Anesthesia for Special Situations

Cardiac Cath Lab (Peds) Radiology: CT-Guided Liver Ablation
ERCP in Xray Radiology: CT-Guided RF Lung Ablation
Intraperitoneal Hyperthermic ChemoRx (IPHC) Radiology: Porto-Systemic Shunts (TIPSS)
Orthopedics: Knees, Hips Radiology: Cerebral Embolization
Neurosurgery: "Awake" Craniotomy Radiology: Carotid Endovascular Stents UPDATED
ECT Room 17:  AAA Endovascular Stents  

ERCP in Xray:

Updated 8/28/2002- Tom VerLee, with input from KSP & RFl
 
Preop:

Patients can be seen In Hallway outside the Endoscopy Suite. They will be NPO for several hours, and ASU will usually start an IV. Blank paperwork is in bottom drawer of the anesthesia cart.

 Equipment and Supplies:

The Endo Suite contains a:

>  Bluebell cart,  fully stocked with drugs, propofol, a Bard infusion pump, tubing, airway equipment, and IV parts.
> Compact Narkomed anesthesia machine & ventilator.
> standard Hewlett-Packard full monitor setup.
> Pyxis drug dispenser; Versed and fentanyl are available for the asking.

Operative Management:

Most patients can be done with IV deep sedation/anesthesia and spontaneous ventilation.

A Suggested Approach:

1) Nasal prongs O2, with ETCO2 sampling
2) IV from ASU or you place for inpatients
3) Monitors: BP, SpO2, EKG
4) Let patient position themselves: prone or ¾ lateral, left arm at side, right arm up, head on small pad.
5) "Premed"= fentanyl 25-50 mcg (blunts gag reflex)
6) put Bite Block in before starting propofol
7) Propofol bolus (20-50 mg) & infusion: 75-150 mcg/kg/min
8) Intermittent glucagon boluses per operator request (decreases GI motility). They'll draw it up, you give it.
9) Occasional oral suction is necessary; they have dentist-office type suckers which work great.

Comments:

A. I have had 3 patients (elderly) that required neosynephrine infusions to maintain adequate Blood Pressure on a propofol infusion.

B. GE Reflux is not necessarily a contraindication to this technique. The prone position helps maintain a clear airway, and once the endoscope is in the stomach, it is decompressed. You could also argue that an endoscope in the stomach makes Everyone's sphincter incompetent.  

C. Some patients, esp. the obese, may obstruct their airways even in the prone position. I have used an LMA in these cases with success (placing it while the patient is prone). The gastroscope can easily be passed around the LMA by temporarily deflating the cuff, and then re-inflating.

Recovery:

Most patients wake up shortly after the propofol infusion stops, especially if they have received little-no Versed. They may then move themselves to the stretcher, and you can provide face mask O2 while you transport them to Radiology PACU. 

Other Info:

Endo Suite Phone No.: x3590
Endo Office Door Code: 2135
Endo Techs: Michelle, Caroline, Karen, Cindy, Stephanie
GI Endo Fellow 

 

Cardiac Cath Lab Sedation, Peds Suggestions

1. Ketamine + Midazolam

Bolus:
K 0.25-0.5 mg/kg IV
M 0.1-0.2 mg/kg IV

Infusion:
K 1 mg/kg/hr
M 0.1 mg/kg/hr

2. Propofol

po sedation with Midazolam (0.2-0.5 mg/kg po)

Bolus:
0.5 mg/kg every 60 sec until 2 mg/kg

Infusion:
100 - 150 mcg/kg/min

 

Radiology: Cerebral Embolization

      Go to Neuroradiology Page

Radiology: Carotid Artery Endovascular Stents UPDATED
(N. Boulanger 4/07, updated 8/10)


PreOp:
* Patient admitted through ASU as a Same Day Admit. Preop workup similar to that for CEA.
* Orderly brings patient to Angio suite (telephone 662-4541).
* One large bore IV w/ blood set (manifold is helpful)
* Bair Hugger may be needed due to cold environment.
* A-Line (side not important) at discretion of anesthesiologist.  Both arms tucked;  toboggans can be helpful.

