Central Venous Catheter Insertion Depth

Adapted with permission from Andropoulos D, Bent ST, Skjonsby B, et al. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93:883–886.

2) Size of central venous catheters for right internal jugular vein cannulation

    a) patients <10 kg 4 French →(Fr)

    b) patients 10–30 kg 5 → Fr

    c) patients 30–50 kg 7 → Fr

    d) patients >50 kg 9 → Fr

1) Special anesthetic considerations

    a) Visualization with an ultrasound prior to cannulation is recommended to assess size, verify patency of the vein, and check position of vein relative to artery.

    b) Position of catheter in vein should be confirmed with ultrasound visualization in vein or right heart, transducing a venous waveform, or confirmation with venous blood gas measurements.

    c) Confirmation of position of tip of catheter can be made by chest radiograph or transesophageal echocardiographic visualization of tip in SVC or RA.

Hematology (Table 129-8)

Table 129-8
Transfusion Estimates

1) Pediatric red cell transfusion should be calculated according to the following formula (7)

2) Maximum allowable blood loss (MABL)

Table 129-10
Vasoactive Drugs for Infusion^a

How to determine the volume of propofol (or any other drug) to draw up for a case to minimize waste

Method

1) Take the patient’s weight in kg and convert to mL of propofol (e.g., for a 12-kg child, draw up 12 mL).

2) That amount will last 1 hour at a dose of 166 mg/kg/min.

1) Estimate the duration of the case, mulitply the hours times the volume per hour for the patient, and you can determine the amount needed.

4) Knowing the amount will help decide whether to open a large or small vial and may help to minimize wastage. This formula can also be used for other drugs as long as the concentration is prepared in multiples of 10. Using the same example: For remifentanil if prepared as 10 mg/mL, 12 mL will last 1hour at a dose of 0.166 mg/kg/min. For a drug prepared as 1 mg/mL, 12 mL will last 1 hour at a dose of 16.6 mg/kg/min.

Suggested Reading/References

1. Holzman RS, van der Velde ME, Kaus SJ, et al. A Practical Approach to Pediatric Anesthesia. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

2. Cote CJ, Lerman J, Todres ID. A Practice of Anesthesia for Infants and Children. Philadelphia, PA: Saunders Elsevier, 2009.

3. Andropoulos D, Bent ST, Skjonsby B, et al. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93:883–886.

4. LMA website. www.lmana.com.

5. Golianu B, Hammer GB. Pediatric thoracic anesthesia. Curr Opin Anaesthesiol 2005;18:5–11.

6. Mariano ER, Ramamoorthy C, Chu LF, et al. A comparison of three methods for estimating appropriate tracheal tube depth in children. Ped Anesth 2005;15:846–851.

7. Morris KP, Naqvi N, Davies P, et al. A new formula for blood transfusion volume in the critically ill. Arch Dis Child 2005;90:724–728.

SECTION IX. Anesthetic Concerns in Subspecialty Anesthesia

Outpatient Anesthesia

Steve Melton, MD • Stephen M. Klein, MD

1) Overview

    a) Outpatient anesthesia, or ambulatory anesthesia, is an anesthesiology subspecialty encompassing the preoperative, intraoperative, and postoperative anesthetic care of patients undergoing elective, same-day surgical procedures.

    b) By definition, patients undergoing ambulatory surgery do not require admission to the hospital and are well enough to be discharged from the facility after the procedure.

    c) From 1996 to 2006, the number of outpatient surgery visits in the United States increased from 20.8 to 34.7 million, accounting for approximately half of all surgery visits in 1996 and two thirds of all surgery visits in 2006 (1).

    d) Advancements in surgical technique and technology resulting in less invasive surgery, and advancements in anesthesia care and postoperative pain management, are allowing patients and surgeries once requiring inpatient care and resources to be scheduled in the outpatient setting. These advancements have resulted in reduced expenses in a competitive, cost-conscious healthcare environment with improved patient satisfaction (2).

    e) The ASA Guidelines for Ambulatory surgery (3) encompass recommendations pertaining to physicians, staff, facility, equipment, and clinical care that apply to anesthesiology personnel administering ambulatory anesthesia in all settings.

