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TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) Transcatheter Aortic Valve Replacement (TAVR) , also known as Transcatheter Aortic Valve Implantation (TAVI), is a minimally invasive surgical procedure that replaces a diseased aortic valve in the heart. This procedure is typically used for patients who are at intermediate or high risk for traditional open-heart surgery. Here's an overview of TAVR: ​ Procedure: TAVR involves inserting a catheter (a thin, flexible tube) into the patient's blood vessel, usually through a small incision in the leg. The catheter is then guided to the heart, and a replacement valve is positioned inside the diseased aortic valve. Once in place, the new valve is expanded, pushing the old valve leaflets out of the way and taking over the regulation of blood flow. Valve Types: The replacement valves used in TAVR are typically made from biological materials, such as cow or pig heart tissue, and are mounted on a collapsible metal frame. Candidates: TAVR is often recommended for patients who have severe aortic stenosis (a narrowing of the aortic valve opening) and are considered at increased risk for traditional surgery due to factors like age, other medical conditions, or previous heart surgeries. Advantages: The main advantage of TAVR is its minimally invasive nature, which generally results in shorter hospital stays, faster recovery times, and lower risks of complications compared to open-heart surgery. ​ TAVR represents a significant advancement in the treatment of heart valve diseases, especially for those patients for whom traditional surgery is not a viable option. Minimally invasive transcatheter aortic valve replacement (TAVR) may involve either a percutaneous (transfemoral or transaxillary/ subclavian) approach or an open (transapical or transaortic) approach . ​ ​ Anesthetic Implications for Transcatheter Aortic Valve Replacement (TAVR) ​ Anesthesia type: General, Monitored Anesthesia Care (MAC) ​ Airway: ETT, natural airway ​​ Preoperative: ​ ​ Assess for acute decompensated heart failure, pulmonary hypertension, CAD, OSA, pulmonary edema Assess ECG and Echocardiography Low left ventricular EF is a risk factor for persistent hypotension after rapid pacing TAVR is guided by angiography and fluoroscopy Left arterial line placement preferred Have heparin and protamine available ​​ Intraoperative: ​ The aortic valve is retrogradely accessed via one of the femoral arteries Position: Supine, arms tucked Duration: 1-3 hours Venous access is obtained for transvenous pacing Rapid pacing will be induced during TAVR deployment Rapid ventricular pacing minimizes heart movement during implantation of device Watch for hypotension during induced fibrillation ​ Postoperative: ​ Assess for vascular complications associated with femoral access including hematoma, retroperitoneal bleeding, and arterial occlusion Clinical findings of retroperitoneal bleeding include back, flank, or abdominal pain; hypotension, decreased H/H, and tachycardia. ​​ Complications: ​ Bleeding Hypotension Arrhythmia Vascular injury Stroke Emboli Pericardial effusion/tamponade Complete heart block MI Aortic dissection Contrast-induced nephropathy Perivalvular leaks Pneumothorax Acute coronary obstruction Retroperitoneal hematoma Femoral artery dissection Femoral seroma ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ 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 Essentia Health Transcatheter Aortic Valve Replacement (TAVR) Nucleus Medical Media Transcatheter Aortic Valve Replacement (TAVR) University of Kentucky High Yield Cardiac Keywords

AMPUTATION - ABOVE AND BELOW THE KNEE (AKA & BKA) ​ Below-the-knee amputation (BKA), also known as transtibial amputation, is a surgical procedure in which the lower leg is removed due to various reasons, such as trauma, infection, severe peripheral vascular disease, or cancer. The goal of the procedure is to remove the affected part of the limb and create a healthy residual limb that can be fitted with a prosthetic. ​ Above-the-knee amputation (AKA), also known as transfemoral amputation, is a surgical procedure that involves the removal of the lower limb above the knee joint. ​ Anesthetic Implications for AKA & BKA ​ Anesthesia type: General ETT or LMA, peripheral nerve block or neuraxial anesthesia ​ Airway: Endotracheal tube or LMA ​​ Preoperative: ​ Common significant coexisting diseases include diabetes, peripheral vascular, and cardiovascular disease. Diabetic patients may have peripheral and autonomic neuropathy​ ​ Limb ischemia can result in myoglobinemia due to rhabdomyolysis Regional anesthesia from T12 (T8 with tourniquet) is adequate Long-standing insulin-dependent diabetics may be difficult airways Diabetic patients with coronary artery disease are at high risk for perioperative myocardial ischemia ​ Intraoperative: ​ Tourniquet may be used Maximum safe tourniquet time is less than 2 hours Tourniquet deflation and limb reperfusion Reperfusion can cause the release of toxic metabolic byproducts and inflammatory mediators ​Position: Supine with arms out EBL: Expect 100-300 ml ​ Postoperative: ​ ​ Multimodal analgesia. Epidural placement can help with phantom pain postoperatively. A fibers transmit pain described as “sharp” C fibers are not myelinated and pain may be described as “dull” or “aching” ​ Complications: ​ Phantom pain Stump pain Central sensitization Femoral/sciatic nerve damage Infection Hematoma Deep vein thrombosis ​​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. 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 The University of Kentucky Anesthesia Diabetes Basics The University of Kentucky Anesthesia Renal Basics AltoseAnesthesia ESRD

