Adductor Canal Block

Sartorius muscle 

Mid thigh

Nerve lateral to artery

Larval to medial

AICD

Most AICD are turned off by cardiologist

If fired accidentally call cardiologist in pacu to interrogate.

Fresh Gas Low in Drager

Empty water trap

High peep and pip can sometimes be from water in the circuit

Abdominal Liposarcoma Excision

Large tumors have potential for extensive blood loss. There will also be extensive third spacing and loss of protein and albumin. Transfusion with combination of PRBC, FFP, Albumin will be necessary. 

Drug dosage

Propofol induction 2mg/kg

Rocuronium 1mg/kg

Succinylcholine 1mg/kg

Vecuronium 0.1mg/kg

Phenylephrine initial dose 100-180 mcg/min maintenance 40-60 mcg/min.

OB Anesthesia

Beginning of the day

Bring donuts, I phone with music
Pick up the phone and key
Take sign out, familiarize with all the patients
Assign all patients with epidurals to you
Check with nurse regarding patient's anesthesia preference
Check OR - make sure to have ETT 6,7 LMAs, LMA supreme

Labor Epidural

Bring tagerderm and tape, Bupivicaine 0.25%

Bicitra and fluid bolus before epidural 

Average epidural space is 5 cm in

Leave 5 cm of catheter in the epidural space

Aspirate before injecting local anesthetic 

Place patient in LUD after epidural injection. Patient will have to switch sides to achieve bilateral block.

Test dose 3cc 1.5% Lidocaine with 1:200,000 epi

Bolus dose - 

< 3cm - 0.125% Bupivicaine. 10cc. Severe pain 15cc.

> 3cm - 0.125% Bupivicaine. 15cc in 2 doses. Severe pain 0.25% Bupivicaine 

> 8cm - 0.25% Bupivicaine 10cc in 2 doses. + Fentanyl 50 mch prn.

Continuous infusion 12-15cc/hour, bolus 12, lock out 12 minutes

For perineal pain Lidocaine 1.5% 12-15cc with patient sitting

Top up

10cc 0.125% Bupivicaine 

10cc 0.25% Bupivicaine 

C-Section

Bacitra and ranitidine 

Bupivicaine 0.75% with dextrose 1.6 cc  + 0.2 mg Morphine (Fentanyl 15-35mcg optional. Last 45 mins)

Left uterine tilt

Phenylephrine, ephedrine, bolus fluid for hypotension

T4 level

Epidural for C-section

Lidocaine 2% + epi + bicarbonate 1mEq per 10cc of Lidocaine 20-30cc

Fentanyl 50mcg

Morphine 4mg after delivery 

Chloroprocaine 15-20cc for STAT section

Pitosin 20 units in first bag of IV fluid and 20 units in the second bag.
If surgeon ask for IV can give 5 units IV if VSS amenable.

GA for C-Section 

Propofol 2-2.5mg/kg, Succinylcholine 1.5mg/kg
Rocuronium 10-20mg
If on magnesium no muscle relaxant is necessary
O2/N2O 50/50 + 1 MAC Sevo
After delivery 70% N2O + 0.5 MAC Sevo , Midazolam 2mg, Fentanyl 200-300mcg
Fully awake and reversed before extubation

Epidural cart code 6789

Oral Narcotics

Percocet - oxycodone + acetaminophen 

(5/325)

Norco - hydrocodone + acetaminophen (5/325), (7.5/325), (10/325)

Vicodin - hydrocodone + acetaminophen 

Vicodin (5/500)

Vicodin ES (7.5/750)

Vicodin HP (10/660)

Midazolam for Amnesia

http://www.ncbi.nlm.nih.gov/m/pubmed/10464905/

Study done with bronchoscopy showed that 10mg of midazolam in average is required to achieve amnesia. 

Cardiac Ablation

The patient should continue anticoagulant if already on.

GETA

Muscle relaxant to control respiration. I:E ratio 1:4

Pediatric temperature probe

Heparinization.

VP Shunt

Anesthesia for VP Shunt

Type and cross 2 unit of blood although blood loss is usually minimal.

Transfusion

Recipient     RBC Doner     FFP Doner

AB               AB,A,B,O        AB

A                 A,O                 A, AB

B                 B,O                 B, AB

O                 O                   O, A, B, AB

Rh+             Rh- or Rh+     Rh+ or Rh-

Rh-              Rh-                 Rh+ or Rh-

Introp Fluid Management

Introp Fluid Management

Cerebral Aneurysm

Nitroprusside 0.3-10  mcg/kg/min. Usual range 3-4 mcg/kg/min.

Esmolol 50-200 mcg/kg/min

Nitroglycerin 5-400 mcg/min

Protonix IV

40mg reconstituted in 10cc NS ivp over 2-3 minutes

AV Fistual

Usually can be done under MAC.

Heparinization

Reverse with Protamine. (0.25mg - 1mg) of Protamine per 100 unit of heparin depending how long ago the heparin was given. Max dose 50mg.
Do not exceed rate of 5mg/minute

D & C

Oxytocin 20 units not to run too quickly to avoid hypertension.

Adrenalnectomy

Potential for blood loss.

Lateral position.

Steroid replacement hydrocortisone 100mg.