2) Risk evaluation for outpatient surgery

    a) Risk identification is the foundation for perioperative risk reduction.

    b) Conditions associated with increased risk in the outpatient population include (4–6):

  i) Congestive heart failure (CHF)

  ii) Coronary artery disease (CAD)

  iii) Hypertension

  iv) Asthma

  v) COPD

  vi) Pulmonary hypertension

  vii) Obesity

  viii) Smoking

  ix) Sleep apnea

  x) Gastroesophageal reflux (GERD)

    c) Signs and/or symptoms of instability or insufficient management in any of these areas require further investigation, optimization and/or inpatient setting.

    d) It is important for the anesthesiologist to know which pre-existing medical condition predicts a specific intraoperative and/or postoperative adverse event (AE).

    e) Based on risk identification the anesthesiologist should be able to mitigate adverse events and provide optimal care for the case (7) (Table 130-1).

    f) While an individual risk factor is important, it is the combination of different factors and their management that determines the final outcome, increasing or decreasing the risk of AEs (8) (Table 130-2).

    g) When deciding whether a particular surgery and/or patient is suitable for the outpatient setting, it is necessary to identify whether the risk would be minimized in an inpatient environment and what hospital-based resources might be needed.

    h) A multidisciplinary approach to handling concerning issues will optimize perioperative management and lead to system improvements (9).

  i) While current evidence-based medicine can provide recommendations on some high-risk ambulatory issues, for others the evidence is still lacking and/or requires larger, well-designed studies (Table 130-3).

1) Postanesthetic recovery and discharge

    a) Reasons for delays after ambulatory surgery are multifactorial (9) (Table 130-4).

    b) Postoperative pain and postoperative nausea and vomiting (PONV)

  i) Commonly prolongs PACU stay after ambulatory surgery (14,15).

  ii) An aggressive plan for each of these issues must be addressed prior to surgery.

    c) Pain

  i) Pain control should be managed using a multimodal coordinated approach.

(1) Agents should be used in combination to provide analgesia with a focus on minimizing side effects

(2) Frequently used medications may include some or all of the following to maximize analgesia and minimize side effects: nonsteroidal anti-inflammatory, acetaminophen, NMDA antagonists, and opioids.

  ii) Peripheral nerve blocks (PNBs) provide site-specific surgical anesthesia and postoperative analgesia, reducing opioid requirements and opioid-related side effects (16).

  iii) As part of a multimodal approach to postoperative pain management, PNBs with long-acting local anesthetic (LA) can provide prolonged analgesia.

(1) The duration can be extended further with the placement of a perineural catheter and subsequent continuous LA infusion at home (16).

(2) Discharging patients home prior to regression of motor and sensory block can be done safely (17).

(3) Patients receiving lower-extremity PNBs should receive coaching on crutch walking.

(4) Alternative care should be arranged for those identified as unsafe or without adequate home resources.

(5) Patients receiving upper-extremity PNBs should have the affected extremity placed in a sling.

(6) Instructions specific to protection and care of the blocked extremity should be provided.

(7) If being discharged with a perineural catheter, additional instructions on catheter care and removal, and signs and symptoms of local anesthetic toxicity should be included.

(8) Timing of PNB resolution and initiation of pain medications should be reviewed to minimize and anticipate pain when the PNB resolves.

(9) Intravenous lipid emulsion 20% must be available as part of the treatment strategy for local anesthetic–induced cardiotoxicity if PNBs are utilized.

    d) PONV

  i) PONV associated with ambulatory surgery increases health care costs due to delayed discharge (pharmaceutical costs and nursing care) and hospital admission.

  ii) It accounts for 0.1% to 0.2% of unanticipated admissions, which is significant in the United States where more than 31 million patients undergo ambulatory anesthesia each year (18).

  iii) An aggressive PONV prophylaxis and treatment algorithm is prudent (18).

    e) Discharge criteria

  i) The major accreditation bodies in the United States require that policies and procedures be implemented to ensure the safe recovery of patients after ambulatory anesthesia.

  ii) Various scoring systems have been devised to facilitate timely and safe patient postanesthesia care unit (PACU) discharge and home readiness after ambulatory surgery (9,19).

  iii) Discharge criteria of an outcome-based system.

