This document provides information about anesthesia for genitourinary surgeries and procedures. It discusses considerations for cystoscopy, transurethral resection of the prostate (TURP), lithotripsy, and the lithotomy position. Regional or general anesthesia is typically used depending on the procedure and patient factors. Complications of TURP can include hemorrhage, TURP syndrome from fluid absorption, bladder perforation, hypothermia, septicemia, and disseminated intravascular coagulation. Careful monitoring is important to detect issues like fluid overload and hyponatremia.
This document provides an overview of anesthesia considerations for laparoscopic surgeries. It discusses the history of laparoscopy, physiological effects of pneumoperitoneum including on the cardiovascular, respiratory, central nervous and renal systems. It also outlines respiratory complications like subcutaneous emphysema, pneumothorax, gas embolism and their treatment. The effects of patient positioning and conduct of anesthesia are summarized.
Anesthesia in Transurethral resection of prostateAshish Dhandare
1) The document discusses preoperative considerations and risks for anesthesia in transurethral resection of the prostate (TURP), with a focus on risks in elderly patients.
2) It provides details on TURP syndrome, a cluster of symptoms caused by absorption of irrigating fluid during surgery, and treatments for TURP syndrome and its complications like glycine toxicity, hemolysis, hypothermia, and bleeding.
3) Factors that can minimize risks of TURP syndrome are limiting surgery duration to under 1 hour, maintaining fluid bag height below 60cm, frequent bladder drainage, and careful surgical technique to preserve prostatic capsule integrity. Spinal anesthesia is recommended for its benefits in T
(1) Postoperative nausea and vomiting (PONV) is a common complication following anesthesia and surgery, with incidence rates of 22-38% for nausea and 12-26% for vomiting. (2) The vomiting center located in the brainstem plays a key role in coordinating the vomiting reflex in response to various emetogenic stimuli. (3) Identifying patient, anesthesia, and surgery risk factors can help determine those at higher risk of PONV and guide prophylaxis.
The document discusses the posterior fossa, including its boundaries, contents, blood supply, clinical presentation of lesions, and considerations for anesthesia. The posterior fossa is bounded anteriorly by the clivus and petrous bone, posteriorly by the occipital bone, and laterally by the temporal bone. It contains the cerebellar hemispheres, brainstem, and cranial nerves III-XII. Lesions can cause a variety of signs and symptoms depending on location, including ataxia, nystagmus, limb weakness, and cranial nerve deficits. Anesthesia for posterior fossa surgery requires careful monitoring and positioning to maintain stability while allowing surgical access.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Anaesthetic considerations for laser surgeryAnamika yadav
This document discusses anaesthetic considerations for laser surgery. It begins by outlining the objectives which are to discuss the types of lasers used, preoperative assessment and preparation, airway management and ventilation options, laser hazards and prevention, and crisis management for airway fires. It then provides details on the types of lasers used clinically, biological effects of lasers, and clinical applications of lasers. The role of anesthesiologists is to maintain oxygenation, remove carbon dioxide, keep the patient anesthetized, and reduce risks. Various airway management techniques and their advantages/disadvantages are discussed such as intubation, spontaneous ventilation, insufflation, and jet ventilation. Laser hazards like atmospheric contamination, perforation
Anaesthetic management in a patient of burns injurykshama_db
This document provides an overview of the anaesthetic management of a burn patient. It begins with definitions and classifications of burns. It then discusses the pathophysiology of burns which involves inflammatory and circulatory changes, injury to the airway and lungs, immune system response, and effects on other organ systems. The document outlines assessment of burn wounds including total body surface area involved and depth of burns. It discusses the role of the anaesthesiologist in airway management, vascular access, fluid resuscitation, and surgical procedures for burn patients. The goal of management is to maintain intravascular volume following a burn to provide sufficient circulation to preserve organ function.
This document provides an overview of anesthesia considerations for laparoscopic surgeries. It discusses the history of laparoscopy, physiological effects of pneumoperitoneum including on the cardiovascular, respiratory, central nervous and renal systems. It also outlines respiratory complications like subcutaneous emphysema, pneumothorax, gas embolism and their treatment. The effects of patient positioning and conduct of anesthesia are summarized.
Anesthesia in Transurethral resection of prostateAshish Dhandare
1) The document discusses preoperative considerations and risks for anesthesia in transurethral resection of the prostate (TURP), with a focus on risks in elderly patients.
2) It provides details on TURP syndrome, a cluster of symptoms caused by absorption of irrigating fluid during surgery, and treatments for TURP syndrome and its complications like glycine toxicity, hemolysis, hypothermia, and bleeding.
3) Factors that can minimize risks of TURP syndrome are limiting surgery duration to under 1 hour, maintaining fluid bag height below 60cm, frequent bladder drainage, and careful surgical technique to preserve prostatic capsule integrity. Spinal anesthesia is recommended for its benefits in T
(1) Postoperative nausea and vomiting (PONV) is a common complication following anesthesia and surgery, with incidence rates of 22-38% for nausea and 12-26% for vomiting. (2) The vomiting center located in the brainstem plays a key role in coordinating the vomiting reflex in response to various emetogenic stimuli. (3) Identifying patient, anesthesia, and surgery risk factors can help determine those at higher risk of PONV and guide prophylaxis.
The document discusses the posterior fossa, including its boundaries, contents, blood supply, clinical presentation of lesions, and considerations for anesthesia. The posterior fossa is bounded anteriorly by the clivus and petrous bone, posteriorly by the occipital bone, and laterally by the temporal bone. It contains the cerebellar hemispheres, brainstem, and cranial nerves III-XII. Lesions can cause a variety of signs and symptoms depending on location, including ataxia, nystagmus, limb weakness, and cranial nerve deficits. Anesthesia for posterior fossa surgery requires careful monitoring and positioning to maintain stability while allowing surgical access.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Anaesthetic considerations for laser surgeryAnamika yadav
This document discusses anaesthetic considerations for laser surgery. It begins by outlining the objectives which are to discuss the types of lasers used, preoperative assessment and preparation, airway management and ventilation options, laser hazards and prevention, and crisis management for airway fires. It then provides details on the types of lasers used clinically, biological effects of lasers, and clinical applications of lasers. The role of anesthesiologists is to maintain oxygenation, remove carbon dioxide, keep the patient anesthetized, and reduce risks. Various airway management techniques and their advantages/disadvantages are discussed such as intubation, spontaneous ventilation, insufflation, and jet ventilation. Laser hazards like atmospheric contamination, perforation
Anaesthetic management in a patient of burns injurykshama_db
This document provides an overview of the anaesthetic management of a burn patient. It begins with definitions and classifications of burns. It then discusses the pathophysiology of burns which involves inflammatory and circulatory changes, injury to the airway and lungs, immune system response, and effects on other organ systems. The document outlines assessment of burn wounds including total body surface area involved and depth of burns. It discusses the role of the anaesthesiologist in airway management, vascular access, fluid resuscitation, and surgical procedures for burn patients. The goal of management is to maintain intravascular volume following a burn to provide sufficient circulation to preserve organ function.
The document discusses the approach to anesthesia for patients with cardiac disease undergoing non-cardiac surgery. It emphasizes the importance of preoperative evaluation and risk stratification to determine the safest anesthetic plan. During surgery, careful monitoring is recommended to detect any deterioration in cardiac function. The appropriate selection of anesthetic drugs and techniques can help minimize stress on the heart. Overall, the key is choosing an anesthetic that provides stability for the patient's cardiac condition.
