Port a cath

Plan: GA with LMA vs. sedation.
GA MUCH more common especially at a training institution.
Can consider sedation if you are confident you can keep patient calm and they give good local
Remember they are doing a quite stimulating procedure in a sensitive area (near the heart, carotids, etc)
High airway fire risk (shared field near the head, O2) further supports securing the airway rather than sedation
Considerations:
They are working near the head. For your prep, keep ekg leads on the back, moves wires tube etc away from the field
Ectopy while getting access. If lots of PVCs, you’re tickling the heart, tell them to come back
Steps of procedure:
- Usually access is obtained before port placement. This way if you can’t get access on one side you can go to the other side before placing the port.
- Dr. Christian always does it in reverse. Port placement → access.

Laparoscopic Distal Pancreatectomy

General Anesthesia + Thoracic epidural
Preop: Tylenol and celebrex, midaz
Induction: lido, fent, roc, prop
Maintenance: 1/2 Mac Sevo, 1/2 Mac Prop
PONV: Decadron/Zofran for PONV
Reverse with sugammadex and tell her to use barrier protection for a week (or neo/glyco)

Umbilical hernia repair

General Anesthesia with 8.0 ET tube
Standard pre-op, induction, maintenance, PONV
Preop: Midazolam for anxiety
Induction: lido, prop, fentanyl, and rocuronium
Maintenance: sevo
Decadron and zofran for PONV
Reverse with suggamadex
Toradol for pain control

Exploratory laparotomy

General anesthesia with ETT
Special considerations: Long case, lots of evaporative heat and fluid losses —>
Fluid warmer ideally connected to blood tubing in case blood is needed later
Two IVs
A line depending on length of surgery / sickness of pt

Sigmoid Colectomy

GETA +- epidural for intra and postop analgesia
Thoracic epidural is associated with improved post-op pain control, earlier return of bowel function, out of bed mobilization. laparoscopic approach has small incision and can be managed with opioids
No OGT/NGT, until Dr El Sedfy asks for it. They give an expensive medication in Preop that serves a promotility agent, so they don’t want us to aspirate that medication.
No need to prophylactically hydrate (textbooks will say these patients are usually under-resuscitated). Pt are given instructions on taking clears the morning of. And increased fluid during the case, leads to bowel edema and possible dissection, and failure of anastomosis.
Steps of the surgery:
1. mobilization of colon and mesentery
1. proximal and distal sites for resection are selected --> intervening mesentery is divided
1. choice of type of anastamosis vs diverting stoma
Complications / precautions for large bowel surgeries:
for emergency colectomies d/t obstruction/perforation/peritonitis --> significant pain may limit diaphragmatic excursion --> rapid desat after induction
bowel prep and NG tube suctioning means these patients are usually quite hypovolemic and may have electrolyte abnormalities

Open Inguinal Hernia Repair

Plan: GETA vs GA LMA vs Local with sedation
90% of the time will do general anesthesia. Dr. Maheshweri at Mikes does a very good local block so you can do just sedation.

Open Hernia Repair with Full Component Separation (combined plastics and GI)

Plan: GETA
What is component separation? By separating layers of the abdominal wall, component separation allows for increased mobilization of the rectus abdominis muscles to the midline. This technique has been suggested for larger hernia defects when fascial closure may lead to excess tension, resulting in a greater risk of failure or respiratory compromise
Pain management: Higher levels of pain post-operatively → blocks are good
Anterior blocks are difficult to do. If you do it post-op, the surgery has really messed with visibility across planes. If you do it pre-op, surgeons will complain that you’ve messed with their visibility / distinction between layers
A good option is a QL block, which has a more lateral approach and is less affected by the surgery
Does the patient need to stay paralyzed? Need for paralysis: theoretically not as important as in robotic/incisional repairs, but these tend to be quite large dissections and relaxation helps the surgery.

Anorectal exam under anesthesia (for hemorrhoids, anal fistulas, abscesses, etc)

Plan is MOST COMMONLY: GA Natural Airway
Alternatives include: spinal w sedation, GA with ETT
Why GA? Why not MAC? It is a very stimulating case (once you see it once you know….). Especially when applying local anesthesia in that area. You really want to make sure the pt is deep enough for that part.
Why natural airway? These cases are usually quite quick. The whole process of putting a tube and extubating may take longer than the case itself.
If they don't move when their butt cheeks are being taped apart that means they're probably deep enough. obviously watch for surgery start / incision and bolus more of sedative agent if needed.
When to tube?
- Remember the patient is PRONE and in jacknife position → if they have a stiff neck and can’t turn their head sideways, you probably have to put a tuve.
- Other reasons are:
- c/f obstruction w/o secure airway (severe OSA, obstructive lung dz)
- c/f hypercarbia while sedated and need for controlled ventilation (e.g. pt with pHTN)
- Normal stuff like if pt is vomiting then you have to RSI.
E.g.
- 2 versed, 50 fent, started prop drip @ 150
- The Grayson way: 2mg versed, 30 mg ketamine -- get em in la la land but still breathing spontaneously. this should be enough analgesia no fentanyl needed and respiratory drive conserved.
- bolus ketamine as needed