Craniotomy

Type and cross 2 units of blood.
Use normal saline for fluid.
Do not volume over load the patient. However the patient does have increase urine due to mannitol, and occasionally lasix is given.  Therefore the I & O should be balanced.

Check with surgeon regarding

Decadron
Mannitol 0.5-2g/kg - usually come in 25g bottles
Keppra - 1 vial 500mg TRO 15 minutes

Some surgeon use Optisome with ultrasound to help visualize the tumor.

Propofol 100mg can be given before head pinning.

References:

Perioperative Management of Complex Skull Base Surgery: the Anesthesiologist's Point of View

Endovascular AAA

ETT

A line

Heparin

Hold respiration during contrast injection to visualize the aorta.

Thoracoscopic Lobectomy

A line

Type and Cross 2 units prbc 
Left sided double lumen tube
35
37
39
41
Fluid restriction < 1 liter

Male 39F if > 170cm then 41F

Female 37F if < 160cm then 35F

170cm patient insert tube to 29cm. For every 10cm in height insert tube 1cm deeper, for every 10cm shorter in height insert 1cm less. 
Insert double lumen tube, twist left.
Inflate tracheal cuff.
Check end tidal CO2.

Make sure have clamp

Drop lung as soon as in later decubitus position.

Glidescope Intubation

1 - Mid-line Insertion
2- Insert styleted tube under direct vision - invert the curve if necessary. First from the side then turn along the curvature of the scope.
3 - Guide the tube under video. Cricoid pressure instead of lifting otherwise the larynx becomes more anterior.
4 - Insert the tube as the stylet comes out.

Cepacol Lozenges for sore throat

Management of DM medication and Insulin

Hold all oral hypoglycemic agents the day of surgery.

Only Thiazolidiediones (Actos, Avandia) and DPP-IV (Januvia, Onglyza) can be given the morning of the surgery.

Patient on insulin - half of morning intermediate or long acting insulin. May need glucose infusion.

Spinal Anesthesia for Total Joints

Bupivicaine 0.75% 1.6cc = 12mg
Duramorph 0.1mg

Bupivicaine 0.5% 2.5cc = 12.5mg
Duramorpha 0.1mg

For longer cases

15mg with epi wash or 0.2mg epi

Should last 2.5 hours

Use Isobariac for hip

If only hyperbaric bupivicaine available
For knee - tilt table 15 degrees to operative side
For hip - position patient operative side down for 3 minutes, then while supine for foley tilt table to operative side.

Tranexamic acid contraindicated in patients with PTCA and stent

Nubain 5-10mg Q4 for pruritis

Horacek - no duramorph, tranexams acid 1gm in 50cc ivpb 

Metta prefer GA and Vancomycin and toradol

Gerhart - spinal without duramorph. Tranexamic acid x 2, toradol

Banffy- spinal + ga. Ask for muscle relaxation. +/- femoral nerve block. No duramorph.

Kevin Ehrhart - Spinal no duramorph, 2 doses of Tranexamic Acid

Moreland- Spinal with 100mcg Duramorph

Elbow Surgery

Supraclavicular block for elbow surgery works well. 10cc of 1% lidocaine and 20cc of 0.5% ropivicaine plus 6mg of decadron.

Anesthesia and Prescription Amphetamine Use

Prescription amphetamines do not need to be discontinued for general anesthesia. A small study has shown patients who used prescription amphetamines chronic maintained hemodynamic stability during general anesthesia.

http://www.ncbi.nlm.nih.gov/pubmed/16790654

Bariatric Surgery

Back up or reverse Trendelenburg
Sniff and CPAP during induction
Restrict FIO2 < 80%

Balloon or boogie 

Carcinoid

Octreotide

Median dose intraop was 350 mcg
30-4000 mcg have been given
Upto 1mg dose have been given during crisis.

Prophylactic dose of 50mcg/hour for 12 hours

H2 blockers can also be given to prevent histamine enhaneced hypotention

Avoid epinephrine and norepinephrine. Phenylephrine can be used carefully in small doses.

Avoid ondanstrone with maybe also cause QT prolongation like octreotide.

Betablocker, labetolol can be given for hypertension.

Avoid beta agonist for bronchospasm.

Anesthesia for Urological Surgery

Radical orchiectomy

Radical orchiectomy can be done with spinal anesthesia. Minimally L1 dermatome needs to be achieved for adequate anesthesia. 

Bupivicaine 0.75% with dextrose 1.5-2cc (10-15mg)


TURP

Spinal anesthesia is the preference.
T10 - T6-7 Dematome will be needed.

Before proceeding with spinal, clear patient of valvular heart disease or coagulopathy

Hyperbaric 

Bupivicaine 0.75% with dextrose 1.5cc (10-15mg)

Isobaric

Bupivicaine 0.5% - 15mg
Tetracaine 0.5% with saline or CSF - 15mg (3cc)

25mcg of fentanyl or morphine 0.2mg can be added

Atropine 0.5mg for bradycardia

Minimal amount of NS can be given due to circulatory overload.

20cc/minute of irrigation solution can be absorbed during TURP up to 200cc/min.

Prepare pressors

Treatment of TURP symdrome
- Lasix 20mg
- ABG, check for serum Na+
- Midazolam for seizures
- Hypertonic saline for hyponatremia

Radical Prostatectomy

Can be done with epidural

 1-2 cc of local anesthetic per segment of dermatome