This document provides an overview of monitoring depth of anesthesia. It discusses the aims of monitoring to ensure patient safety and prevent awareness during surgery. It reviews the historical background of defining anesthesia stages. Modern concepts view anesthesia as a complex interaction between stimuli, patient responses, and drug-induced effects. Factors like patient characteristics, drug combinations, and surgery duration impact correct drug dosing. Memory is gradually impaired with deeper anesthesia levels before autonomic responses. The document outlines stages of awareness and discusses specific drugs' relationships to anesthesia depth.
The document discusses the role of anesthesiologists in trauma care. It covers various topics including pre-hospital care, emergency department care, operating room roles, and postoperative care in intensive care units. Key responsibilities of anesthesiologists include securing airways, ensuring ventilation, and providing anesthesia. The document focuses on airway management and ventilation challenges in trauma patients, with strategies around intubation, chest tube insertion, and management of injuries like tension pneumothorax. Ketamine is discussed as an agent of choice for pre-hospital general anesthesia due to its cardiovascular stability in shocked patients.
Robotic surgeries are becoming most popular in field of surgical departments due to its precision of hand in many cancer surgeries. Anaesthesia in these places are quite challenging due to lack place to move , a meticulous vigilance is always required for safety of patient and conduct safe Anesthesia
This document discusses airway local blocks and awake intubation. It describes the indications for awake intubation including comorbidities, risk of aspiration, difficult airway assessment, and emergencies. It provides details on the pharmacological agents, equipment, personnel, and techniques used for airway local blocks and awake intubation. Specifically, it outlines common methods for anesthetizing different areas of the airway using lidocaine, including dosage calculations and risks of lidocaine toxicity. The goal is to safely anesthetize the airway to allow for awake intubation.
This document discusses neuromuscular monitoring during surgery using peripheral nerve stimulation. It describes:
1) The objectives of neuromuscular monitoring which include determining the onset and level of muscle relaxation during surgery and assessing recovery to minimize risk of residual paralysis.
2) The types of patients that should be monitored which include those with comorbidities and those receiving certain medications.
3) The different patterns of nerve stimulation used for monitoring including single twitch, train-of-four, and double burst stimulation and what each assesses.
This document discusses various methods for monitoring the depth of anesthesia. It describes clinical techniques such as assessing autonomic responses and muscle movement. It also discusses pharmacological principles like minimum alveolar concentration for different anesthetic responses. Methods for monitoring brain electrical activity are outlined, including spontaneous EEG, compressed spectral analysis, bispectral index, and entropy monitors. Brain electrical activity monitors provide quantitative measures of anesthetic effect but can be influenced by other physiological factors. Overall, the document provides an overview of traditional and advanced techniques for assessing depth of anesthesia.
This document discusses non-operating room anesthesia (NORA). It begins by defining NORA as anesthesia provided outside the operating room, such as in radiology, endoscopy suites, MRI, and dental clinics. It then outlines a three step approach to NORA involving thorough patient assessment, appropriate monitoring and anesthesia care, and post-procedure management. Several ASA guidelines for equipment and facilities in NORA locations are also reviewed. Complications associated with NORA and special considerations for procedures like X-rays, MRIs, and IV contrast administration are discussed. The document emphasizes choosing anesthesia techniques based on patient factors and needs for each specific non-operating room procedure.
HIV infection is a global pandemic that can present challenges for anesthesia. The virus is transmitted through bodily fluids and causes AIDS by depleting CD4+ cells. While treatment with HAART can suppress the virus, it interacts with many anesthetic drugs and may require adjustments. Anesthesiologists must take precautions like universal precautions and post-exposure prophylaxis to prevent infection. When providing anesthesia for HIV patients, it is important to consider potential organ manifestations of disease, interactions between antiretrovirals and anesthetics, and the patient's immune status.
THRIVE is a method using warmed, humidified high flow oxygen via the nose to increase apnea time in patients with difficult airways. It works by flushing carbon dioxide from the nasopharynx, providing mechanical splinting and distention pressure, and allowing apneic oxygenation. A case series of 25 patients with difficult airways found THRIVE increased the median apnea time to 17 minutes without any oxygen saturations dropping below 90%, allowing more time for airway management. While observational and involving expert airway management, the study concludes THRIVE can safely extend the apnea window for difficult airway situations.
This document discusses anesthesia considerations for procedures performed outside the operating room. It notes that the number and complexity of such procedures has increased, bringing additional responsibilities for anesthesiologists. Special challenges include limited space, equipment, and support staff unfamiliar with patient management. Proper equipment, monitoring, and planning are important when providing anesthesia or sedation in remote locations. The document discusses various locations like radiology suites, specific procedures like ECT, and choices of anesthetic agents and techniques. Patient safety is the top priority for remote location anesthesia.
This document discusses the peri-operative management of hypertension. It notes that hypertension occurring before, during or after surgery increases the risk of cardiovascular events and postoperative morbidity and mortality. It provides guidelines on evaluating and controlling pre-operative hypertension, managing anesthesia for hypertensive patients, monitoring blood pressure during surgery, and treating postoperative hypertension. The effects of hypertension on organ systems like the heart, brain and kidneys are reviewed. Acute hypertensive crises are also discussed.
This document discusses different oxygen therapy techniques including conventional oxygen therapy and high flow nasal cannula (HFNC) oxygen therapy. It provides details on:
- How HFNC works by using an air/oxygen blender to deliver high flows of humidified oxygen at variable concentrations.
- The physiologic effects of HFNC including improved oxygen delivery to the alveoli and prevention of adverse effects from lack of humidification.
- Techniques called THRIVE and STRIVE-Hi that use HFNC to provide apneic oxygenation and tubeless anesthesia, extending the time available to secure an airway without risk of hypoxemia.
This document discusses low-flow and minimal-flow anesthesia techniques. It begins by defining low-flow as a fresh gas flow of 1 L/min and minimal-flow as 0.5 L/min. Rebreathing systems allow reuse of exhaled gases after removal of carbon dioxide. Using these techniques can reduce costs by 55-75% and minimize environmental pollution from volatile anesthetic gases. Proper monitoring and maintenance of breathing gas conditions is important for patient safety when using low fresh gas flows.
This document provides background information and details on the technique of performing a transversus abdominis plane (TAP) block. It begins with an overview of the TAP block, including its original description and subsequent modifications using ultrasound guidance. Next, it discusses the indications for TAP blocks, including postoperative analgesia for various abdominal surgeries. The anatomy section describes the layers and nerves of the abdominal wall targeted by the block. Finally, the technique section outlines the materials, patient positioning, ultrasound probe placement, needle insertion, and local anesthetic injection steps to perform a TAP block.
This document discusses anaesthesia for electroconvulsive therapy (ECT). It describes ECT as the artificial induction of a grand mal seizure through electrical stimulation of the brain to treat severe mental illnesses. It notes the common indications for ECT and outlines the anaesthetic considerations and techniques used to control physiological responses and complications during the procedure, including preoxygenation, induction agents like methohexital or propofol, and muscle relaxants like succinylcholine to prevent injury during seizures. Risks associated with ECT like increased intracranial pressure, blood pressure changes, and memory loss are also summarized.