(1) Patient alert and oriented to time and place.

(2) Stable vital signs.

(3) Pain controlled by oral analgesics or peripheral nerve block.

(4) Nausea or emesis controlled.

(5) Able to walk without dizziness.

(6) No unexpected bleeding from the operative site.

(7) Oral fluid intake and voiding on case-by-case basis (9,20) (Table 130-5).

(8) Discharge instructions and prescriptions received from surgeon and anesthesiologist.

(9) Patient accepts readiness for discharge.

  iv) These systems maximize patient safety and avoid inappropriate or premature discharge.

  v) Responsible adult escorts are mandatory after ambulatory surgery (21).

4) Unanticipated inpatient admission after ambulatory surgery

    a) The reported incidence of unanticipated inpatient admission after ambulatory surgery is 1% to 2% (9).

    b) Reasons for unanticipated inpatient admissions are multifactorial including long duration of surgery, postoperative bleeding, pain, and PONV (9) (Table 130-6).

    c) The low incidence reflects that preoperative identification and management of identified factors is successful.

  i) Risk identification, including case selection

  ii) Multidisciplinary approach to handling concerning problems

  iii) Multimodal analgesia including regional anesthesia with PNBs

  iv) Aggressive PONV prophylaxis and treatment algorithm

5) Perioperative emergencies and transfer

    a) Anesthesiologist should be physically present until all patients have been discharged from anesthesia care.

    b) Personnel with training in advanced resuscitative techniques (e.g., ACLS, PALS) should be immediately available.

    c) Availability of these providers allows for acute stabilization of perioperative emergencies.

    d) Perioperative emergencies extending beyond the resources or available patient care of the ambulatory or office-based setting must be identified immediately.

    e) Emergency care and transfer protocols must be in place and activated without hesitation.

    f) Options for transfer to the inpatient setting.

  i) Activation of the 911 system.

  ii) Hospital emergency medical services.

  iii) Physically transporting the patient across a parking lot, hospital tunnel, etc. in a stretcher with oxygen, monitors, manual resuscitator, and any other resuscitative equipment.

    g) Direct communication between the anesthesiologist, the admitting physician, and the emergency room or intensive care unit physician receiving the patient must occur, providing a thorough transfer of care.

    h) Training for such emergencies should occur at frequent intervals to ensure that in the event of an emergency all personnel, both medical and administrative, can execute their roles, and that supplies are in order (22).

  i) All outpatient centers should have the medications including Dantrolene, equipment, and written protocols available to treat malignant hyperthermia when triggering agents are used.

    j) All outpatient centers should have intravenous lipid emulsion 20% available as part of the treatment strategy for local anesthetic–induced cardiotoxicity if PNBs are utilized.

    k) Surgeons should have admitting privileges at nearby hospitals, a transfer agreement with another physician who has admitting privileges, or an emergency transfer agreement with a nearby hospital (22).

6) Office-based anesthesia

    a) Like surgery visits to freestanding outpatient surgery centers, office-based surgery visits are increasing in number.

    b) There are special problems that anesthesiologists must recognize when administering anesthesia in the office setting (23).

    c) In a comparative outcome analysis of procedures performed in physicians’ offices and ambulatory surgery centers, the death rate per 100,000 procedures was 9.2 in offices and 0.78 in day surgery centers (8).

    d) ASA guidelines for office-based anesthesia encompass recommendations pertaining to physicians, staff, facility, equipment, and clinical care that apply to anesthesiology personnel administering ambulatory anesthesia in the office-based setting: (23)

  i) Compared with acute care hospitals and licensed ambulatory surgical facilities, office operatories currently have little or no regulation, oversight or control by federal, state, or local laws.

