
• (Drugs, Emergency) Epinephrine 100mcg/mL
• (Drugs, Emergency) Epinephrine 10mcg/mL
• (Drugs, Emergency) Calcium chloride 2000mg
• (Drugs, Emergency) Nitroglycerin x1
• (Drugs, Infusion) Norepinephrine, programmed
• (Drugs, Infusion) Vasopressin, programmed
• (Drugs, Infusion) Insulin, programmed
• (Drugs, Infusion) Epinephrine
• (Drugs, Infusion) Sodium bicarbonate (precipitates with calcium)
• (Drugs, Infusion) Calcium chloride 5000mg
• (Drugs, Infusion) Fentanyl 250mcg
• (Drugs, Transplant) Solumedrol
• (Drugs, Transplant) Unasyn
• (Special) Primed thermacor
• (Special) Blood bank liver transplant tier with 12 pRBC and 12 FFP
• (Special) Cardiac output ice bucket
• +/- hyponatremia precautions (discuss d5w, 1/2ns with attending)
• +/- dialysis orders by attending
• +/- perfusionist orders by attending
Key Events
• Preanhepatic Phase (Dissection)
• Hepatectomy often drains large volume of ascites -> albumin or blood products (to maintain preload in a low to normal range)
• Bleeding during the preanhepatic phase is related moreso to the severity of portal HTN and surgical complexity than pre-existing coagulopathy
• "Maintaining a low preload is associated with a reduced portal pressure which lessens dissection-related bleeding."
• Coagulopathy -> platelets or cryoprecipitate
• Worsening acidosis, hyperkalemia, ionized hypocalcemia (treat with CaCl), glucose management (avoid BG >180 mg/dL due to increased surgical site infections), and sodium management (avoid rapid corrections)
• Cross-clamping can decreased venous return by as much as 50%
• Bicaval Clamp: Significant drop in preload -> Consider VVB (diverts IVC and portal venous flow to the SVC), volume loading prior to clamp (but keep in mind volume returns after unclamping), augment BP in anticipation of drop
• “Piggyback” Sidebiter Clamp: Preload and IVC flow preserved with less swings after unclamping
• Anhepatic Phase
• Liver functions cease -> acidosis, coagulopathy, hypovolemia, hyperkalemia
• Blood loss is usually limited by cross-clamping
• Neohepatic Phase
• Reperfusion: Returns preload and cold, acidotic blood with K+ load and vasoactive peptides -> bradycardia, decreased inotropy, profound vasodilation
• Postreperfusion Syndrome (PRS): Systemic hypotension and pulmonary hypertension within the first 5 minutes after reperfusion
• HyperK: CaCl, insulin, glucose, HCO3
• Coagulopathy: FFP, factors
• Acidosis: worsened
• Hypovolemia: fluids, pressors
• Chronotropic support: epi, atropine
• Inotropic support: NE, epi
• Vasodilatory support: NE, vaso
• "Fibrinolysis, most severe after reperfusion, is caused by abrupt increased in TPA from graft endothelial cell release. Antifibrinolytic drugs (TXA, aminocaproic acid) and cryoprecipitate may be needed."
• Liver functions resumes synthesis and clearance -> signs of graft function:
• Calcium homeostasis normalizes -> stop CaCl infusion (unless continued RBC transfusion)
• Acid clearance -> improving base deficit
• Gluconeogenesis -> start insulin infusion
• Ongoing coagulopathy -> correct PRN
• Rise in core temperature
• Increased urine output in some patients
• ABG every 30-60 minutes
Contingencies
• Common complication. Why? Answer. How? Answer.

obgyn surgery

Hysterectomy

• Case explained in general terms. Why? Answer. How? Answer.
Room setup?
• GETA/GA LMA/MAC
• Special Considerations
• Monitor: BIS or sedline
Key Events
• Lithotomy positioning Why? Answer. How? Answer.
Contingencies
• Common complication. Why? Answer. How? Answer.

cardiovascular

Ischemic Heart Disease. Risk stratification guidelines?

• AHA/ACC Guidelines (AHA, 2014)
Generally, what should you optimize (1) and minimize (1) in patients with IHD to prevent myocardial ischemia?
• Optimize myocardial oxygen supply. Why? Answer. How? Answer.
• Minimize myocardial oxygen demand. Why? Answer.
• "A common recommendation is to keep the heart rate and blood pressure within 20% of the normal awake value for that patient." (Stoelting, 8e, p105)
What are some intraoperative examples of factors that decrease myocardial oxygen supply? (HR, BP, CO2, O2, Hgb)
• Tachycardia. Why? "Decreases diastolic time for coronary blood flow and therefore oxygen delivery" (Stoelting, 8e, p105)
• Hypotension. Why? Answer.
• Hypocapnia. Why? "Coronary artery vasoconstriction" (Stoelting, 8e, p105)
• Decreased oxygen content. Why? Answer.
• Anemia. Why? Answer.
What are some intraoperative examples of factors that increase myocardial oxygen demand? (2 CV, 2 Pulm, 1 Heme)
• Sympathetic stimulation. Why? Answer.
• Tachycardia. Why? Answer.
• Hypertension. Why? Answer.
• Increased myocardial contractility. Why? Answer.
• Increased afterload. Why? "In specific patient populations, primarily hypovolemic patients with cardiac dysfunction, phenylephrine can increase afterload more so than preload, causing decreased cardiac output and potentially an exacerbation of angina, heart failure, and pulmonary hypertension." (Statpearls, Int J Cardiol)
• Increased preload. Why? Answer.

Mitral Regurgitation. General goals? (HR, Preload, Afterload)

• "Fast, Full, Forward" Why? ("SAM is an important exception to this rule")
How should you manage heart rate for MR?
• Maintain HR between normal and high. Why? "Bradycardia must be avoided" ... "as slower heart rates will increase LVEDV, increase RF, and decrease forward CO"
How should you manage preload for MR?
• Maintain volume status as euvolemic. Why? "Hypovolemia is poorly tolerated because preload is essential for adequate forward flow" and "excessive fluid administration may dilate both the LV and mitral annulus and worsen the degree of MR"
How should you manage afterload for MR?
• Maintain afterload. Why? Answer.
How should you manage contractility for MR?
• Maintain contractility. Why? Answer.

pulmonary

OSA

pHTN