Low flow anaesthesia systems aim to reuse exhaled gases and minimize fresh gas flow. John Snow recognized in 1850 that most inhaled anaesthetics are exhaled unchanged, and rebreathing exhaled gases could prolong their effects. Developments over the 20th century led to widespread use of circle absorption systems. Factors like cost and pollution concerns have renewed interest in low flow anaesthesia. It requires a well-functioning circle system, gas monitoring, and attention to factors like circuit volume and gas solubility when initiating and maintaining the desired anaesthetic concentrations with minimal fresh gas flows.
Awareness under anesthesia occurs when a patient becomes conscious during a surgical procedure performed under general anesthesia and later recalls events from surgery. It has an incidence rate of 0.1-0.2% for most surgeries, but is higher for some like cardiac surgery at 1.1-1.5%. Risk factors include light anesthesia, certain types of surgeries or patients, equipment issues, and prior experiences with awareness. Patients who experience awareness may suffer from sleep disturbances, nightmares, anxiety, depression or post-traumatic stress disorder. Prevention strategies include evaluating risk factors preoperatively, checking anesthesia equipment, maintaining adequate anesthetic levels intraoperatively, and postoperative interviews to screen for recall.
This document discusses patient selection criteria and preoperative assessment and preparation for ambulatory anesthesia. It covers suitable procedures, duration limits, patient characteristics, contraindications, preoperative evaluation, and both nonpharmacologic and pharmacologic preparation. For patient selection, it recommends considering factors like procedure type, duration, medical history, age and contraindications. It also discusses anxiolysis, sedation, preemptive analgesia and preventing nausea for premedication. The goal is to safely perform procedures as outpatients and facilitate early recovery.
Anesthesia awareness occurs when a patient becomes conscious during a surgical procedure performed under general anesthesia and has recall of events. The incidence is 0.1-0.2% but higher for certain procedures like cardiac surgery. Patients at risk include women, those under 60, long surgeries, and prior awareness. Causes include light anesthesia, increased anesthetic requirements, and equipment errors. Patients commonly recall sounds and paralysis. Aftereffects may include PTSD. Prevention strategies include preoperative evaluation, proper equipment use, and intraoperative monitoring like BIS monitoring to maintain anesthesia levels.
TURP is a common procedure for treating enlarged prostate but it carries risks. Regional anesthesia is preferred to allow early detection of complications like fluid absorption. Irrigation solutions must be nontoxic if absorbed. Complications can include TURP syndrome from fluid shifts, leading to hyponatremia, seizures, or pulmonary edema. Treatment involves terminating surgery, diuresis, oxygen, and correcting electrolyte imbalances with hypertonic saline if needed.
Transurethral resection of the prostate (TURP)JOFREY MTEWELE
TURP (transurethral resection of the prostate) is a common surgery to remove parts of an enlarged prostate gland through the penis to relieve urinary obstruction caused by BPH (benign prostatic hyperplasia). During TURP, a resectoscope is inserted through the urethra to cut and remove prostate tissue blocking the urethra using an electrical loop, with pieces flushed out by irrigating fluid. Complications can include bleeding, infection, and electrolyte imbalances from excessive fluid absorption. Nurses prepare instruments, assist during irrigation, and clean equipment after the procedure.
The document discusses the approach to anesthesia for patients with cardiac disease undergoing non-cardiac surgery. It emphasizes the importance of preoperative evaluation and risk stratification to determine the safest anesthetic plan. During surgery, careful monitoring is recommended to detect any deterioration in cardiac function. The appropriate selection of anesthetic drugs and techniques can help minimize stress on the heart. Overall, the key is choosing an anesthetic that provides stability for the patient's cardiac condition.
This document provides an overview of monitoring depth of anesthesia. It discusses the aims of monitoring to ensure patient safety and prevent awareness during surgery. It reviews the historical background of defining anesthesia stages. Modern concepts view anesthesia as a complex interaction between stimuli, patient responses, and drug-induced effects. Factors like patient characteristics, drug combinations, and surgery duration impact correct drug dosing. Memory is gradually impaired with deeper anesthesia levels before autonomic responses. The document outlines stages of awareness and discusses specific drugs' relationships to anesthesia depth.
The document discusses the role of anesthesiologists in trauma care. It covers various topics including pre-hospital care, emergency department care, operating room roles, and postoperative care in intensive care units. Key responsibilities of anesthesiologists include securing airways, ensuring ventilation, and providing anesthesia. The document focuses on airway management and ventilation challenges in trauma patients, with strategies around intubation, chest tube insertion, and management of injuries like tension pneumothorax. Ketamine is discussed as an agent of choice for pre-hospital general anesthesia due to its cardiovascular stability in shocked patients.
Robotic surgeries are becoming most popular in field of surgical departments due to its precision of hand in many cancer surgeries. Anaesthesia in these places are quite challenging due to lack place to move , a meticulous vigilance is always required for safety of patient and conduct safe Anesthesia
This document discusses airway local blocks and awake intubation. It describes the indications for awake intubation including comorbidities, risk of aspiration, difficult airway assessment, and emergencies. It provides details on the pharmacological agents, equipment, personnel, and techniques used for airway local blocks and awake intubation. Specifically, it outlines common methods for anesthetizing different areas of the airway using lidocaine, including dosage calculations and risks of lidocaine toxicity. The goal is to safely anesthetize the airway to allow for awake intubation.
This document discusses neuromuscular monitoring during surgery using peripheral nerve stimulation. It describes:
1) The objectives of neuromuscular monitoring which include determining the onset and level of muscle relaxation during surgery and assessing recovery to minimize risk of residual paralysis.
2) The types of patients that should be monitored which include those with comorbidities and those receiving certain medications.
3) The different patterns of nerve stimulation used for monitoring including single twitch, train-of-four, and double burst stimulation and what each assesses.
This document discusses various methods for monitoring the depth of anesthesia. It describes clinical techniques such as assessing autonomic responses and muscle movement. It also discusses pharmacological principles like minimum alveolar concentration for different anesthetic responses. Methods for monitoring brain electrical activity are outlined, including spontaneous EEG, compressed spectral analysis, bispectral index, and entropy monitors. Brain electrical activity monitors provide quantitative measures of anesthetic effect but can be influenced by other physiological factors. Overall, the document provides an overview of traditional and advanced techniques for assessing depth of anesthesia.
This document discusses non-operating room anesthesia (NORA). It begins by defining NORA as anesthesia provided outside the operating room, such as in radiology, endoscopy suites, MRI, and dental clinics. It then outlines a three step approach to NORA involving thorough patient assessment, appropriate monitoring and anesthesia care, and post-procedure management. Several ASA guidelines for equipment and facilities in NORA locations are also reviewed. Complications associated with NORA and special considerations for procedures like X-rays, MRIs, and IV contrast administration are discussed. The document emphasizes choosing anesthesia techniques based on patient factors and needs for each specific non-operating room procedure.
HIV infection is a global pandemic that can present challenges for anesthesia. The virus is transmitted through bodily fluids and causes AIDS by depleting CD4+ cells. While treatment with HAART can suppress the virus, it interacts with many anesthetic drugs and may require adjustments. Anesthesiologists must take precautions like universal precautions and post-exposure prophylaxis to prevent infection. When providing anesthesia for HIV patients, it is important to consider potential organ manifestations of disease, interactions between antiretrovirals and anesthetics, and the patient's immune status.
