Search Results

There’s Nothing Here... We can’t find the page you’re looking for. Check the URL, or head back home. Go Home

There’s Nothing Here... We can’t find the page you’re looking for. Check the URL, or head back home. Go Home

There’s Nothing Here... We can’t find the page you’re looking for. Check the URL, or head back home. Go Home

There’s Nothing Here... We can’t find the page you’re looking for. Check the URL, or head back home. Go Home

There’s Nothing Here... We can’t find the page you’re looking for. Check the URL, or head back home. Go Home

BRONCHOSCOPY ​ Bronchoscopy is a medical procedure that involves the examination of the respiratory system, including the trachea, bronchi, and lower airways, using a thin, flexible tube called a bronchoscope. This tube is equipped with a light and a small camera at its tip, which allows the doctor to visualize the airways and diagnose various respiratory conditions. ​ There are two types of bronchoscopy: ​ Flexible bronchoscopy: This is the most common type, where a flexible, fiberoptic bronchoscope is inserted through the patient's nose or mouth and passed down the throat to reach the airways. It is generally well-tolerated and requires only local anesthesia or moderate sedation. Rigid bronchoscopy: In this type, a rigid metal tube is used instead of a flexible bronchoscope. It is less commonly performed, typically in cases where a larger airway opening is needed or when removing foreign objects, tumors, or large amounts of secretions. This procedure often requires general anesthesia. ​ The flexible scope allows more peripheral subdivisions to be inspected than a rigid scope. The disadvantage of the flexible scope is that foreign objects or thick mucus cannot be removed through the lumen. Bronchoscopy can be performed for various purposes, including: Diagnosing respiratory conditions, such as infections, tumors, or airway blockages. Collecting samples of lung tissue or fluids for laboratory analysis (biopsies or bronchoalveolar lavage). Treating airway problems, such as removing foreign objects, controlling bleeding, or dilating narrowed airways with stents. Assessing the extent of lung damage or disease, such as in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease. ​ Anesthetic Implications for Bronchoscopy ​ Anesthesia type: General, topical local anesthesia, total intravenous anesthetic (TIVA), MAC, regional anesthesia ​ Airway: Endotracheal tube (> 8.0 tube) or LMA ​​ Preoperative: ​ ​ Glycopyrrolate (antisialagogue) can be administered to decrease airway/oral secretions Albuterol can be administered for wheezing Consider LTA lidocaine and dexamethasone administration Rigid bronchoscopy is preferred when airway patency is important Suctioning ability is better with a rigid scope Higher risk of damage to soft tissue with rigid scope Tooth guard can be placed to protected teeth from scope Spontaneous ventilation can be maintained when using a flexible bronchoscope Special attention should be given to the patient’s pulmonary function High incidence of COPD and respiratory disease in this population Patients may have limited cardiac and pulmonary function Have bronchoscopy adapter to connect to ETT or LMA General anesthetic with paralysis is the preferred MAC and LMA associated with risk of laryngospasm and bronchospasm Be prepare to intervene if rapid oxygen desaturation and airway obstruction occur Regional anesthesia via a superior laryngeal nerve block (blocks cough reflex) Presence of stridor may alert to the potential narrowing in the upper airway ​ Intraoperative: ​ Position: The head of the table may be turned away at least 90 to 180 degrees Laser may be used for the removal of tracheal papillomas Prevent airway fire by using fire-resistant ETT and keeping FiO2 as low as possible Avoid using nitrous oxide with laser, as this gas is highly combustible Leaking of gases can occur around bronchoscope Maintain our patients on 100% oxygen due to the possibility of inadequate ventilation and frequent leaks Duration 10-30 minutes EBL minimal ​ Postoperative: Pain management Observation for complications Respiratory care ​ Complications: ​ Bleeding Bronchospasm Laryngospasm Airway fire Sore throat Infection Pneumothorax Hypoxia Arrhythmias Damage to teeth or airways Laryngeal edema Airway obstruction Risk of local anesthetic systemic toxicity (LAST) Barotrauma Inadequate anesthetic level and awareness Inadequate ventilation Air emboli Aspiration pneumonia ​ ​ Sources: ​ Galway U, Zura A, Khanna S, Wang M, Turan A, Ruetzler K. Anesthetic considerations for bronchoscopic procedures: a narrative review based on the Cleveland Clinic experience. J Thorac Dis 2019;11(7):3156-3170. doi: 10.21037/jtd.2019.07.29 ​ Lentini C, Granlund B. Anesthetic Considerations For Bronchoscopic Procedures. [Updated 2022 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips CTSNetVideo Mastering Bronchoscopy 1 CTSNetVideo Mastering Bronchoscopy 2 CTSNetVideo Mastering Bronchoscopy 3 Child Talks Flexible Bronchoscopy Prof&Head Ram Nandan Prasad Rigid Bronchoscopy Kristin Bronchial Tree