  ii) Anesthesiologists must satisfactorily investigate. Anesthesiologists must satisfactorily investigate the office-based setting and structure

(1) Governance

(2) Organization

(3) Construction

(4) Equipment

(5) Policies and procedures, including fire, safety, drugs, emergencies, staffing, training, and unanticipated patient transfers.

  iii) All office-based facilities should have a reliable source of oxygen, suction, resuscitation equipment, and emergency drugs including Dantrolene if triggering agents are used and intravenous lipid emulsion 20% if PNBs are utilized.

  iv) The anesthesiologist should adhere to the standards for pre- and postanesthesia care, anesthetic monitoring, and guidelines for ambulatory anesthesia and surgery (3).

References

1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report 2009;11:1–25.

2. White PF. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000;90:1234–1235.

3. www.asahq.org. Guidelines for Ambulatory Anesthesia and Surgery, October 22, 2008.

4. Bryson GL, Chung F, Finegan BA, et al. Patient selection in ambulatory anesthesia—an evidence-based review: part I. Can J Anaesth 2004;51:768–781.

5. Bryson GL, Chung F, Cox RG, et al. Patient selection in ambulatory anesthesia—an evidence-based review: part II. Can J Anaesth 2004;51:782–794.

6. Chung F, Mezei G Adverse outcomes in ambulatory anesthesia. Can J Anaesth 1999;46:R18–R34.

7. Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. Br J Anaesth 1999;83:262–270.

8. Bettelli G. High risk patients in day surgery. Minerva Anestesiol 2009;75:259–268.

9. Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Can J Anaesth 2006;53:858–872.

10. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007;50:1707–1732.

11. Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg 2008;107:1543–1563.

12. Cote CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology 1995;82:809–822.

13. Fleisher LA, Pasternak LR, Herbert R, et al. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg 2004;139:67–72.

14. Junger A, Klasen J, Benson M, et al. Factors determining length of stay of surgical day-case patients. Eur J Anaesthesiol 2001;18:314–321.

15. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 1997;85:808–816.

16. Klein SM, Evans H, Nielsen KC, et al. Peripheral nerve block techniques for ambulatory surgery. Anesth Analg 2005;101:1663–1676.

17. Klein SM, Nielsen KC, Greengrass RA, et al. Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine. Anesth Analg 2002;94:65–70, table of contents.

18. Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2007;105:1615–1628.

19. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89–91.

20. Mulroy MF, Salinas FV, Larkin KL, et al. Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology 2002;97:315–319.

21. Chung F, Imasogie N, Ho J, et al. Frequency and implications of ambulatory surgery without a patient escort. Can J Anaesth 2005;52: 1022–1026.

22. Desai MS. Office-based anesthesia: techniques and procedures. In: Steele SM, ed. Ambulatory Anesthesia and Perioperative Analgesia. New York, NY: McGraw-Hill Companies, Inc.; 2005:345–355.

23. www.ashq.org. Guidelines for Office-Based Anesthesia. October 22, 2009.

Robotic Surgery

Allison Long, MD

1) Robotic systems

    a) The da Vinci surgical system is currently the only commercially available system in the United States.

    b) This system has three components: a console, an optical three-dimensional vision tower, and a surgical cart.

    c) Advantages of computer-assisted robotic surgery over standard laparoscopy include

  i) Improved operative field visibility with three-dimensional imaging systems

  ii) Computer-assisted scaling improves control of fine movements and reduces the “fulcrum effect” that amplifies unwanted motions such as hand tremor.

  iii) More ergonomic, anatomic control of instruments that closely mimics the movement of the human wrist

    d) Pitfalls/limitations include

  i) Several pieces of large, bulky equipment require large amounts of OR space.

  ii) The robot itself is quite large and care must be taken in positioning robotic arms.