POSTERIOR CERVICAL FUSION Posterior cervical fusion is a type of spinal surgery that aims to relieve pain and instability in the cervical spine (the neck region). This procedure is typically considered when other treatments, such as physical therapy or medications, have failed to provide relief. The main reasons for undergoing this surgery include conditions like spinal stenosis, cervical degenerative disc disease, fractures, tumors, or instability caused by rheumatoid arthritis. ​ Here's an overview of the procedure and its implications: ​ Objective: The primary goal is to stabilize the cervical spine by fusing two or more vertebrae together. This is done to eliminate the motion between these vertebrae, which can reduce pain and stabilize the spine. Procedure: Approach: As the name suggests, the surgery is performed from the back (posterior) of the neck. Bone Grafts: The surgeon places bone graft material between the vertebrae. This material can be sourced from the patient’s own body (autograft), a donor (allograft), or synthetic materials. Hardware: Metal plates, screws, and rods may be used to hold the vertebrae together while the bone graft heals and fuses the vertebrae. Anesthetic Implications for Posterior C ervical Fusion ​ Anesthesia type: General anesthesia with ETT. Partial or total intravenous anesthesia (TIVA) to optimize neuromonitoring ​ Airway: ETT ​​ Preoperative: ​ ​ Baseline neurologic assessment of sensory and motor function Assess cervical range of motion Patients may be difficult to intubate due to the inability to place in the sniffing position Intubate with the head in the neutral position Log rolling patient: Maintain cervical neutrality while moving patient to prone position Consider having a video laryngoscope or fiberoptic bronchoscopy Bed may be turned 180 degrees Spinal cord trauma may be associated with loss of sympathetic tone, which can cause peripheral vasodilation and bradycardia Fractures above C5 may result in quadriplegia and loss of phrenic nerve function Manipulation of the head and neck could produce permanent injury Patients are often on chronic pain medications Find out if the surgeon wants the patient relaxed by neuromuscular blockers Shared airway with surgeon ​​ Intraoperative: ​ ​ Neurologic monitoring may be used during the cervical fusion ​Somatosensory evoked potentials (SSEPs) monitoring may be used. SSEPs assess the integrity of the posterior spinal cord Volatile anesthetics over 0.5 MAC decrease amplitude and increase the latency of SSEP waveforms (false positive) Motor evoked potentials (MEPs) monitoring may be used. MEPs assess the integrity of the anterior spinal artery MEPs are affected by neuromuscular blocking agents The bispectral index (BIS) monitor can be used Tongue lacerations from MEPs can occur. Apply tongue protection Duration: 1-4 hours Position: Prone, arms tucked EBL 50-500 ml Fluoroscopy or portable X-ray is used Controlled hypotension may be requested to reduce bleeding ​ The overall aim is to keep patients euvolemic, while avoiding excessive fluid administration ​ Postoperative: ​ Extubation/emergence: Avoid coughing and bucking Perform neurologic exam Cervical collar may be utilized to allow bone graft healing ​​ Complications: ​ Acute spinal cord injury Infection Bleeding Quadriplegia Myelopathy Nerve injury​ Airway edema Chronic pain Thrombophlebitis Nonunion of the cervical vertebrae Venous air embolism Dural tear Bone graft migration ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ Khanna P, Sarkar S, Garg B. Anesthetic considerations in spine surgery: What orthopaedic surgeon should know! J Clin Orthop Trauma. 2020 Sep-Oct;11(5):742-748. doi: 10.1016/j.jcot.2020.05.005. Epub 2020 May 11. PMID: 32879562; PMCID: PMC7452283. ​ 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 NuVasiveInc PCF Patient Animation Armaghani Spine Posterior Cervical Laminectomy and Fusion Seattle Science Foundation Posterior Cervical Spine Fixation

ANTERIOR CRUCIATE LIGAMENT (ACL) REPAIR ​ Anterior cruciate ligament (ACL) repair is a surgical procedure to reconstruct or repair a torn ACL in the knee. The ACL is one of the four main ligaments in the knee that connects the femur (thigh bone) to the tibia (shin bone), providing stability and allowing for proper knee movement. ACL injuries are common in athletes and can occur due to sudden changes in direction, awkward landings, or direct contact to the knee. ​ The cruciate ligaments support the knee anteriorly and posteriorly The collateral ligaments support the knee medially and laterally ​ There are 4 types of grafts:: ​ Autografts: from the patient's own body Allografts : from cadavers Xenografts : from animals Synthetics (high rate of complications) ​ Postoperative care and rehabilitation are crucial for a successful recovery. Patients typically participate in physical therapy, starting with gentle range-of-motion exercises and gradually progressing to strength training and sport-specific exercises. The rehabilitation process can take anywhere from six months to a year or more, depending on the individual and the extent of the injury. ​ Anesthetic Implications for ACL repair ​ Anesthesia type: General ETT or LMA, peripheral nerve block or neuraxial anesthesia ( spinal or epidural with IV sedation) ​ Airway: Endotracheal tube or LMA ​​ Preoperative: ​ ​ ​ Trauma is the most common cause of knee ligament tears Trauma patients with sports injuries are often young