GASTROSTOMY TUBE INSERTION ​ A gastrostomy tube (G-tube) insertion is a surgical procedure performed to provide a means of feeding and administering medications to patients who cannot take food or drink through the mouth. This procedure involves creating a direct access point into the stomach, bypassing the mouth and esophagus. ​ PEG stands for percutaneous endoscopic gastrostomy. Anesthetic Implications for Gastrostomy Tube Insertion ​ Anesthesia type: General, TIVA, MAC, local anesthesia ​ Airway: ETT ​​ Preoperative: ​ ​ The procedure is aided by endoscopy Antibiotic is administered Prevent corneal drying or abrasions by taping the eyes Patients may be hypovolemic due to poor oral intake Patients may be malnourished and have electrolyte imbalances A bite block is placed into the patient’s mouth ​ Intraoperative: ​ Risk of aspiration Gastroscope is passed into the stomach The stomach is insufflated Duration: 15-30 minutes Position: Supine with arms to sides EBL: Minimal ​ Postoperative: ​ PONV prophylaxis Pain management ​ Complications: ​ Infection Bleeding Blockage of the tube Dislodgement of the tube Damage to surrounding organs Aspiration pneumonia VTE ​ Sources: ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Nucleus Medical Media PEG Tube SAGES The Perfect PEG GastroCenter PEG Tube Insertion

BREAST RECONSTRUCTION ​ Breast reconstruction is a surgical procedure that aims to restore the shape, size, and appearance of one or both breasts following a mastectomy (complete removal of the breast), lumpectomy (partial removal of the breast), or congenital deformities. The goal of breast reconstruction is to help improve the patient's quality of life and self-esteem after breast cancer treatment or other breast-related surgeries. ​ There are several methods of breast reconstruction, and the most suitable option depends on the individual's needs, preferences, and medical history. The main types of breast reconstruction include: ​ Implant-based reconstruction: This method involves the use of saline or silicone-filled implants to recreate the breast mound. A tissue expander may be placed under the chest muscle to stretch the skin and create space for the implant. Once the desired size is reached, the expander is replaced with a permanent implant in a separate surgery. Autologous tissue reconstruction: Also known as flap reconstruction, this method uses tissue (skin, fat, and sometimes muscle) from other parts of the patient's body, such as the abdomen, back, or thighs, to create a new breast mound. Common flap techniques include the TRAM flap (transverse rectus abdominis myocutaneous flap), DIEP flap (deep inferior epigastric perforator flap), and latissimus dorsi flap. Combined reconstruction: This approach involves using both an implant and a flap of the patient's tissue to reconstruct the breast. This can provide additional coverage and support for the implant. Fat grafting: In some cases, fat can be harvested from other parts of the patient's body, purified, and then injected into the breast area to add volume and shape. ​ Breast reconstruction can be performed immediately after a mastectomy (immediate reconstruction) or at a later time, after the patient has healed and completed additional cancer treatments (delayed reconstruction). Some women may also choose not to undergo breast reconstruction and instead opt for a prosthesis or embrace their new appearance. ​ Anesthetic Implications for Breast Reconstruction ​ Anesthesia type: General ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Doxorubicin chemotherapy can cause cardiomyopathies Bleomycin carries the risk of pulmonary toxicity Avoid FiO2 > 30% in bleomycin patients Methotrexate can produce renal and hepatic dysfunction Tamofixfen can cause N/V and dehydration Check for anemia and thrombocytopenia after chemotherapy The blood pressure cuff and the peripheral IV should be placed on the nonoperative-side arm Ensure arm abduction is <90° to prevent brachial plexus injury Placed EKG leads away from the sterile field Patient anxiety associated with breast cancer and altered body image Larger tumors, lymph node involvement, and the lack of estrogen and progesterone receptors are associated with worse prognosis Smokers are advised to stop smoking for at least 4 weeks before surgery Smoking complications: Nicotine-induced vasoconstriction, carbon monoxide-induced tissue hypoxia, and hypercoagulability from increased platelet aggregation The duration of surgery may be > 8 hours ​ Intraoperative: ​ ​ Position: The patient is placed in the lateral decubitus position for latissimus dorsi myocutaneous (LDM) flap harvest, then supine. Position: For tissue expanders/implants, the patient may have to be placed in the sitting position during the procedure Maintain a stable blood pressure (MAP 70 mm Hg) for perfusion of the flap tissue A Doppler may be used to check for flap pulses Keep patient warm and hydrated for flap perfusion (minimize peripheral vasoconstriction) Hypothermia may impair flap perfusion It is preferred to maintain a stable BP with volume replacement Careful use of vasopressors IV fluorescein dye may be used to determine the viability of the flap with breast reconstruction Skin fluorescence correlates with flap survival Duration: Tissue expander 1-2 hours, latissimus dorsi flap 4 hours + mastectomy time, TRAM flap 4-8 hours + mastectomy time EBL minimal to 500 mL Primary ischemia of the flap occurs as blood flow ceases during flap transfer Reperfusionphase in free flap surgery begins with vessel declamping after completion of microvascular anastomosis Ischemia/reperfusion injury may occur Overzealous fluid administration can result in interstitial edema Avoid hypovolemia, vasoconstriction, and hypothermia to prevent flap compromise Hypocapnia will also lead to vasoconstriction Hypercapnia can cause sympathetic nervous system stimulation A hyperdynamic circulation (high cardiac output, peripheral vasodilation, and large pulse pressure) is the ideal to maintain adequate microcirculatory perfusion During the dissection stages of surgery, controlled hypotension can be requested ​ Postoperative: ​ Smooth emergence Pain management PONV prophylaxis Higher incidence of flap loss in obese, smokers, and diabetics ​ Complications: ​ PONV Flap loss Seroma Infection Pneumothorax Hematoma Injury to axillary neurovascular structures Psychological trauma Venous thromboembolism ​ Sources: ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ N Nimalan, BSc MBBS FRCA, O Alexandre Branford, BA (Hons) MA (Cantab) MBBS (Lon) PhD (Lon) MRCS (Eng) FRCS (Plast), G Stocks, BSc MB BS FRCA, Anaesthesia for free flap breast reconstruction, BJA Education, Volume 16, Issue 5, May 2016, Pages 162–166, https://doi.org/10.1093/bjaed/mkv036 ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Johns Hopkins Medicine Tissue Expander for Staged Breast Reconstruction Asan Medical Center TRAM Flap Breast Reconstruction North Bristol NHS Trust LD Plastic Surgery Breast Reconstruction