  iii) Invasion of the anesthetic work space

  iv) Impaired access to patient once robotic arms are positioned and engaged

2) Indications: Although the da Vinci robotic systems were initially designed for cardiothoracic surgeries, there are an increasing number of other surgical procedures utilizing robots. These include

    a) General surgery: Virtually all gastrointestinal procedures have been performed safely by surgeons using this technology. Procedures most commonly performed include cholecystectomy, fundoplication, Heller myotomy, bariatric surgery, and colectomy (2).

    b) Cardiac surgery: Mitral valve surgery, atrial septal defect repair, internal mammary artery harvest, PDA ligation, coronary artery bypass grafting, atrial fibrillation surgery, and left ventricular pacemaker lead placement

    c) Thoracic surgery: Esophageal procedures, resection of mediastinal masses, and thymectomy

    d) Urologic surgery: Radical prostatectomy, radical cystectomy, radical and simple nephrectomy, live donor nephrectomy, pyleoplasty, and adrenalectomy

    e) Gynecologic surgery: Sacral colpopexy, myomectomy, treatment of endometriosis, hysterectomy, salpingo-oopherectomy, ovarian cystectomy, and repair of vesicovaginal fistula

    f) Pediatric surgery

    g) Orthopedic surgery: Total hip and knee arthroplasty

1) Contraindications

    a) Poor pulmonary function test results may be a contraindication to robotically assisted cardiac surgery because single-lung ventilation may be poorly tolerated.

    b) The prolonged Trendelenburg position required for robotically-assisted radical prostatectomy is relatively contraindicated in patients with a history of stroke or cerebral aneurysm (2).

4) Anesthetic considerations

Patient safety during robot-assisted surgery requires advance planning and preparation.

    a) Patient positioning: robotic surgery with the da Vinci system does not allow for changes in patient position on the OR table once the robot has been docked.

  i) Pelvic procedures such as prostatectomy are usually done in lithotomy and steep Trendelenburg position, while upper abdominal surgeries are best done in the supine position with reverse Trendelenburg position.

  ii) Intrathoracic procedures often require the lateral position with variations of Trendelenburg and reverse Trendelenburg depending on the surgical site.

  iii) Mediastinal surgeries often require lateral positioning with lateral table tilt.

  iv) Before positioning the robotic cart, pressure points must be carefully padded.

  v) Close attention should be directed to the robot and the patient’s head and chest during placement and removal of the robot to avoid injury.

  vi) After robotic instruments are engaged, any patient movement can be disastrous.

    b) Limited intraoperative access to patient

  i) Preparation and open communication between the anesthesiologist and the surgical team is essential.

  ii) Because of the proximity of the side cart to the patient’s head, there is limited access to the patient’s airway and neck, and the head must be protected against inadvertent collision with the robotic arms when moving.

    c) Patient preparation and monitoring

  i) Bilateral peripheral IV access is valuable because the left upper extremity is not immediately available during surgery.

  ii) Neuromuscular blockade is very important in avoiding any patient movement while the robot is engaged.

  iii) Arterial and central venous catheterization, if necessary, should be placed prior to robotic docking.

  iv) Core temperature should be maintained with warm IV fluids and forced air warming.

    d) Special considerations for intrathoracic robot-assisted surgery

  i) All robotic procedures that demand entrance into the thoracic cavity require single-lung ventilation.

  ii) Most commonly, the left-sided double lumen endotracheal tube is used for lung isolation.

  iii) CO₂ insufflation into the thoracic cavity to a pressure of 10 to 15 mm Hg maintains the lung away from the operative area.

    e) Special considerations for pediatric robot-assisted surgery

  i) Confirming proper endotracheal tube depth with fluoroscopy after patient positioning may help prevent an airway emergency (3).

  ii) A left-sided precordial stethoscope monitors for inadvertent right main stem intubation.

Related posts:

Fiberoptic Intubation Obstructive Sleep Apnea Thyroid Disease Burn Injuries Transesophageal Echocardiography: Indications as a Monitoring Tool Adult Cardiac Surgery

Stay updated, free articles. Join our Telegram channel

Join