THRIVE is a method using warmed, humidified high flow oxygen via the nose to increase apnea time in patients with difficult airways. It works by flushing carbon dioxide from the nasopharynx, providing mechanical splinting and distention pressure, and allowing apneic oxygenation. A case series of 25 patients with difficult airways found THRIVE increased the median apnea time to 17 minutes without any oxygen saturations dropping below 90%, allowing more time for airway management. While observational and involving expert airway management, the study concludes THRIVE can safely extend the apnea window for difficult airway situations.
This document discusses anesthesia considerations for procedures performed outside the operating room. It notes that the number and complexity of such procedures has increased, bringing additional responsibilities for anesthesiologists. Special challenges include limited space, equipment, and support staff unfamiliar with patient management. Proper equipment, monitoring, and planning are important when providing anesthesia or sedation in remote locations. The document discusses various locations like radiology suites, specific procedures like ECT, and choices of anesthetic agents and techniques. Patient safety is the top priority for remote location anesthesia.
This document discusses the peri-operative management of hypertension. It notes that hypertension occurring before, during or after surgery increases the risk of cardiovascular events and postoperative morbidity and mortality. It provides guidelines on evaluating and controlling pre-operative hypertension, managing anesthesia for hypertensive patients, monitoring blood pressure during surgery, and treating postoperative hypertension. The effects of hypertension on organ systems like the heart, brain and kidneys are reviewed. Acute hypertensive crises are also discussed.
This document discusses different oxygen therapy techniques including conventional oxygen therapy and high flow nasal cannula (HFNC) oxygen therapy. It provides details on:
- How HFNC works by using an air/oxygen blender to deliver high flows of humidified oxygen at variable concentrations.
- The physiologic effects of HFNC including improved oxygen delivery to the alveoli and prevention of adverse effects from lack of humidification.
- Techniques called THRIVE and STRIVE-Hi that use HFNC to provide apneic oxygenation and tubeless anesthesia, extending the time available to secure an airway without risk of hypoxemia.
This document discusses low-flow and minimal-flow anesthesia techniques. It begins by defining low-flow as a fresh gas flow of 1 L/min and minimal-flow as 0.5 L/min. Rebreathing systems allow reuse of exhaled gases after removal of carbon dioxide. Using these techniques can reduce costs by 55-75% and minimize environmental pollution from volatile anesthetic gases. Proper monitoring and maintenance of breathing gas conditions is important for patient safety when using low fresh gas flows.
This document provides background information and details on the technique of performing a transversus abdominis plane (TAP) block. It begins with an overview of the TAP block, including its original description and subsequent modifications using ultrasound guidance. Next, it discusses the indications for TAP blocks, including postoperative analgesia for various abdominal surgeries. The anatomy section describes the layers and nerves of the abdominal wall targeted by the block. Finally, the technique section outlines the materials, patient positioning, ultrasound probe placement, needle insertion, and local anesthetic injection steps to perform a TAP block.
This document discusses anaesthesia for electroconvulsive therapy (ECT). It describes ECT as the artificial induction of a grand mal seizure through electrical stimulation of the brain to treat severe mental illnesses. It notes the common indications for ECT and outlines the anaesthetic considerations and techniques used to control physiological responses and complications during the procedure, including preoxygenation, induction agents like methohexital or propofol, and muscle relaxants like succinylcholine to prevent injury during seizures. Risks associated with ECT like increased intracranial pressure, blood pressure changes, and memory loss are also summarized.
Low flow anaesthesia systems aim to reuse exhaled gases and minimize fresh gas flow. John Snow recognized in 1850 that most inhaled anaesthetics are exhaled unchanged, and rebreathing exhaled gases could prolong their effects. Developments over the 20th century led to widespread use of circle absorption systems. Factors like cost and pollution concerns have renewed interest in low flow anaesthesia. It requires a well-functioning circle system, gas monitoring, and attention to factors like circuit volume and gas solubility when initiating and maintaining the desired anaesthetic concentrations with minimal fresh gas flows.
Awareness under anesthesia occurs when a patient becomes conscious during a surgical procedure performed under general anesthesia and later recalls events from surgery. It has an incidence rate of 0.1-0.2% for most surgeries, but is higher for some like cardiac surgery at 1.1-1.5%. Risk factors include light anesthesia, certain types of surgeries or patients, equipment issues, and prior experiences with awareness. Patients who experience awareness may suffer from sleep disturbances, nightmares, anxiety, depression or post-traumatic stress disorder. Prevention strategies include evaluating risk factors preoperatively, checking anesthesia equipment, maintaining adequate anesthetic levels intraoperatively, and postoperative interviews to screen for recall.
This document discusses patient selection criteria and preoperative assessment and preparation for ambulatory anesthesia. It covers suitable procedures, duration limits, patient characteristics, contraindications, preoperative evaluation, and both nonpharmacologic and pharmacologic preparation. For patient selection, it recommends considering factors like procedure type, duration, medical history, age and contraindications. It also discusses anxiolysis, sedation, preemptive analgesia and preventing nausea for premedication. The goal is to safely perform procedures as outpatients and facilitate early recovery.
Anesthesia awareness occurs when a patient becomes conscious during a surgical procedure performed under general anesthesia and has recall of events. The incidence is 0.1-0.2% but higher for certain procedures like cardiac surgery. Patients at risk include women, those under 60, long surgeries, and prior awareness. Causes include light anesthesia, increased anesthetic requirements, and equipment errors. Patients commonly recall sounds and paralysis. Aftereffects may include PTSD. Prevention strategies include preoperative evaluation, proper equipment use, and intraoperative monitoring like BIS monitoring to maintain anesthesia levels.
TURP is a common procedure for treating enlarged prostate but it carries risks. Regional anesthesia is preferred to allow early detection of complications like fluid absorption. Irrigation solutions must be nontoxic if absorbed. Complications can include TURP syndrome from fluid shifts, leading to hyponatremia, seizures, or pulmonary edema. Treatment involves terminating surgery, diuresis, oxygen, and correcting electrolyte imbalances with hypertonic saline if needed.
Transurethral resection of the prostate (TURP)JOFREY MTEWELE
TURP (transurethral resection of the prostate) is a common surgery to remove parts of an enlarged prostate gland through the penis to relieve urinary obstruction caused by BPH (benign prostatic hyperplasia). During TURP, a resectoscope is inserted through the urethra to cut and remove prostate tissue blocking the urethra using an electrical loop, with pieces flushed out by irrigating fluid. Complications can include bleeding, infection, and electrolyte imbalances from excessive fluid absorption. Nurses prepare instruments, assist during irrigation, and clean equipment after the procedure.
This document discusses Transurethral Resection of the Prostate (TURP) and associated anaesthetic considerations. TURP is the second most common surgery for men over 65 and involves using an electrically energized wire loop to resect prostatic tissue through continuous irrigation. Large volumes of irrigating fluid are commonly absorbed, which can cause TURP Syndrome characterized by fluid overload, hyponatremia, and potential solute toxicity. Patients undergoing TURP are often elderly with cardiovascular or pulmonary comorbidities and optimal anaesthetic management requires addressing these conditions as well as risks of fluid absorption, blood loss, and postoperative care.
1. Common procedures for treating nephrolithiasis include cystoscopic procedures like ureteroscopy with stone extraction and lithotripsy, as well as extracorporeal shock wave lithotripsy (ESWL) and percutaneous or laparoscopic nephrolithotomy.