* Pressor drips set up by CVATs (page 662-4800: 0722). CVAT will also bring down transducers and tubing, but will not set up unless instructed.

IntraOp Management:

* Very light sedation; nasal O2 cannula.
* Phenylephrine gtt- premixed bag and syringe (concentration 80 mcg/ml). Have ready in the room at beginning of case. Dopamine bag and tubing also immediately available.
* Heparinization by surgeon.
* They may request atropine just prior to stent deployment (prophylaxis for bradycardia).
* Dopamine drip sometimes necessary for bradycardia and /or pressure support; if required post-procedure, will require SCU bed (see Flowchart, below)

Carotid Stent Flowchart (pdf) NEW

Recovery:
* see Flowchart for disposition (above)

 

Endovascular (Intraluminal ) AAA Stents
M. Green/L. Mamchur (updated 10/09)

(For OPEN AAA Management, go to Cardiovascular Page)

PreOp
Same Day Patient (most common): admitted through ASU
Inpatient: brought to Holding Room. 

Preop workup similar to that for open AAA.
All patients should have a Type & Screen. 

Two large bore IV's for access (second line accessed post induction). 
Bicarb drip (to reduce incidence of contrast-nephropathy) would usually be started in preop and ordered by surgeon. Usual regimen:
     - 3cc/kg/hr for 1st hour prior to administration of contrast 
     - after the first hour decrease to 1cc/kg/hr for 6 hours. 
     - Mixed in D5, so follow Blood Glucose.

If Thoracic Stent planned, ask Surgeon about ?spinal drain catheter

Induction &  IntraOp

GA vs Regional:
Either is fine however, there will be times when the surgeon asks to have respirations halted thus if the patient is having a regional anesthetic they need to be awake enough to follow directions and be able to hold their breath. LMA's may be less than ideal if halted respirations are required. Patient will be anticoagulated.

Heat Loss: High potential-
     - Prewarm room, table, fluids
     - Fluid Warmer
     - Bair Hugger

Arterial Line: after induction unless indicated prior. Right arm preferred, in case Left brachial artery needed for angiography.

Central Line: usually not routine.

Vasoactive Drugs:
     - Phenylephrine should be set up in line and ready for use. 
     - Inotropes should be in the room – Dopa or Epi. 

Foley: to follow U/O, keep bladder decompressed.

Fluid Management:
Typically the patient will receive 2-3 liters of crystalloid in an effort to flush out the average 100 cc of IV contrast unless there is an indication to avoid fluid overload (ie. CHF, ESRD, etc).

EBL is usually <300 cc. There is potential for rapid blood loss, but this is unusual. Emergency Aortic Occlusion Balloon (supra-renal) buys time until conversion to open procedure. 

Duration: Case typically lasts 2-3 hours. 

Thoracic Stent: 
If a doing a thoracic stent graft, it is important to drop the BP during proximal deployment therefore clear communication with surgeon is very important.

Adenosine
Have ready in the room. Occasionally, surgeon may ask for adenosine to temporarily pause everything during thoracic device deployment. 

Post Op

Pain usually managed readily with fentanyl 2-4 mcg/kg intraop. 
Patients typically recover in PACU then go to Short Stay.


Cytoreductive Surgery (CS) &
Intraperitoneal Hyperthermic Chemotherapy (IPHC)

aka "Hot Chemo"

L. Rutstein & Sugarbaker 11/04

Indications:
certain GI Tract cancers and sarcomas with peritoneal carcinomatosis

Procedure synopsis:

1) Laparotomy, with complete removal of large tumor masses, and resection of all involved non-essential organs (e.g., omentum, spleen)
2) Two hour intraperitoneal perfusion with hyperthermic chemotherapy (42 deg C) (usually mitomycin C)
3) Closure and Treatment of subsequent metabolic acidemia

Specific Considerations:

Preop: Patients usually present with:

