For procedures up to (max) 2 hours duration.
Quicker recovery than bupivicaine making it suitable for day-case
Max dose:
3.5ml of 2% hyperbaric prilocaine +/- 20mcg fentanyl
Dose range:
Saddle block: 0.5 – 1.0 ml
> T10 block: 3+ ml
< T10 block: 2-3 ml
From RDH
Key points:
Maintain muscle paralysis while robot is docked – consider infusion of relaxant
Meticulous positioning with pressure point protection
Difficult to access patient intra-op
Have enough slack on lines
If steep trendelunburg e.g. prostatectomy caution with fluids, raised ICP and IOP, airway oedema.
Recipe for radical prostatectomy:
GA, ETT, 2x IVI, a-line
O2/air/desflurane. MAC 0.8-1.0
Remifentanil (0.1-0.2mcg/kg/min) and atracurium infusion
<500ml prior to anastomosis, max 2000ml in total (if no significant blood loss).
Loading dose: 50mg/kg
then 15mg/kg/hr
NB will potentiate neuromuscular blockade
If easy airway and no risk of reflux:
IV access
nasal cannula with etCO2
left lateral with slight head up
Propofol TCI
PRN alfentanil
Job done!
Advantages: Smooth induction and emergence, efficient turnover
PR @ LRI
Equipment:
Catheter pack or Epidural pack
20ml of 0.25% l-bupivicaine for each side
Using US identify rectus muscle. Above umbilicus. Transverse plane if necessary.
Then view in longitudinal/sagittal plane
Enter as close to midline as possible, but alow enough clearance for dressing and wound.
Identify plane. Hydrodissect using saline and create space
Thread catheter as far as it goes
Then attach filter etc and inject remaining LA to see spread
Dressing pack – catheter to be exiting caudally. May use glue.
Attach infusion devise.
Link:
http://e-safe-anaesthesia.org/e_library/09/Ultrasound_guided_rectus-sheath_block_Update_2010.pdf
Used for opioid sparing analgesia and enhanced recovery in colorectal , cystectomy…
Recipe for intra-op +/- post-op lidocaine infusion (aka lignocaine for us Brits!)
Lidocaine 1%
Loading dose: 1.5mg/kg over 10min
Maintenance intra-op and post-op: 1% in 50ml syringe at 1.5mg/kg/hr
Post-op use 0.4% lidocaine (in 250ml bag)
Dose range 0.5-2mg/kg/hr
MONITOR FOR LOCAL ANAESTHETIC TOXICITY SIDE EFFECTS!
Use IBW if BMI>30
Optional extra:
Add 50mg ketamine to 50ml syringe. Run at 10mg per hour.
Ref: http://prc.coh.org/FF%20LidoIVPer12-10.pdf
RDH
Propofol +
Alfentanil: 40mcg/kg
or
Remifentanil: 4mcg/kg
– slowly over 1min. caution if slow resting HR. May need pre-med with glycopyrrolate
Intubating conditions when apnoea, low HR, in approx 15-60 sec
– FA @ LCH
Issues:
Un-cooperative patients
Remote site anaesthesia
Physiological changes: seizure, high O2 consumption, parasympathetic activity (even asystole) then sympathetic (hypertension, tachycardia)
Short procedure
Preparation:
Have atropine drawn up know where emergency drugs are
Have airway plan B & C and know where airway equipment is
Recipe:
Monitoring & IV access
Pre-O2 WELL (as much as possible)
Etomidate (up to 0.3mg/kg – refer to previous ECT session). some centres use propofol, ketamine
Sux (up to 0.5mg/kg)
Insert bite block
Maintain gentle ventilation and O2 during induction
ECT
Maintain gentle ventilation and O2 until return spent respiration
Check ons/vital signs
Principle: minimise time from induction->paralysis->ECT(->return spent resp)
– PG, GGH
+/- pre-med temazepam 10-20mg
Peripheral access 14/16G
Midazolam 0.5-2mg
Start remi at 0.1mcg/kg/min
Art line
Sit up for thoracic epidural
Supine, full monitoring inc. BIS
Epidural test-dose
Pre-O2
co-induction with propofol + sevo. 1mg/kg roc.
Miniman bagging. DLT using asleep fibre optic intubation technique.
+/- CVP
Top-up epidural 10ml of 0.25% l-bupivicaine.
Intra-op: O2/air/desflurane. Remi at 0.1mcg/kg/min.
JB, GGH
Full monitoring
IVI + arterial line
Pre-O2
Propofol & remi TIVA induction -> maintenance
(or remi in mcg/kg/min or ml/hr)
[Check ventilation]
Paralyse
Insert ventilating bronchoscope. Attach Sanders Jet Ventilator. Beware of loose connection, kinks in tubing
Jet ventilate 10-12 bpm. Allow expiration
Pause as needed e.g. laser
Suction + Insert LMA
Wake-up