2. ESWL uses focused acoustic shockwaves to fragment stones within the kidney without invasive surgery. It is commonly used for stones 4-20mm in size.
3. Radical prostatectomy and cystectomy are major surgeries for urological cancers that require extensive dissection and carry risks of significant blood loss. Robotic assistance and laparoscopic approaches are now commonly used.
This document describes various imaging techniques used to evaluate the kidneys, including plain X-rays, ultrasound, intravenous urography, pyelography, arteriography, computed tomography, magnetic resonance imaging, and radionuclide studies. It also discusses renal biopsy indications, contraindications, complications, and how to prepare for the procedure. The imaging techniques can identify renal and urinary tract abnormalities while renal biopsy provides kidney tissue for analysis.
LECTURE NOTE ON URETHRAL STRICTURES AND STENOSIS.pdfSolomon Lakew
Urethral strictures are usually acquired due to trauma, inflammation, or medical instrumentation. The most common causes are trauma, iatrogenic factors, and inflammation. Strictures occur most often in the bulbar urethra and can be treated with internal urethrotomy or open repair techniques like resection and reanastomosis or graft urethroplasty. Endoscopic treatments have a low success rate so open repair is often recommended for recurrent strictures.
The document provides information on the anatomy, microscopic anatomy, blood supply, nerve supply, and common conditions of the prostate gland such as benign prostatic hyperplasia. It discusses the procedure of transurethral resection of the prostate in detail, including preoperative considerations, choices of anesthesia, intraoperative monitoring, complications such as TURP syndrome, and their prevention and management. TURP syndrome is caused by excessive absorption of irrigating fluids and can lead to hyponatremia, hypervolemia, and other electrolyte abnormalities.
TURP syndrome occurs when too much irrigating fluid is absorbed during a transurethral resection of the prostate (TURP) surgery. It can cause electrolyte imbalances and fluid overload that manifest as tachycardia, hypotension, hypertension, nausea, and seizures. Management may include intubation, IV saline, frusemide, sodium bicarbonate, and diazepam. Spinal anesthesia is preferred for TURP to allow early detection of TURP syndrome and glycine is commonly used for irrigation despite risks of seizures, visual issues, and metabolic effects at high levels. Preventing TURP syndrome involves limiting surgery time, controlling irrigation pressure, and avoiding hypotonic IV
Benign prostatic hyperplasia (BPH) is a common condition among older men that involves the noncancerous enlargement of the prostate gland. It can cause lower urinary tract symptoms by constricting the urethra. BPH is typically treated through medical management with alpha-blockers or 5-alpha-reductase inhibitors or through surgical procedures like transurethral resection of the prostate (TURP). TURP uses an endoscope inserted through the urethra to surgically remove parts of the prostate. For larger prostates, open prostatectomy techniques like the Millin or Young approaches may be used, removing the prostate through an abdominal incision. Lasers and newer technologies
This document discusses complications that can occur with transurethral resection of the prostate (TURP). It describes TURP syndrome, which involves excessive absorption of irrigating fluid during the procedure leading to dilutional hyponatremia and related neurological and cardiovascular issues. The document outlines other potential complications like perforation of the bladder, urinary retention, erectile dysfunction, and bleeding requiring transfusion. It provides details on the causes and treatment of TURP syndrome.
Portal hypertension results from increased resistance to blood flow through the liver and can cause dangerous complications like variceal bleeding and ascites. The most common cause is cirrhosis which scars and narrows vessels in the liver. Initial presentations may be asymptomatic but can include gastroesophageal varices, ascites, and splenomegaly. Prevention and treatment of variceal bleeding involves beta blockers, band ligation, and as a last resort transjugular intrahepatic portosystemic shunt placement. Ascites is treated through dietary sodium restriction, diuretics, and paracentesis while spontaneous bacterial peritonitis requires antibiotics.
Portal hypertension results from increased resistance to blood flow through the liver and can cause dangerous complications like variceal bleeding and ascites. Variceal bleeding is a major cause of mortality in cirrhosis and requires rapid fluid resuscitation and treatment to stop bleeding, often through vasoactive drugs, endoscopic variceal ligation or transjugular intrahepatic portosystemic shunt placement. Ascites develops due to fluid leakage from blood vessels and impaired fluid regulation, and is treated through dietary sodium restriction, diuretics and paracentesis.
Transurethral resection of the prostate (TURP) is a common surgery performed to relieve urinary symptoms caused by an enlarged prostate. Regional anesthesia such as spinal anesthesia is generally preferred over general anesthesia for TURP. Key complications during the procedure include hypotension from sympathetic blockade, hemorrhage, perforation of the bladder or prostate capsule, hypothermia from cold irrigation fluids, and potential for developing TURP syndrome from fluid absorption. Careful patient assessment, fluid management, and monitoring are important to help prevent complications during this common urological procedure.
TURP is a procedure to relieve urinary symptoms from an enlarged prostate. It carries risks due to the elderly patient population and long duration. A thorough pre-op assessment helps determine anesthesia technique, with subarachnoid block preferred. Potential complications include hypotension, hemorrhage, bladder perforation, hypothermia, and the rare but serious TURP syndrome caused by excessive fluid absorption. Close monitoring is needed to rapidly identify and treat any issues.
Hydronephrosis is the dilation of the renal pelvis and calyces caused by urinary outflow obstruction. It can result from anatomical or functional issues anywhere along the urinary tract. Chronic or severe hydronephrosis can lead to permanent kidney damage if not treated. Treatment depends on the cause and severity but may include ureteral stents, percutaneous nephrostomy tubes, or open surgery to bypass or remove the obstruction. The goal is to relieve obstruction and preserve kidney function.
Notes complications of liver cirrhosis Prakash Prakh
Portal hypertension is a major complication of liver cirrhosis that can lead to serious issues like variceal hemorrhage and ascites. It is caused by increased resistance to blood flow within the liver and increased blood flow into the portal vein system. Variceal hemorrhage has a high mortality rate and ascites can become refractory to treatment, requiring interventions like TIPS or transplantation. Managing the complications of portal hypertension is challenging and important for patient outcomes.
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Anesthesia for Genitourinary Surgery.pptx
1. Anesthesia for Genitourinary
Surgery: Introduction
Urological procedures account for 10–20% of
most anesthetic practices.
Patients undergoing genitourinary
procedures may be of any age, but most are
elderly and many have coexisting medical
illnesses, particularly
renal dysfunction.
2. Cystoscopy
Preoperative Considerations
Cystoscopy is the most commonly performed
urological procedure.
Indications for cystoscopy include hematuria,
recurrent urinary infections, renal calculi, and
urinary obstruction.
Bladder biopsies, retrograde pyelograms,
resection of bladder tumors, extraction or laser
lithotripsy of renal stones, and placement or
manipulation of ureteral catheters (stents) can
also be performed through the cystoscope
3. Anesthetic management varies with the age and
gender of the patient and the purpose of the
procedure.
General anesthesia is necessary for children.
Topical anesthesia in the form of viscous lidocaine
with or without sedation is used for diagnostic
studies in most women, because of a short urethra.
Operative cystoscopies involving biopsies,
cauterization, or manipulation of ureteral catheters
require regional or general anesthesia.
Most males prefer regional or general anesthesia
even for diagnostic studies.