1) prior abdominal surgery
2) cachexia
3) anemia
4) ascites

-may have other significant system problems: renal, cardiac, pulmonary

IntraOp:
1) Long cases with significant Fluid shifts:
   -blood loss (moderate)
   -third space loss (essentially an intraperitoneal burn) (massive)
   -vasodilation due to heating

Hespan® (hetastarch) use controversial: some feel(1) it contributes significantly to coagulopathy
Suggest Coag Panel before hyperthermia induced, to evaluate & correct deficiencies


2) Systemic hyperthermia >39.5 C may be associated with seizure activity and Heat Stroke


3) Significant metabolic acidemia after hyperthermic perfusion

Suggested monitoring /lines:

-Esophageal Temperature
Arterial Line: for blood gases, hematocrits, 'lytes, coags
-Central Line: infusions, CVP; PA Cath only if cardiac status warrants
-Peripheral IV
-Urine Output*: monitor q 15' during hyperthermia
-Bair Hugger: ambient air only during hyperthermia (no heating)
-Availability of cranial ice packs & cold saline peritoneal lavage in the event of heat stroke syndrome
-Epidural:(thoracic) for PostOp analgesia

PostOp:

-Many patients require post-op ventilation for 2-18 hours
-Treatment of metabolic acidemia with NaHCO3
-Plan on Overnight in PACU minimum; SCU preferable

*All patient body fluids after chemotherapy should be considered contaminated for 48 hrs after chemotherapy. Be sure to empty urinemeter BEFORE the start of chemotherapy, as all subsequent urine must be considered a biohazard and disposed of properly.

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1 Stephens, White, Esquival, Stuart, Sugarbaker: www.surgicaloncology.com/hiicman.htm


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CT-guided Percutaneous RF Liver Ablation

July 05- Boulanger

Lisa Rutstein will do CT-guided percutaneous radiofrequency liver ablations in radiology, in conjunction with the radiologists, much like the AAA stents are now done.
Booked for either Wednesday or Friday mornings. Dr. Rutstein expects to do 2-3 a month.


Management:

  -An OR will be closed for the duration of the procedure as the OR team will be utilized for the case.
  -Most patients will be same day admissions, pre-op'd at Brighton beforehand.
  -Admitted through RADCU.
  -Some pts. fairly healthy with just one or two isolated liver mets; others may be sicker with full-blown cirrhosis, etc.
  -Workroom Techs will set up an anesthesia machine and blue bell cart in the room.
  -General Anesthesia; respirations held several times.
  -EBL is expected to be minimal.
  -E
xpected to last about 2 hours.
  -Recovered in PACU
 
Let me know if you have any questions about these procedures.

N. Boulanger


CT-guided Percutaneous RF Lung Ablation

Nancy Boulanger 9/18/2007 8:11 AM >>>

Tomorrow we'll be doing our first RFA lung case with Dr. Paul Harrod-Kim, the new interventional radiologist. 
They'll take place in the CT scanner near RADCU.
They are for patients who are medically inoperable but have localized disease.
Dr. Harrod-Kim expects to do 1-2 cases a month. At his prior institution they did 80% of these cases with conscious sedation. The other 20% needed general anesthesia because of issues like lesions near ribs which are more painful to ablate. Here we'll be doing the first several cases with GA, then they will probably do most with conscious sedation and we'll only do general anesthesia for the 20% or so that really need it.
He does not need the patients paralyzed. LMA's are fine when appropriate. The patients' positions may vary from supine to prone depending on where the lesion is. No special lines or monitoring are required.
The cases will take from one and a half to two hours.
The patients will be admitted to RADCU the day of the procedure, after being seen at PAU. Dr. Harrod-Kim will order pre-op abx. 
Patients will have a noncontrast CT, get positioned, the RF probe will be placed under CT guidance and the lesion burned, then they'll have another CT post-ablation.
Patients will recover in PACU, at least for the first several cases. They'll spend one night in SS then be discharged home.
Complications: 1) Pneumothorax: 30% get a ptx (about the same % as with lung bxs done in readiology). Most are small. 10% require a small chest tube, which Dr. Harrod-Kim will place at the time of the procedure. 2) Bleeding: this is rare, as the lesions are cauterized by the ablating probe. In cases with significant bleeding patients would likely go to angio rather than the OR. 3) Pleural effusions: rare, tend to develop later over the week.
There is one case tomorrow and one on Friday 9/21. I'll be in touch with the staff doing these cases with more details about the individual patients. Please let me know if you have any questions. Thanks.