and healthy Osteoarthritis and rheumatoid arthritis can also cause tears. Regional is associated with decreased blood loss, decreased risk of DVT, minimal respiratory impairment, and effective postop analgesia. ​​ Intraoperative: ​ ACL repair is commonly done arthroscopically Tourniquet is used Tourniquet is usually set 100 mm Hg above the patient’s systolic blood pressure Maximum safe tourniquet time is less than 2 hours to prevent injury Chart the tourniquet time and location MAP commonly drops by approximately 20% after tourniquet deflation ​Position: Supine with arms out EBL: Expect 50-200 ml The femoral nerve block does not cover the posterior portion of the knee The sciatic nerve block covers the posterior portion of the knee Ketorolac (Toradol) provides analgesic and antiinflammatory properties by inhibiting prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase (early component of arachidonic acid cascade) NSAIDs have been shown to decrease bone formation in spine fusions and rotator cuff surgery ​ Postoperative: ​Maintain knee immobilization with a knee immobilizer Femoral nerve block (FNB) is an effective analgesic technique for ACL reconstruction; however, it weakens the quadriceps muscle. The adductor canal block (ACB) is a distal block of the femoral nerve that preserves the strength of the quadriceps femoris muscle ​ Complications: ​ Embolus Bleeding Infection Thrombophlebitis Tourniquet-related nerve injury​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia . 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.). ​ ​ ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Therapia Physiotherapy ACL Reconstruction Surgery BertramZarinsMD ACL Reconstruction Animation University of Kentucky Lower Extremity Nerve Blocks

ENDOVASCULAR ANEURYSM REPAIR (EVAR) ​ Endovascular Aneurysm Repair (EVAR) is a minimally invasive surgical procedure used to treat an abdominal aortic aneurysm (AAA), a bulging or weakened area in the wall of the aorta, the largest artery in the body. AAA is a potentially life-threatening condition, as the aneurysm can rupture and lead to severe internal bleeding and possibly death. ​ EVAR is performed using a stent-graft, which is a specialized tube made of fabric and metal mesh. The procedure involves the following steps: ​ Preparation: The patient is given general or regional anesthesia to ensure comfort during the procedure. The surgeon may also administer antibiotics to reduce the risk of infection. Access: The surgeon gains access to the arterial system by making small incisions in the groin area. Through these incisions, catheters (thin, flexible tubes) are inserted into the femoral arteries on both sides. Imaging: Using X-ray guidance and contrast dye, the surgeon navigates the catheters through the patient's arterial system and positions them near the aneurysm. Deployment of the stent-graft: The stent-graft is compressed and loaded onto a delivery device, which is then inserted through the catheter. Once the stent-graft is properly positioned within the aorta, it is expanded to fit snugly against the walls of the artery, effectively creating a new path for blood flow and bypassing the aneurysm. Verification: The surgeon verifies the correct positioning and functioning of the stent-graft using imaging techniques. This ensures that the aneurysm is excluded from blood circulation and reduces the risk of rupture. Closure: Once the stent-graft is in place, the catheters are removed, and the incisions in the groin are closed with sutures or staples. ​ EVAR offers several advantages over traditional open surgical repair, including shorter recovery time, reduced pain and blood loss, and a lower risk of complications. However, it may not be suitable for all patients, particularly those with complex aneurysms or other medical conditions that increase the risk of complications. Regular follow-up appointments and imaging studies are necessary to monitor the stent-graft and ensure the long-term success of the repair. ​ An abdominal aortic aneurysm (AAA) is a localized, abnormal enlargement or bulging of the abdominal aorta, which is the largest artery in the body. The aorta is responsible for carrying oxygenated blood from the heart to the rest of the body. In the case of an AAA, the weakened section of the aortic wall becomes prone to rupture or dissection, potentially causing life-threatening internal bleeding. Anesthetic Implications for EVAR ​ Anesthesia type: General, regional, local infiltration with sedation. ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ Identify high-risk patients for preoperative optimization Risk factors of abdominal aortic aneurysm (AAA): increasing age, male gender, smoking, elevated plasma cholesterol levels, hypertension, and family history Patients are vasculopathic Assume patients have disease of cerebral, cardiac, renal, and peripheral vasculature Smoking is the greatest risk factor The patient population undergoing EVAR have multiple underlying comorbidities Surgical repair of a AAA is recommended once the aneurysm expands to more than 5 cm Advances in endovascular procedures have made AAA repair less invasive EVAR should be conducted in a specialized radiology suite The surgeon does not have to cross-clamp the aorta Major advantages of EVAR vs open repair: less blood loss, fewer transfusions, less hemodynamic perturbations, no cross-clamp of the aorta, fewer overall complications, faster ambulation, shorter hospital stay Arterial line should be placed contralateral to the upper limb surgical access Large bore venous access should be placed