4. Intraoperative Considerations
Lithotomy Position
Next to the supine position, the lithotomy position is the most
commonly used position for patients undergoing urological and
gynecological procedures.
Failure to properly position patients can result in iatrogenic
injuries.
Two persons are required to safely move the patient's legs
simultaneously up or down.
Straps around the ankles or special holders support the legs in
position
The leg supports should be padded, and t he legs should hang
freely.
5. c
• Injury to the common peroneal nerve, resulting in
loss of dorsi flexion of the foot, may result if the
lateral thigh rests on the strap support.
• If the legs are allowed to rest on medially placed
strap supports, compression of the saphenous
nerve can result in numbness along the medial
calf.
• Excessive flexion of the thigh against the groin
can injure the obturator and, less commonly, the
femoral nerves. Extreme flexion at the thigh can
also stretch the sciatic nerve.
• It should be noted that the most common nerve
injury associated with the lithotomy position
involves the brachial plexus.
7. The lithotomy position is associated with major physiological
alterations.
Functional residual capacity decreases, predisposing patients
to atelectasis and hypoxia.
This effect is accentuated by the head-down (Trendelenburg)
position (> 30°).
Elevation of the legs increases venous return acutely and may
exacerbate congestive heart failure.
Mean blood pressure often increases, but cardiac output does
not change significantly.
Conversely, rapid lowering of the legs acutely decreases
venous return and can result in hypotension.
8. Choice of Anesthesia
General Anesthesia
• Because of the short duration (15–20 min) and the
outpatient setting of most cystoscopies, general
anesthesia is usually used.
• Most patients are apprehensive about the procedure
and prefer to be asleep. Any anesthetic technique
suitable for outpatients may be used.
• Oxygen saturation should be closely monitored when
obese or elderly patients or those with marginal
pulmonary reserve are placed in the lithotomy or
Trendelenburg position.
A laryngeal mask airway (LMA) is often used.
9. Regional Anesthesia
• Both epidural and spinal blocks can provide
satisfactory anesthesia.
• However, satisfactory sensory blockade may
require 15–20 min for epidural anesthesia
compared with 5 min for spinal anesthesia.
• Consequently, most clinicians prefer spinal
anesthesia, particularly for procedures lasting
more than 30 min with elderly and high risk
patients.
10. c
• A sensory level to T10 provides excellent
anesthesia for nearly all cystoscopic procedures.
• Regional anesthesia, however, does not abolish
the obturator reflex (external rotation and
adduction of the thigh secondary to stimulation
of the obturator nerve by electrocautery current
through the lateral bladder wall).
• The reflex (muscle contraction) is reliably blocked
only by muscle paralysis during general
anesthesia.
11. Transurethral Surgery of the Prostate
• Preoperative Considerations
• Benign prostatic hypertrophy frequently leads to
symptomatic bladder outlet obstruction in men
older than 60 years.
• Indications of surgery include moderate to
severe lower urinary tract symptoms (LUTS) in
patients who do not respond to or decline
medical therapy, persistent gross hematuria,
recurrent urinary infections, renal insufficiency,
or bladder stones.
12. One of several operations may be selected to remove the
hypertrophied and hyperplastic prostatic tissue:
transurethral resection of the prostate (TURP), transurethral
electrovaporization, transurethral incision, transurethral laser
techniques, suprapubic (transvesical) prostatectomy, perineal
prostatectomy, or retropubic prostatectomy.
All require general or regional anesthesia.
Some less invasive procedures, such as transurethral
microwave treatments, may be performed with just topical
anesthesia.
The transurethral approach for surgery is nearly always
selected for patients with prostate gland volumes less than
40–50 mL.
13. c
• An alternative approach is chosen if the
prostate is over 80 mL.
• Patients with advanced prostatic carcinoma
may also present for transurethral resections
to relieve symptomatic urinary obstruction.
Regardless of its cause, long-standing
obstruction can lead to impaired renal
function.
14. x
• Patients undergoing prostate surgery should be
carefully evaluated for coexistent cardiac and
pulmonary disease as well as renal dysfunction
• Because of their age these patients have a relatively
high (30–60%) prevalence of both cardiovascular and
pulmonary disorders.
• TURP is reported to carry a 0.2–6% mortality rate,
which correlates best with the American Society of
Anesthesiologists' (ASA) physical status scale.
• Common causes of death include myocardial infarction,
pulmonary edema, and renal failure.
15. Intraoperative Considerations
• TURP is performed by passing a loop through a special
cystoscope (resectoscope).
• Using continuous irrigation and direct visualization,
prostatic tissue is resected by applying a cutting
current to the loop.
• Because of the characteristics of the prostate and the
large amounts of irrigation fluid often used, TURP can
be associated with a number of serious complications .
Although experience is more limited with other
transurethral prostate procedures, their complication
rate (and possible efficacy) may be less
17. TURP Syndrome
• Transurethral prostatic resection often opens the
extensive network of venous sinuses in the prostate and
potentially allows systemic absorption of the irrigating
fluid.
• The absorption of large amounts of fluid (2 L or more)
results in a constellation of symptoms and signs
commonly referred to as the TURP syndrome .
• This syndrome presents intraoperatively or
postoperatively as headache, restlessness, confusion,
cyanosis, dyspnea, arrhythmias, hypotension, or
seizures.
• Moreover, it can be rapidly fatal.
• The manifestations are primarily those of circulatory
fluid overload, water intoxication, and, occasionally,
toxicity from the solute in the irrigating fluid.
19. c
• Electrolyte solutions cannot be used for irrigation during
TURP because they disperse the electrocautery current.
Water provides excellent visibility because its
hypotonicity lyses red blood cells, but significant
absorption can readily result in acute water intoxication.
• Water irrigation is generally restricted to transurethral
resection of bladder tumors only.
• For TURP, slightly hypotonic nonelectrolyte irrigating
solutions such as glycine 1.5% (230 mOsm/L) or a
mixture of sorbitol 2.7% and mannitol 0.54% (195
mOsm/L) are most commonly used.
• Less commonly used solutions include sorbitol 3.3%,
mannitol 3%, dextrose 2.5–4%, and urea 1%.
20. v
• Because all these fluids are still hypotonic,
significant absorption of water can
nevertheless occur.
• Solute absorption can also occur because the
irrigation fluid is under pressure.
• High irrigation pressures (bottle height)
increase fluid absorption
21. v
• Absorption of irrigation fluid appears to be
dependent on the duration of the resection as
well as the height (pressure) of the irrigation
fluid.
• Most resections last 45–60 min, and, on average,
20 mL/min of the irrigating fluid is absorbed.
• Pulmonary congestion or florid pulmonary
edema can readily result from the absorption of
large amounts of irrigation fluid, particularly in
patients with limited cardiac reserve.
22. c
• The hypotonicity of these fluids also results in
acute hyponatremia and hypoosmolality, which
can lead to serious neurological manifestations .
• Symptoms of hyponatremia usually do not
develop until the serum sodium concentration
decreases below 120 mEq/L.
• Marked hypotonicity in plasma ([Na+] < 100
mEq/L) may also result in acute intravascular
hemolysis.
23. c
• Toxicity may also arise from absorption of the solutes
in these fluids.
• Marked hyperglycinemia has been reported with
glycine solutions and is thought to contribute to
circulatory depression and central nervous system
toxicity.