First case done today. Overall went well. Once again, I did not notify the workroom so they were unaware we were doing this. We need to make sure they are made aware so we will have necessary equipment from one of the other radiology sites. Had to get the machine and bluebell from angio. 

Did this with LMA, GA. Partial prone induction and LMA insertion (sorry PL). This was a rib lesion so expected to be painful but evidently the radiologist thoroughly injected the site because the anesthetic requirements were very low thru case. Took about 2 hours, half of this was positioning, getting used to new equipment etc. 

Another case on Friday (this one is a more central lung lesion) then none for a while until radiology techs and nurses get better prepared. Sounds like there are plenty of candidates for this though, based on the discussions with the new interventionist. 

BR

 


"Awake" Craniotomy Guidelines
NEW

T. Rintel April 2009

A. Two neurosurgeons, Drs. Florman and Desai, are performing "awake" craniotomies on select patients. The increased number of &#34awake" cases is based on new data that suggests that there is a near linear relationship between tumor mass excision and survival. In the past, were a mass in an "inaccessible" area (motor, speech, etc.), the patient was biopsied only, leaving the mass to non-surgical therapy. Now with the advent of "awake" surgery; one can resect a much greater tumor mass.

It is worthwhile for the anesthesia care team to take the time to establish rapport with the patient. The patient will naturally have some level of apprehension and will need reassurance. Confused, agitated, or demented patients are very poor candidates for this procedure. 

Dr. Florman has performed the majorities of awake cranis at Maine Medical Center. His preferred technique is:

-Mild sedation in the ASU, versed and ± fentanyl
   - Propofol bolus for pin placement
   - Propofol infusion (spontaneous ventilation) for the craniotomy – through the dura then turn off!
   - Having checked with the surgeon, small amounts of versed and/or fentanyl may be given intermittently
   - Restart the propofol infusion for closure.
   - Standard monitors, ETCO2, BP cuff, EKG, mask or nasal prong O2

For Dr. Desai a similar technique will work, though he is not averse to using remifentanil. [search ‘remifentanil' on this website for mixing and dosing remifentanyl and Dr. J. Flowerdew's article on anesthesia for scoliosis with intra-op wakeup]

II. Common problems (see Handbook of Neuroanesthesia for comprehensive review)
   - Airway complications
   - Pain
   - Seizures (may occur during cortical stimulation and can be treated with versed)
   - Less commonly; disinhibition, cortical swelling, n/v

As a rule, communication between the surgeon and the anesthesia care team is critical and a brief pre-op discussion can be very helpful



 

Trans-Jugular PortoSystemic Shunts aka "TIPSS" (In Radiology)

Rob Hubbs Oct 2007

It is a good idea to type and cross blood (or at the very least type and screen) for TIPSS procedures far in advance of the procedure.  These patients are by definition coagulopathic, have multiple medical problems, are invariably anemic, and usually have received blood in the past.  The interventional radiologists may or may not appreciate the full extent of the issues with these patients.

 
Today's patient had a starting HCT of 27.9 and no type and screen/cross despite being admitted last night for her "work up."  I sent a specimen just after induction for 2 units.  I called the blood bank about 45 min later to see if they received the specimen and were doing the cross match.  They asked how soon I needed the blood because it would take "a few hours or a day" since the patient had multiple blood antibodies (from prior transfusions).
 
Soon after that the IR guy said, "how's she doing?" with a worried look on his face.  I said fine, and why do you ask. He said, well I think I just punctured her liver capsule...
 
In the end the patient did OK but it would have been ugly if she bled significantly.  He said they "usually" don't bleed much but if they puncture the capsule it "can be catastrophic."
 
The patient was not a Jehovah's Witness.