Consider central venous access for longer procedures 5-lead electrocardiogram (monitor for ST changes) Evoked potentials monitoring may be requested for high-risk of spinal cord ischemia (SCI) patients Have access to rapid infusion devices Have IV fluid warmers and blood transfusion tubing available Patients are commonly on antiplatelet medications Bladder catheterization is indicated to monitor urine output Prep from nipples to knees in case it converts to open repair ​​ ​ Intraoperative: ​ An endograft is placed in the lumen of the aorta at the level of the aneurysm The device is advanced and deployed via the femoral arteries Endograft position is assessed under fluoroscopy Provide hemodynamic stability, perfusion to vital organs, avoid imbalance in myocardial oxygen supply and demand, maintain intravascular volume, maintain normothermia and manage bleeding Be prepared for open repair and massive bleeding Heparinization and activated clotting time (ACT) checks 3 min after heparin and every 30 min thereafter Minimizing renal impairment: adequate hydration, limiting contrast, avoidance of nephrotoxic drugs Deployment of the stent graft within the aorta is normally pain free The artery of Adamkiewicz (supplies the anterior spinal arteries and perfuses the anterior third of the spinal cord) is at risk from occlusion with stent grafts that extend suprarenally​ Spinal drains have been shown to be beneficial in the prevention and reversal of SCI Stent deployment takes case during apnea (hold ventilation) Stent deployment can result in transient ischemia distal to the graft Muscle relaxation is indicated Position: Supine with arms tucked EBL: Minimal Marked hypotension may indicate a retroperitoneal bleed or intra-abdominal bleeding ​ Postoperative: ​ Perform neurologic exam EVAR reduces the time spent in the intensive care unit Heparin reversal with protamine might be required at the end of the procedure Intensive care unit admission No flexion at the groin for several hours after removal of arterial sheath Regular lower limb arterial assessment Pain is usually minimal Postimplantation syndrome: pyrexia, leukocytosis and elevated inflammatory markers. Manifests as sepsis but without evidence of infection. Avoid hypertension on emergence Avoid coughing and bucking on emergence Hospital stay is 2-3 days ​​ ​ Complications: ​ Cardiac complications are the most common Endoleak Spinal cord ischemia (SCI) Arterial rupture/arterial dissection Aneurysm rupture Damage to the femoral arteries Graft migration Infection Paralysis Venous thromboembolism Bowel ischemia Renal artery occlusion from stenting Stroke Arrhythmia Acute renal failure Acute coronary syndromes Postimplantation syndrome Reaction to contrast media Postoperative delirium in the elderly ​ 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.). ​ Kothandan H, Haw Chieh GL, Khan SA, Karthekeyan RB, Sharad SS. Anesthetic considerations for endovascular abdominal aortic aneurysm repair. Ann Card Anaesth. 2016 Jan-Mar;19(1):132-41. doi: 10.4103/0971-9784.173029. PMID: 26750684; PMCID: PMC4900395. ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ V Nataraj, MD FRCA, AJ Mortimer, BSc MD FRCA, Endovascular abdominal aortic aneurysm repair, Continuing Education in Anaesthesia Critical Care & Pain, Volume 4, Issue 3, June 2004, Pages 91–94, https://doi.org/10.1093/bjaceaccp/mkh025 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​​ Back to Surgical Tips NEJM Deployment of an Endovascular Graft Vanguard Vascular & Vein The EVAR procedure Houston Methodist Hospital Endovascular Repair (EVAR) Anatomy Knowledge Anatomy - Abdominal Aorta Branches Dr.G Bhanu Prakash Abdominal aorta Kenhub Abdominal Aorta - Branches and Anatomy

VENTRAL HERNIA REPAIR Ventral hernia repair is a surgical procedure used to correct ventral hernias. Ventral hernias are a type of abdominal wall hernia where tissue, usually intestine, protrudes through a weak spot in the abdominal muscles. These hernias can occur at any location on the abdominal wall but are most common along the midline. ​ The goals of ventral hernia repair are to return the herniated tissues to their proper place, strengthen the weakened area of the abdominal wall, and reduce the risk of hernia recurrence. This repair can be done using different surgical techniques, which are generally categorized into two main types: open repair and minimally invasive repair. ​ Open Repair: This traditional method involves making a large incision over the hernia site. The surgeon then pushes the protruding tissue back into place and repairs the weakened area. This is often reinforced with surgical mesh to provide additional support. Minimally Invasive Repair: This approach, which includes laparoscopic and robotic surgeries, involves making several small incisions through which surgical instruments and a camera are inserted. The surgeon performs the repair guided by the video from the camera. This method typically results in less pain and a quicker recovery compared to open repair. Anesthetic Implications for Ventral Hernia Repair ​ Anesthesia type: General, regional anesthesia ​ Airway: ETT ​​ Preoperative: ​ ​ The procedure can be performed as open or laparoscopic approach The patient’s peritoneum is insufflated OG tube to suction out stomach prior to insufflation Paralytics are used Pneumoperitoneum effects: decreased in functional residual capacity (FRC), increased systemic vascular resistance (SVR), decreased venous return, decreased renal blood flow, increased risk of regurgitation and aspiration of gastric content TAP block can be considered for large/open procedures ​​ Intraoperative: ​ Position: supine, arms out Traction on the viscera can cause vagal stimulation and bradycardia Mesh is used to help close and supplement large umbilical hernias ​ Postoperative: ​ PONV prophylaxis Pain management Avoid coughing and straining on emergence ​​ Complications: ​ Urinary retention Infection Hernia recurrence Nerve damage Hemorrhage Organ damage Subcutaneous emphysema from pneumoperitoneum Bowel obstruction Bladder injury Postoperative ileus seroma DVT ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ 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 Amerra Medical Ventral Hernia Repair California Hernia Specialists Laparoscopic Ventral Hernia Repair with Mesh Forever Learning PHYSIOLOGIC CHANGES IN LAPAROSCOPIC SURGERY