Total Thyroidectomy

GA w NIMS ETT
NIMS tube is used to neuromonitor recurrent laryngeal nerve which can get damaged during procedure, damage to this nerve can result in vocal cord paralysis
Preop: midaz, 2 good IVs (arms will be tucked so having good access is important)
Induction: standard lido prop fent, Succinylcholine (no long acting NMB because of neuromonitoring with NIMs tube)
Intubation: Tube has lines on it which have to be positioned correctly around the vocal cord
Maintenance: TIVA with propofol and Remi gtt
Vent: Volume control (need to have patient very deep with no NMB, dont want patient breathing on their own because bucking/their own breaths can interfere with neuromonitoring of recurrent laryngeal nerve)
Intraop: dexamethasone, zofran
Complications to be prepared for:
Parathyroid
Hematoma -> secure airway & decompress

Parathyroidectomy

GETA with NIMS ETT (this is a special neuromonitoring tube, intubation is basically the same except that it may be a bit more difficult to place the tube since the balloon is more in the way)
Preop: midaz, 2 good IVs (arms will be tucked so having good access is important)
Induction: standard lido prop fent, Succinylcholine (no long acting NMB because of neuromonitoring with NIMs tube)
Maintenance: Just like a total thyroidectomy, the pt isn’t fully paralyzed, but there is a very high risk if the patient moves at all. As a result, you want to make sure the patient is deep enough → maintenance of analgesia with a titratable narcotic like remifentanil.
Special:
Hypercalcemia is common in patients getting a parathyroidectomy (hyperparathyroidism) --> avoid using LR (in my case with Kanetkar, we gave 1L LR then switched to NS)
For visualization of the correct tissue, surgery may sometimes administer methylene blue pre-op. This may cause a spurious decrease in SpO2.
10 min after removal of the adenoma, they may ask you to get a PTH level. If they took out the right tissue, the PTH should have dropped by 50% or more. While waiting for the result, you will need to keep the pt intubated. PTH has a half life of 2 min.

Temporal Artery Biopsy

Procedural Sedation
Midazolam and fentanyl as needed
Propofol at the beginning as they inject local

Cervical Lymph Node Biopsy

GETA
Why not sedation? Dr. Christian said it’s because they are really close to sensitive structures in the neck and are operating near the airway so their sterile field is right in the patient’s face. It is safer and more convenient to have the airway secured with an ETT or LMA

Trauma ex lap/open abd

Plan: GETA
Pre-op:
Check for antibiotics and pain medications the patient received in the trauma bay. This information may need to be confirmed with the nurse if it's not in the chart.
Induction: RSI
Intra-op:
Use an underbody Bair Hugger and a fluid warmer to manage heat loss from the open abdomen.
Insert an OG/NG tube. If the surgeon asks to "pump air into the stomach," request a bulb syringe from the circulating nurse.
Use an esophageal temperature probe.
Emergence:
If the patient is hypothermic, some attendings will keep the patient intubated and sedated for transfer to the SICU, with the plan to extubate once they are warm to reduce shivering and metabolic demand.
Another attending said Demerol can be used to reduce shivering, and the patient can be extubated in the OR as usual.

Trach Exchange

The exchange itself is usually simple — done over a suction catheter, often with minimal or no sedation. However, if surgery is booking it and asking for anesthesia – that means you need to be prepared to either 1) sedate the patient and keep them spontaneously ventilating; 2) Use fiberoptic to provide an interior view of the trach stoma; 3) Go to GA and secure the airway. In my case, we needed to do an awake bronch for trach visualization but not put a breathing tube.

Pre-op functional airway assessment (chronic trach patient): The single most informative bedside test is the cap/occlusion test — occlude the trach (finger or cap) under monitoring and have them breathe through nose/mouth; watch SpO₂, work of breathing, stridor, air movement. Can't tolerate capping = red flag for inadequate upper airway/subglottis. Also assess: baseline tolerance of a cap/speaking valve, voice/phonation, positional or phasic symptoms (stridor, worse lying flat → dynamic/malacic component), prior instrumentation from above (what size passed, what was seen), and OSA/obesity burden (collapsible pharynx compounds everything).

Intra-op / lessons from the failed awake bronch: basically there was terrible communication between the anesthesia team and the pulmonologist who came in at the last minute to do the scope. The patient was severely uncomfortable during the trach because we never discussed how we were going to facilitate the bronch. She needed either better sedation or better airway topicalization

Nerve Blockade:
Nebulized lidocaine through the trach tube goes down the trachea — it does NOT reach the cords from below. So it won't topicalize for a scope trying to pass the cords from above.
In this case, spraying lidocaine through the bronchoscope was very unsuccessful.
In severe OSA, some proceduralists avoid SLN/airway blocks over collapse concerns
Sedation with an unsecured airway:
Anesthesia considers a cuffed trach secure; an uncuffed trach is not.
- (Pulmonologist argued that the patient’s uncuffed trach was a secure airway. I.e. if we needed to ventilate through it, we could account for any leak by increasing our volumes. I discussed it with Dr. Gadalla and we disagreed. What if the patient bronchospasmed? Which she did….air will follow the path of least resistance and leave through the mouth if it can't easily go down the bronchial tree)
If you do sedate, keep them spontaneously ventilating (versed + sevo via trach was used here)
Maintaining a secure airway with fiberoptic bronch in ETT:
If the proceduralist runs a fiberoptic scope through your tube, keep the video laryngoscope (McGrath) in place the whole time so you always know where the cords are and don't accidentally extubate.