ARTHROSCOPY- SHOULDER ​ Shoulder arthroscopy is a minimally invasive surgical procedure used to examine, diagnose, and treat various conditions within the shoulder joint. An arthroscope, a small camera attached to a thin, flexible tube, is inserted through a small incision in the skin, allowing the surgeon to visualize the joint and surrounding structures on a monitor. This procedure is performed under general or regional anesthesia, depending on the patient and the specific condition being treated. ​ The recovery process after shoulder arthroscopy varies depending on the specific procedure performed and the patient's individual condition. Generally, patients can expect to wear a sling for a few weeks, followed by a gradual return to normal activities. Physical therapy is often recommended to help restore strength, flexibility, and range of motion. ​ Some common reasons for shoulder arthroscopy include: ​ Rotator cuff repair: Tears in the rotator cuff can be repaired using arthroscopic techniques, which are less invasive and have shorter recovery times compared to open surgery. Labral repair: The labrum is a ring of cartilage that surrounds the shoulder socket, providing stability to the joint. Labral tears can cause pain and instability and can be repaired using arthroscopy. Bone spur removal: Bone spurs, or osteophytes, can develop around the shoulder joint and cause pain and inflammation. They can be removed arthroscopically. Debridement: This involves the removal of damaged tissue, such as loose cartilage or inflamed synovium, to alleviate pain and improve joint function. Frozen shoulder (adhesive capsulitis) treatment: In some cases, arthroscopy can be used to release tight or scarred joint capsule tissue, improving shoulder mobility. Stabilization: For patients with shoulder instability or recurrent dislocations, arthroscopic surgery can be used to tighten or repair damaged ligaments. Anesthetic Implications for Shoulder Arthroscopy ​ Anesthesia type: General ETT, LMA, or peripheral nerve block ​ Airway: Endotracheal tube or LMA ​ Preoperative: ​ Patients may have osteoarthritis or rheumatoid arthritis Shoulder conditions may result from either arthritis or trauma Arthritic patients may have pleural effusion or pulmonary fibrosis Arthritic patients may have valvular heart disease and cardiac conduction defects Arthritic patients may have cervical or lumbar radiculopathies Arthritic patients may have limited neck and jaw range of motion Rheumatoid arthritis can be associated with cervical nerve root compression and/or atlantooccipital instability Check neck X-ray for subluxation of the cervical spine Shoulder dislocations can be accompanied by axillary nerve palsy Combined regional-general anesthetic techniques are commonly used An interscalene block is commonly performed Assess the quality of the block by asking the patient to lift the arm Place IVs and the blood pressure cuff on the nonoperative arm During positioning, careful attention during the stabilization of the patient's head It may be difficult to access the patient's face after the drapes are up. Tape ETT securely ​ ​ Intraoperative: ​ Interscaleene block may be associated with phrenic nerve palsy and ipsilateral hemidiaphragmatic paresis Postural hypotension is a common complication of the sitting position Position: beach-chair position or lateral decubitus position is used The bed is positioned 45-90 degrees away from the anesthetist Keep MAP within 20% of the patient's baseline The blood pressure (BP) measured in the arm will be higher than the BP in the brain Beach chair position may decrease cerebral perfusion Hydrostatic gradient: There is a 0.77 mmHg decrease for every centimeter gradient (1 mmHg for each 1.25 cm change in height between heart and head) Duration: 1-3 hours EBL: 50-100 ml The Bezold-Jarisch reflex (profound bradycardia and hypotension) may be activated during shoulder surgery in the beach-chair position Postoperative: ​ Multimodal analgesia Patients should remain anesthetized until the shoulder is immobilized (sling placement) Pain following shoulder surgery may be severe Interscalene brachial plexus block may be used to reduce postoperative pain ​ Complications: ​ Infection Bleeding Nerve or blood vessel damage Venous air embolism (VAE) Stroke Hypotension ​​ ​ Sources: ​ Christina L. Beecroft, FRCA, FDS RCS, David M. Coventry, FRCA, Anaesthesia for shoulder surgery, Continuing Education in Anaesthesia Critical Care & Pain, Volume 8, Issue 6, December 2008, Pages 193–198, https://doi.org/10.1093/bjaceaccp/mkn040 ​ David J. Cullen, MD; Robert R. Kirby, MD. Beach chair position may decrease cerebral perfusion. Anesthesia Patient Safety Foundation. Retrieved from https:// www.apsf.org/article/beach-chair-position-may-decrease-cerebral-perfusion/ ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Randale Sechrest Shoulder Anatomy Animated Pocket Pimped: Orthopedic Surgery The Basics of Shoulder Arthroscopy The Noted Anatomist Brachial Plexus University of Kentucky Orthopedics & Anesthesia NUSGRA Ultrasound guided interscalene NYSORA INTERSCALENE BLOCK: DON'T DO THIS!

EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) ​ Extracorporeal Shockwave Lithotripsy (ESWL) is a non-invasive procedure used to treat kidney stones and gallstones. The term "extracorporeal" means "outside the body," while "lithotripsy" is derived from the Greek words "lithos" meaning stone and "tripsis" meaning crushing. Therefore, ESWL literally means crushing stones outside the body. Here's how the procedure works: ​ Imaging: Before the procedure begins, the patient will undergo imaging tests, such as an ultrasound or a CT scan, to locate the stones. Shockwave Generation: Once the stones are located, a machine called a lithotripter generates shockwaves. The patient lies on a cushion through which the shockwaves are directed. Shockwave Delivery: The shockwaves travel through the body, reaching the stones without damaging the surrounding tissues. These high-energy shockwaves break the stones into tiny pieces, roughly the size of grains of sand. Stone Elimination: The small stone fragments are then naturally eliminated from the body through urine over the course of a few weeks. ​ Absolute contraindications: Pregnancy, bleeding disorder, anticoagulation ​ Relative contraindications: Large calcified aorta, renal artery aneurysm, untreated UTI, pacemaker/AICD, morbid obesity ​ After the procedure, patients may experience blood in the urine or pain as the small stone fragments are passed. In some cases, multiple ESWL sessions may be required to effectively break down larger or stubborn stones. ​ Anesthetic Implications for ESWL ​ Anesthesia type: General, TIVA, MAC ​ Airway: LMA ​​ Preoperative: ​ ​ You will need a lead apron due to the use of X-rays to localize stones During ESWL, repetitive high-energy shocks (sound waves) are used and focused on the stone Renal insufficiency may be present if there is an obstruction Patients with a history of cardiac arrhythmias and patients with a pacemaker or internal cardiac defibrillator (ICD) may be at risk for developing arrhythmias If the patient has a pacemaker, programmability should be established prior to treatment AICD/defibrillator may misinterpret shock waves as an arrhythmia and inappropriately deliver a shock Pacemakers may "sense" shock waves and inhibit or trigger activity. ​ Intraoperative: ​ The surgeon may place a stent prior to pulverizing the stones Decreased tidal volumes and increased respiratory rates are better for treatment efficacy Minimizing patient movement and respiratory excursion increase efficiency of stone damage Position: Supine, one arm extended. Sometimes prone Duration: 30-60 minutes The shock wave can cause dysrhythmias (R on T phenomenon) Shock waves can potentially trigger ventricular arrhythmias when they coincide with the repolarization period of the cardiac cycle Pain and discomfort are caused due to impact through cutaneous tissue and viscera ​ Postoperative: ​ Pain management PONV prophylaxis ​ Complications: ​ Hematuria Dysrhythmias PONV Adjacent Tissue/Organ Injury Infection ​ Sources: ​ Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed. ​ Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. ​ Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips European Association of Urology ESWL Khanacademymedicine Kidney function and anatomy | Renal system Dr. Matt & Dr. Mike Renal System - Overview