TOTAL HIP ARTHROPLASTY (THA) Total Hip Arthroplasty (THA) , commonly known as total hip replacement, is a surgical procedure to replace a damaged or worn hip joint with an artificial joint (prosthesis). This procedure is typically performed to relieve pain and improve mobility in patients who have not responded well to other treatments. Here's an overview: ​ Indications for Surgery: THA is commonly indicated for conditions like osteoarthritis, rheumatoid arthritis, avascular necrosis, and fractures or injuries of the hip. It's considered when other treatments, such as medication, physical therapy, or less invasive surgical procedures, have failed to provide adequate pain relief and improved joint function. Surgical Procedure: The surgery involves removing the damaged head of the femur (thighbone) and replacing it with a metal or ceramic ball. The damaged part of the hip socket (acetabulum) is also removed and replaced with a metal socket, and a plastic, ceramic, or metal spacer is placed between the new ball and the socket to allow for smooth movement. Surgical Approaches: There are different surgical approaches for THA, such as the posterior approach, anterior approach, and lateral approach. The choice of approach depends on the surgeon's experience and preference, the patient's anatomy, and specific health conditions. Longevity of the Implants: Modern hip implants are designed to last for many years. Most patients can expect their hip replacement to last for 15 to 20 years or more. ​ THA restores movement and relieves pain Anesthetic Implications for Total Hip Arthroplasty (THA) ​ Anesthesia type: General, regional anesthesia ​ Airway: ETT ​​ Preoperative: ​ ​ Osteoarthritis is the most common indication for hip arthroplasty. Patients are usually elderly Consider preemptive analgesia Rheumatoid arthritis: assess for atlanto-occipital instability, valvular pathology, pericardial effusion Preoperative hemoglobin and type and screen Tranexamic acid may be administered prior to incision and at closure ​​ Intraoperative: ​ Position: Supine for anterior approach, lateral decubitus for lateral or posterior approaches In lateral position, patient will be positioned in bean bag and/or kidney rest Duration: 2-3 hours EBL :250-1000 cc Maintain normothermia Induced hypotension minimizes blood loss Polymethylmethacrylate (PMMA) is used for the cement The proximal femur is trimmed and the medullary canal reamed to accept the prosthesis ​ Postoperative: ​ PONV prophylaxis Multimodal analgesia ​​ Complications: ​ Fat embolism Air embolism Thromboembolism Pulmonary embolism Bone marrow embolism Hip dislocation Infection Deep vein thrombosis Femoral/sciatic nerve injury Vascular injury to ileac vessels Bleeding Risk for bone cement implantation syndrome (BCIS) ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ 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 The Visual Surgery Total Hip Replacement (Surgery) Radlink, Inc. Anterior Hip Replacement University of Kentucky Orthopedic Anesthesia

TOTAL KNEE ARTHROPLASTY (TKA) Total Knee Arthroplasty (TKA) , also known as total knee replacement, is a surgical procedure to replace a knee damaged by arthritis or injury. The main goals of TKA are to relieve pain, improve mobility, and restore the function of the knee joint. Here's a brief overview: ​ Indications for Surgery: TKA is typically considered when non-surgical treatments (like medication, physical therapy, or injections) have failed to relieve symptoms of severe arthritis or knee injury. Common conditions leading to TKA include osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis. Surgical Procedure: During the surgery, the damaged cartilage and bone are removed from the surface of the knee joint and replaced with artificial components. These components are usually made of metal and plastic. The metal parts replicate the surface of the joint, and a plastic spacer is placed between them to ensure smooth movement. Longevity of Implants: Modern knee implants can last for many years. It's estimated that around 90% of modern implants still function well 15 years after surgery. ​ TKA restores movement and relieves pain. Anesthetic Implications for Total Knee Arthroplasty (TKA) ​ Anesthesia type: General, neuraxial, regional, TIVA, IV sedatio n ​ Airway: LMA or ETT ​​ Preoperative: ​ ​ DVT prophylaxis If rheumatoid arthritis patients, special focus on airway and cervical spine evaluation Routine antibiotic prophylaxis should be administered prior to tourniquet inflation and incision Blocking the saphenous nerve at the femoral level results in weakness of the quadriceps femoris and inability to extend the knee Adductor Canal Block: involves injecting anesthetic into the adductor canal of the thigh. It primarily blocks the saphenous nerve, providing