• Plasma glycine concentrations in excess of 1000 mg/L
have been recorded (normal is 13–17 mg/L).
• Glycine is known to be an inhibitory neurotransmitter
in the central nervous system and has also been
implicated in rare instances of transient blindness
following TURP.
24. c
• Blood ammonia levels in some patients
exceeded 500 mol/L (normal is 5–50 mol/L).
• The use of large amounts of sorbitol or
dextrose irrigating solutions can lead to
hyperglycemia, which can be marked in
diabetic patients.
• Absorption of mannitol solutions causes
intravascular volume expansion and
exacerbates fluid overload.
25. c
• Treatment of TURP syndrome depends on early
recognition and should be based on the severity
of the symptoms.
• The absorbed water must be eliminated, and
hypoxemia and hypoperfusion must be avoided.
Most patients can be managed with fluid
restriction and a loop diuretic.
• Symptomatic hyponatremia resulting in seizures
or coma should be treated with hypertonic saline
.
26. f
• The amount and rate of hypertonic saline
solution (3% or 5%) needed to correct the
hyponatremia to a safe level should be based
on the patient's serum sodium concentration
• Hypertonic saline solution should not be given
at a rate faster than 100 mL/h so as not to
exacerbate circulatory fluid overload.
27. Hypothermia
• Large volumes of irrigating fluids at room
temperature can be a major source of heat loss in
patients.
• Irrigating solutions should be warmed to body
temperature prior to use to prevent hypothermia.
• Postoperative shivering associated with
hypothermia is particularly undesirable, as it can
dislodge clots and promote postoperative
bleeding
28. Bladder Perforation
• The incidence of bladder perforation during
TURP is estimated to be approximately 1
Perforation may result from the resectoscope
going through the bladder wall or from over
distention of the bladder with irrigation fluid.
• Most bladder perforations are extraperitoneal
and are signaled by poor return of the irrigating
fluid.
• Awake patients will typically complain of nausea,
diaphoresis, and retropubic or lower abdominal
pain.
29. Coagulopathy
• Disseminated intravascular coagulation (DIC) has
on rare occasions been reported following TURP
and is thought to result from the release of
thromboplastins from the prostate into the
circulation during surgery.
• Up to 6% of patients may have evidence of
subclinical DIC.
• A dilutional thrombocytopenia can also develop
during surgery as part of the TURP syndrome from
absorption of irrigation fluids.
30. Septicemia
• The prostate is often colonized with bacteria and
may harbor chronic infection.
• Extensive surgical manipulation of the gland
together with the opening of venous sinuses can
allow entry of organisms into the bloodstream.
• Bacteremia following transurethral surgery is not
uncommon and can lead to septicemia or septic
shock .
• Prophylactic antibiotic therapy (most commonly
gentamicin, levofloxacin, or cephazolin) prior to
TURP may decrease the likelihood of bacteremic
and septic episodes.
31. Choice of Anesthesia
• Either spinal or epidural anesthesia with a T10
sensory level provides excellent anesthesia
and good operating conditions for TURP.
• When compared with general anesthesia,
regional anesthesia appears to reduce the
incidence of postoperative venous
thrombosis; it is also less likely to mask
symptoms and signs of the TURP syndrome or
bladder perforation.
32. Monitoring
• Evaluation of mental status in the awake patient is the
best monitor for detection of early signs of the TURP
syndrome and bladder perforation.
• A decrease in arterial oxygen saturation may be an
early sign of fluid overload.
• Some studies have reported perioperative ischemic
electrocardiographic changes in up to 18% of patients.
• Temperature monitoring should be used during long
resections to detect hypothermia.
• Blood loss is particularly difficult to assess because of
the use of irrigating solutions, so it is necessary to rely
on clinical signs of hypovolemia Blood loss averages
about 3–5 mL/min of resection (usually 200–300 mL
total) but is rarely life-threatening.
33. c
• Transient, postoperative decreases in
hematocrit may simply reflect hemodilution
from absorption of irrigation fluid.
• About 2.5% of patients require intraoperative
transfusion; factors associated with
transfusion include a procedure whose
duration is longer than 90 min and resection
of greater than 45 g of prostate tissue.
34. Lithotripsy
• The treatment of kidney stones has changed
significantly over the past two decades from primarily
open surgical procedures to less invasive or completely
noninvasive techniques.
• Stones in the bladder and lower ureters are now
usually treated with cystoscopic procedures, including
flexible and rigid ureteroscopy, stone extraction, stent
placement, and intracorporeal lithotripsy (laser or
electrohydraulic).
• Laser lithotripsy typically utilizes a holmium:YAG laser.
In contrast, stones in the upper two-thirds of the
ureters or kidneys are treated with extracorporeal
shock wave lithotripsy (ESWL) or percutaneous
nephrolithotomy.
35. c
• The latter is reserved for large stones (> 2 cm)
and involves techniques similar to
ureteroscopy; however, application is via a
percutaneous sheath over the kidney in the
prone position.
• Some stones (eg, cystine, uric acid, and
calcium oxalate monohydrate) are particularly
hard and are more likely to require
retreatment.
36. c
Schematic representation of a newer
tubless lithotripsy unit.
Schematic representation of an older tub lithotripsy unit
(Dornier HM3).
37. Preoperative consideration
• Patients with a history of cardiac arrhythmias and
those with a pacemaker or internal cardiac
defibrillator (ICD) may be at risk for developing
arrhythmias induced by shock waves during
ESWL./ extracorporeal shock wave lithotripsy/
(ESWL
• Shock waves can damage the internal
components of pacemaker and ICD devices
• . The manufacturer should be contacted as to the
best method for managing the device (eg,
reprogramming or applying a magnet).
38. Effects of Immersion
• Immersion into a heated water bath (36–37°C) initially results
in vasodilation that can transiently lead to hypotension.
• Arterial blood pressure, however, subsequently rises as
venous blood is redistributed centrally from the hydrostatic
pressure of water on the legs and abdomen.
• Systemic vascular resistance (SVR) rises and cardiac output
often decreases.
• The sudden increase in venous return and SVR can precipitate
congestive heart failure in patients with marginal cardiac
reserve.
• Moreover, the increase in intrathoracic blood volume
significantly reduces functional residual capacity (30–60%)
and predisposes some patients to hypoxemia.
39. Choice of Anesthesia
• Pain during lithotripsy is from dissipation of a small amount
of energy as shock waves enter the body through the skin.
• The pain is therefore localized to the skin and
proportionate to the intensity of the shock waves.
• Older lithotripsy with units employing a water bath
(Dornier HM3) requires 1000–2400 relatively high intensity
shock waves (18–22 kV) that most patients do not tolerate
without either regional or general anesthesia.
• In contrast, newer lithotripsy units that are coupled directly
to the skin utilize 2000–3000 lower intensity shock waves
(10–18 kV) that usually require only light sedation.
40. Regional Anesthesia
• Continuous epidural anesthesia is commonly
used for ESWL using a water bath.
• A T6 sensory level ensures adequate anesthesia,
as renal innervation is derived from T10 to L2.
• Supplementation of the block with fentanyl, 50–
100 mg epidurally, is often useful.
• As little air as possible should be used with the
loss of resistance technique during insertion
large amounts of air in the epidural space can
dissipate shock waves and theoretically may
promote injury to neural tissue.
41. x
• Supplemental oxygen by face mask or nasal cannula is
also useful in avoiding hypoxemia.
