ERCP in Xray:
- Updated 8/28/2002- Tom VerLee, with input from KSP &
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
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.
Most patients can be done
with IV deep sedation/anesthesia and spontaneous ventilation.
A Suggested Approach:
1) Nasal prongs O2, with
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.
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.
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.
Endo Suite Phone No.: x3590
Endo Office Door Code: 2135
Endo Techs: Michelle, Caroline, Karen, Cindy, Stephanie
GI Endo Fellow
Cath Lab Sedation,
1. Ketamine + Midazolam
K 0.25-0.5 mg/kg IV
M 0.1-0.2 mg/kg IV
K 1 mg/kg/hr
M 0.1 mg/kg/hr
po sedation with Midazolam (0.2-0.5 mg/kg
0.5 mg/kg every 60 sec
until 2 mg/kg
100 - 150 mcg/kg/min
Go to Neuroradiology
Artery Endovascular Stents
(N. Boulanger 4/07, updated 8/10)
admitted through ASU as a Same Day Admit.
Preop workup similar to that for CEA.
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.
(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
* Very light sedation; nasal O2
* 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
* Dopamine drip sometimes necessary for bradycardia and /or pressure
support; if required post-procedure, will require SCU bed (see
Stent Flowchart (pdf)
* see Flowchart for disposition (above)
Endovascular (Intraluminal ) AAA Stents
M. Green/L. Mamchur (updated 10/09)
(For OPEN AAA Management, go to Cardiovascular
Same Day Patient (most common): admitted through
Inpatient: brought to Holding Room.
Preop workup similar to that for open
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.
- 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.
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.
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.
Have ready in the room. Occasionally, surgeon may ask for adenosine to
temporarily pause everything during thoracic device deployment.
Pain usually managed readily with fentanyl 2-4 mcg/kg intraop.
Patients typically recover in PACU then go to Short Stay.
Intraperitoneal Hyperthermic Chemotherapy (IPHC)
aka "Hot Chemo"
L. Rutstein & Sugarbaker 11/04
certain GI Tract cancers and sarcomas with peritoneal carcinomatosis
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
Preop: Patients usually present
1) prior abdominal surgery
-may have other significant system
problems: renal, cardiac, pulmonary
1) Long cases with significant Fluid shifts:
-blood loss (moderate)
-third space loss (essentially an intraperitoneal burn)
-vasodilation due to heating
Hespan® (hetastarch) use controversial:
some feel(1) it contributes significantly to coagulopathy
Suggest Coag Panel before hyperthermia induced, to evaluate &
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:
Arterial Line: for blood gases, hematocrits, 'lytes, coags
-Central Line: infusions, CVP; PA Cath only if cardiac status warrants
-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
-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.
1 Stephens, White, Esquival,
Stuart, Sugarbaker: www.surgicaloncology.com/hiicman.htm
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.
will be closed for the duration of the procedure as the OR team will be
utilized for the case.
patients will be same day admissions, pre-op'd at Brighton beforehand.
pts. fairly healthy with just one or two isolated liver mets; others may
be sicker with full-blown cirrhosis, etc.
Techs will set up an anesthesia machine and blue bell cart in the room.
-General Anesthesia; respirations held several times.
is expected to be minimal.
-Expected to last about 2
Let me know if you have any questions about these procedures.
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
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.
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
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.
"Awake" Craniotomy Guidelines
T. Rintel April 2009
A. Two neurosurgeons, Drs. Florman and Desai, are performing "awake"
craniotomies on select patients. The increased number of "awake"
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
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
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
- 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
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
- 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
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.