effective analgesia to the knee while sparing motor function, which is beneficial for early mobilization ​Tranexamic acid may be administered prior to incision and/or at closure ​​ Intraoperative: ​ Position: Supine, with arms extended on armboards Duration: 1 to 3 hours Embolism can occur at any time during surgery Transesophageal echocardiogram (TEE) detects embolism A thigh tourniquet may be used The tourniquet should be released after 2 hours to prevent injury Tourniquets reduce blood loss and provide a bloodless operating field Polymethylmethacrylate (PMMA) is used for the cement The prosthesis is bonded to the femoral and tibial bones with methylmethacrylate​ A dressing is applied and covered with an Ace wrap A knee binder may be wrapped around the leg ​ Postoperative: ​ Pain management Regional analgesia An injection of ropivacaine, epinephrine, clonidine and ketorolac (R.E.C.K) is used as part of a multimodal pain regimen Be mindful of the effects of tourniquet deflation (↓ MAP and SVR, ↑ Venous capacitance, ↓ CO, acidosis, hypoxemia/hypoxia, ↑ CO2 production, embolism) TKA is associated with a significant incidence of surgically induced peroneal nerve injury (causes foot drop) ​​ Complications: ​ Deep vein thrombosis Pulmonary embolism Hemodynamic instability Bleeding Hypoxia Peroneal nerve injury Infection Urinary retention ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ 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.). ​ Rodriguez-Patarroyo FA, Cuello N, Molloy R, Krebs V, Turan A, Piuzzi NS. A guide to regional analgesia for Total Knee Arthroplasty. EFORT Open Rev. 2021 Dec 10;6(12):1181-1192. doi: 10.1302/2058-5241.6.210045. PMID: 35839095; PMCID: PMC8693230. ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ Turnbull ZA, Sastow D, Giambrone GP, Tedore T. Anesthesia for the patient undergoing total knee replacement: current status and future prospects. Local Reg Anesth. 2017 Mar 8;10:1-7. doi: 10.2147/LRA.S101373. PMID: 28331362; PMCID: PMC5349500. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Dr. Anand Jadhav Total Knee Replacement (TKR) - Animation Prof. Dr. J. Bellemans Total Knee Replacement Surgery by Knee Expert University of Kentucky Orthopedics & Anesthesia

INFERIOR VENA CAVA (IVC) FILTER INSERTION ​ ​ An Inferior Vena Cava (IVC) filter is a small, cone-shaped device that is implanted in the inferior vena cava (the large vein that carries blood from the lower half of the body back to the heart) to prevent blood clots from traveling from the legs or pelvis to the lungs, where they could cause a pulmonary embolism, a potentially life- threatening condition. The insertion procedure of an IVC filter typically goes as follows: ​ Preparation: The patient is usually placed on a table in a procedure room and given local anesthesia or a mild sedative, depending on the patient's condition and the doctor's judgment. Access: A small incision is made in the skin, often in the neck or groin area. Using ultrasound or fluoroscopy (real-time X-ray imaging), the doctor guides a catheter (a thin, flexible tube) into the inferior vena cava. Placement: The IVC filter, which is attached to the end of a catheter, is then threaded up to the correct location in the vena cava. The filter is designed to expand and fit snugly against the walls of the vena cava once in position. Completion: The catheter is withdrawn, leaving the filter in place. The small incision in the skin is closed with stitches if needed. Post-procedure care: After the procedure, patients are observed for a period of time for any immediate complications. Further instructions regarding activity restrictions, potential symptoms, or necessary follow-up imaging will be given before discharge. ​ IVC filters can be temporary or permanent, depending on the patient's condition and risk of blood clots. Temporary (or retrievable) filters can be removed once the risk of clotting has decreased. ​ Anesthetic Implications for IVC Filter Insertion ​ Anesthesia type: General, local anesthesia, and sedation (MAC) ​ Airway: LMA or ETT ​​ Preoperative: ​ ​ Fluoroscopy/Xray is used for this procedure Lead aprons and thyroid shields should be available The filter is placed endovascularly Can be inserted into the right femoral vein, arm vein, or internal jugular vein Assess patient's coagulation status ​ Intraoperative: ​ ​ Position: Supine, arms tucked Duration: 30-60 minutes ​ Postoperative: ​ Pain management PONV prophylaxis ​ Complications: ​ IVC thrombosis Filter migration Vena cava obstruction Vascular complications S ources: ​ 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 Trial Exhibits Surgical Placement of Inferior Vena Cava Filter to Prevent DVT Methodist Hospital Inferior Vena Cava (IVC) Filter Placement Dr. Cellini IVC Filters - Everything You Need To Know