• Spinal anesthesia can also be used satisfactorily, but
because of the potential for an increased incidence of
postdural puncture headache in a seated patient and
less control over the sensory level with spinal
anesthesia, epidural anesthesia is usually preferred.
• Regional anesthesia greatly facilitates positioning and
monitoring.
• Prior intravascular volume expansion with 1000–1500
mL of lactated Ringer's injection may help prevent
severe postural hypotension following the onset of
neuraxial anesthesia, positioning in the hydraulic chair,
and immersion in the warm bath.
42. v
• A major disadvantage of regional anesthesia is the
inability to control diaphragmatic movement.
• Excessive diaphragmatic excursion during spontaneous
ventilation can move the stone in and out of the wave
focus and may prolong the procedure.
• This problem can be partially solved by asking the
patient to breathe in a more rapid but shallow
respiratory pattern.
• Bradycardia from high sympathetic blockade also
prolongs the procedure when shock waves are coupled
to the ECG.
43. General Anesthesia
• General endotracheal anesthesia allows control
of diaphragmatic excursion during tub lithotripsy
(Dornier HM3) and is preferred by many patients.
• The procedure is complicated by the inherent
risks associated with placing a supine
anesthetized patient in a chair, elevating and then
lowering the chair into a water bath to houlder
depth, and then reversing the sequence at the
end.
44. c
• A light general anesthetic technique in
conjunction with a muscle relaxant is preferable
• . The muscle relaxant ensures patient immobility
and control of diaphragmatic movement.
• As with regional anesthesia, intravenous fluid
loading with 1000 mL of lactated Ringer's
injection is generally advisable prior to moving
patients upright into the hydraulic chair to
prevent postural hypotension.
45. f
• Monitored Anesthesia Care
• Intravenous sedation is usually adequate for
low-energy lithotripsy.
• Low-dose propofol infusions together with
midazolam and opioid supplementation may
be used.
46. Monitoring
• Electrocardiograph pads should be attached securely
with waterproof dressing prior to immersion.
• Even with R wave–riggered shocks, supraventricular
arrhythmias can still occur and may require
treatment.
• Changes in functional residual capacity with
immersion mandate close monitoring of oxygen
saturation, particularly in patients at high risk for
developing hypoxemia.
• The temperature of the bath and the patient should
be monitored to prevent hypothermia or
hyperthermia.
47. c
• Intravenous mannitol may also act as a radical
free scavenger and helps establish an osmotic
diuresis after reperfusion.
• Nephrectomy is performed only in the presence
of intractable hypertension or chronic infection.
• Immuno suppression is started on the day of
surgery with combinations of corticosteroids,
cyclosporine (or tacrolimus), and azathioprine (or
mycophenolate mofetil).
48. Fluid Management
• Intravenous fluid therapy is typically generous.
Following the initial intravenous fluid bolus
(above), an additional 1000–2000 mL of
lactated Ringer's injection is usually given with
a small dose of furosemide (10–20 mg) to
maintain brisk urinary flow and flush stone
debris and blood clots.
• Patients with poor cardiac reserve require
more conservative fluid therapy.
49. Noncancer Surgery on the Upper
Ureter & Kidney
• Laparoscopic techniques are increasingly utilized in
urology.
• Advantages include shorter hospital stays, faster
recovery and less pain.
• Laparoscopic procedures include live donor
nephrectomy, nephrectomy, partial nephrectomy, and
pyeloplasty.
• Both transperitoneal and retroperitoneal approaches
have been developed.
• A hand-assisted technique employs an additional
larger incision that allows the surgeon to insert one
hand for tactile sensation and dissection.
50. Renal Transplantation
• The success of renal transplantation, which is largely due to
advances in immunosuppressive therapy, has greatly
improved the quality of life for patients with end-stage
renal disease.
• With modern immunosuppressive regimens, cadaveric
transplants have achieved almost the same 3-year graft
survival rates (80–90%) as living related donor grafts.
• In addition, restrictions on candidates for renal
transplantation have gradually decreased.
• . Infection and cancer are the only remaining absolute
contraindications
• Advanced age (> 60 years) and severe cardiovascular
disease are relative contraindications.
51. Preoperative Considerations
• Preoperative optimization of the patient's medical
condition with dialysis is mandatory.
• Current organ preservation techniques allow ample
time (24–48 h) for preoperative dialysis of cadaveric
recipients.
• Living-related transplants are performed electively
with the donor and recipient anesthetized
simultaneously but in separate rooms.
• The recipient's serum potassium concentration should
be below 5.5 mEq/L, and existing coagulopathies
should be corrected
52. Intraoperative Considerations
• The transplant is carried out by placing the
donor kidney retroperitoneally in the iliac fossa
and anastomosing the renal vessels to the iliac
vessels and the ureter to the bladder.
• Prior to temporary clamping of the iliac vessels,
heparin is administered.
• Injection of a calcium channel blocker (verapamil)
into the arterial circulation of the graft just prior
to revascularization helps protect the kidney from
reperfusion injury.
53. Choice of Anesthesia
. Spinal and epidural anesthesia have been
successfully employed, most transplants are done
under general anesthesia.
• All general anesthetic agents, including enflurane
and sevoflurane, have been employed without
any apparent detrimental effect on graft function;
nonetheless, these two agents are best avoided .
• Atracurium, cisatracurium, and rocuronium may
be the muscle relaxants of choice, as they are not
primarily dependent on renal excretion for
elimination.
• Similarly, vecuronium may be used with only
modest prolongation of its effects.
54. Monitoring
• Central venous pressure monitoring is very useful in
ensuring adequate hydration but avoiding fluid overload.
• Normal saline or half-normal saline solutions are commonly
used.
• A urinary catheter is placed preoperatively.
• A brisk urine flow following the arterial anastomosis
generally indicates good graft function.
• The diuresis that follows may resemble nonoliguric renal
failure .
• If the graft ischemic time was prolonged, an oliguric phase
may precede the diuretic phase, in which case fluid therapy
must be adjusted appropriately.
• The judicious use of furosemide or additional mannitol may
be indicated in such cases.
55. c
• Hyperkalemia has been reported after release of the
vascular clamp following completion of the arterial
anastomosis, particularly in small patients and pediatric
patients.
• Release of potassium contained in the preservative
solution has been implicated in those cases.
• Washout of the preservative solution with ice-cold
lactated Ringer's solution just prior to the vascular
anastomosis may help avoid this problem.
• Serum electrolyte concentrations should be monitored
closely after completion of the anastomosis.
• Hyperkalemia may be suspected from peaking of the T
wave on the ECG.
56. Suggested Reading
• Battillo JA, Hendler MA: Effects of patient
positioning during anesthesia.
• In: Anesthesia for Urological Surgery.
• Lebowitz RW (editor). Int Anesthesiol Clin
1993;31:67. [PMID: 8440533]
• Dobson PM, Caldicott LD, Gerrish SP, et al:
Changes in hemodynamic variables during
transurethral resection of the prostate:
Comparison of general and spinal anaesthesia.
• Br J Anaesth 1994;72:267. [PMID: 8130043
57. c
• Web Site
• http://www.auanet.org/guidelines/
• This site includes clinical guidelines of the
American Urological Association.
Editor's Notes
Iatrogenic injuries are occurred due to health provider manipulation when positioning a patient.eg rash,..