FEMORAL ARTERY ENDARTERECTOMY ​ Femoral artery endarterectomy is a surgical procedure used to remove atherosclerotic plaque material, or blockage, from the femoral artery. The femoral artery, one of the major arteries of the leg, can become blocked due to peripheral artery disease (PAD), often as a result of atherosclerosis. Here is a general description of the procedure: ​ Incision: The surgeon makes an incision in the groin to expose the femoral artery. Clamping: The femoral artery is clamped above and below the blockage to prevent blood flow during the procedure. Arteriotomy: The surgeon makes an incision (arteriotomy) directly into the artery at the site of the blockage. Endarterectomy: The surgeon carefully removes the plaque from the artery using special surgical instruments. Artery Repair: After the plaque has been removed, the artery is repaired. This can be done by sewing it directly or by using a patch graft (using a piece of another vein or synthetic material). Flow Restoration: The clamps are removed, restoring blood flow through the artery. Closure: The surgeon closes the incision. ​ Anesthetic Implications for Femoral Artery Endarterectomy ​ Anesthesia type: General, regional ​ Airway: Endotracheal tube ​​ Preoperative: ​ ​ Patients normally have significant peripheral arterial disease (PAD) Patients may have multiple comorbidities such as diabetes, coronary artery, renal, or respiratory disease Poor exercise tolerance (<4 METS) is associated with an increase in perioperative myocardial ischaemia and cardiac events Diabetic control must be optimized before surgery An arterial line is required for frequent ACT draws and blood pressure management Have heparin and protamine available Protamine use may result in an unwanted allergic-type reaction Urinary catheter inserted to monitor urine output The “five P’s” of acute peripheral vascular disease (PVD) symptoms are pain, paralysis, paresthesia, pulselessness, and pallor Type and cross-match the patient preoperatively Consider having blood units available Coronary artery disease (CAD) is the leading cause of perioperative mortality during vascular surgery Maintain cardiovascular stability during induction, laryngoscopy, intubation and extubation ​ Intraoperative: ​ Position: Supine with arms tucked Muscle relaxation is usually required Tachycardia should be avoided perioperatively as it increases myocardial oxygen demand while decreasing myocardial perfusion Maintain blood pressure within 20% of the patient's baseline Heparin is administered before the clamping of arteries Reperfusion of an ischaemic limb after a prolonged period of clamping may cause transient hypotension Maintaining normothermia is crucial Hypothermia causes vasoconstriction Shivering increases oxygen requirements Aggressively replace blood loss with crystalloids, colloids, and blood products as needed Maintain oxygenation and ventilation guided by blood gas analysis Intraoperative glucose control Hyperglycemia can cause hypovolemia, electrolyte abnormalities, and increased surgical site infections ​ Postoperative: ​ Avoid hypertension with emergence as it may challenge the new graft and incision Pain management Monitor metabolic disturbances ​ Complications: ​ Groin hematoma Bleeding Stroke Cardiorespiratory complications Washout of free radicals Pseudoaneurysm Compartment syndrome Reperfusion injury following revascularization (hyperkalaemia, cardiac arrhythmias, myoglobinuria) ​ 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.). ​ K Fraser, MB ChB FRCA , I Raju, MB BS FRCA, Anaesthesia for lower limb revascularization surgery, BJA Education, Volume 15, Issue 5, October 2015, Pages 225–230, https://doi.org/10.1093/bjaceaccp/mku042 ​ Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult. ​ ​ ​ ​ ​​ ​​ Back to Surgical Tips Calin Calabrese Vascular Anesthesia Considerations Methodist Hospital Common Femoral Endarterectomy About Medicine Femoral Artery - Anatomy & Branches Anatomy Knowledge Femoral Artery and its branches IR Education Peripheral Arterial Disease The Crawford Clinic Common Femoral Endarterectomy

UTE RE ROSCOPY Ureteroscopy is a medical procedure used to diagnose and treat problems in the urinary tract, specifically in the ureters and kidneys. The ureters are the tubes that carry urine from the kidneys to the bladder. Here's an overview of what ureteroscopy involves: ​ Procedure Type: Ureteroscopy is a minimally invasive procedure. It involves the use of a ureteroscope, which is a long, thin, flexible or rigid tube equipped with a light and camera at its tip. Diagnosis and Treatment: It is commonly used for diagnosing and treating kidney stones. The ureteroscope allows the doctor to see the stones directly and then remove them or break them into smaller pieces that can pass out of the body in urine. Additionally, it can be used for diagnosing abnormal growths, strictures (narrowing of the ureter), and for taking biopsies of suspicious areas. Procedure Process: During the procedure, the ureteroscope is inserted through the urethra and bladder and then into the ureter and possibly the kidney. No incisions are made in the skin. This procedure is often done under general anesthesia, although local or spinal anesthesia may be used in some cases. Through a cystoscope, the bladder (cystoscopy), urethra (urethroscopy), and ureteral orifices (ureteroscopy) can be visualized. ​ In a retrograde pyelogram, contrast is injected into the ureter so that the ureter and kidney can be visualized under fluoroscopy. ​ Anesthetic Implications for Ureteroscopy ​ Anesthesia type: General, regional anesthesia, sedation, local anesthesia ​ Airway: ETT or LMA ​​ Preoperative: ​ ​ Ureteroscopy is used to evaluate the upper urinary tract, including the ureter, renal pelvis, and kidneys If neuraxial anesthesia is done, a T6 or a T10 level is necessary for upper tract and lower tract instrumentation Autonomic hyperreflexia can occur in individuals who have sustained a prior spinal cord injury (especially injuries at T6 and above) Autonomic hyperreflexia is associated with severe hypertension, bradycardia, and arrhythmias A cystoscopy is commonly done ​​ Intraoperative: ​ Position: lithotomy Duration: 30-90 minutes Often simple and brief Minimal surgical stimulation if diagnostic More complex procedures involve tumor resection, ureteral dilatation, stenting, or stone extraction Lithotomy position: decreases functional residual capacity, increases venous return, increases mean arterial pressure, and can cause neuropathies or neuropraxia If lasers are used to break the stone, eye protection for staff and the patient may be required After the stone is fragmented and removed, a stent is often placed to prevent obstruction from ureteral edema or fragments ​ Postoperative: ​ Pain management ​​ Complications: ​ Ureteral perforation Pyelonephritis Infection Formation of scar tissue in ureter Bleeding Injury to adjacent organs ​ ​ Sources: ​ Elisha, S. (2010). Case Studies in Nurse Anesthesia. ​ 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 Cleveland Clinic Ureteroscopy Medscape Flexible Ureteroscopy and Laser Dusting Ninja Nerd Renal | Kidney Anatomy Model

ARTERIOVENOUS ACCESS FOR HEMODIALYSIS ​ ​​ Arteriovenous access for hemodialysis is typically created through surgical procedures such as AV fistulas or AV grafts. ​ Arteriovenous (AV) access for hemodialysis is a crucial component of treatment for patients with end-stage renal disease (ESRD) or chronic kidney disease (CKD). Hemodialysis involves filtering the patient's blood through a dialysis machine to remove waste products, excess fluids, and electrolytes when the kidneys are no longer able to function effectively. To facilitate this, an AV access is created to allow for easy, repetitive, and efficient blood flow between the patient and the dialysis machine There are two common types of AV access created through surgical procedures: arteriovenous fistulas (AVF) and arteriovenous grafts (AVG). Arteriovenous Fistula (AVF): An AV fistula is considered the gold standard for hemodialysis access due to its lower risk of complications and longer-lasting patency compared to other access types. The procedure involves surgically connecting a patient's own artery and vein, usually in the arm. Over time, the vein becomes larger and stronger, allowing for easy insertion of dialysis needles and efficient blood flow during hemodialysis sessions. It usually takes several weeks to months for the fistula to mature and become usable for hemodialysis. Arteriovenous Graft (AVG): An AV graft is an alternative option for patients who have poor quality veins or other factors that make AV fistula creation challenging. In this procedure, a synthetic tube (usually made of polytetrafluoroethylene or PTFE) is surgically implanted to connect an artery and a vein, creating a bridge for blood flow. The graft can be placed in various locations, such as the arm or the thigh, depending on the patient's vascular anatomy and needs. AV grafts can be used for hemodialysis sooner than AV fistulas, often within 2-3 weeks after surgery. However, they generally have a higher risk of complications, such as infection and clotting, and a shorter overall lifespan compared to AV fistulas. ​ The choice between an AV fistula and an AV graft depends on the patient's individual circumstances, including their vascular anatomy, overall health, and other factors. A vascular surgeon, in consultation with a nephrologist and the patient, will determine the most appropriate type of AV access. It is essential to monitor and maintain the patency of the AV access regularly to ensure efficient and safe hemodialysis treatments. ​ Anesthetic Implications for A rteriovenous Access for Hemodialysis ​ Anesthesia type: General or regional/local/MAC ​ Airway: ETT/LMA if general anesthesia ​​ Preoperative: ​ Assess volume status and electrolyte imbalance​ Assess for chronic anemia and platelet dysfunction The patient may have uremia and diabetic neuropathy (peripheral and autonomic) Check potassium level ​ Check date of the last dialysis Patients may be hypervolemic, hyperkalemic or volume-depleted Hypoventilation can worsen hyperkalemia Succinylcholine use is normally appropriate if potassium is < 5.5 mEq/L Pulmonary edema may be present from fluid overload Uremic patients may have defective aortic and carotid body reflex arcs Patients can adjust to chronic anemia through increased cardiac output and increased 2,3-DPG levels Uremic patients are prone to developing GI bleeding Renal failure decreases gastric emptying, making the patient susceptible to aspiration Hyponatremia is common in ESRD Metabolic acidosis and increased 2,3-DPG shift the oxyhemoglobin curve to the right Avoid IV placement on the operative site. Avoid blood pressure cuff on operative arm IV placement may be difficult in this population ​ Intraoperative: Use caution with rocuronium as its metabolism is partially renal cleared Sugammadex-rocuronium complexes are renally cleared Cisatracurium undergoes organ-independent Hofmann elimination—a chemical process dependent on pH and temperature Minimize IV fluids due to ESRD Position: Supine with surgical limb abducted Avoid administration of NSAIDs Avoid morphine due to its metabolites (really cleared) Surgical time 1-2 hours EBL minimal (10-50 ml) Treatment of hyperkalemia includes: Insulin and glucose, albuterol, sodium bicarbonate, and calcium chloride/gluconate Calcium chloride/gluconate stabilizes cardiomyocyte membranes Insulin and bicarbonate shift potassium intracellularly ​​ ​ Postoperative: Multimodal analgesia ​​ Complications: ​ ​​ Infection Thrombosis Bleeding/hematoma Aneurysm formation Arrhythmias Limb ischemia Nerve damage Vascular injury Pulmonary edema ​ 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 Kentucky University Anesthesia Anesthesia Renal Keyword Review Kentucky University Anesthesia Keyword Review: Renal Dysfunction Altose Anesthesia Renal Physiology and Anesthesia