Tag Archives: recipe

Anaesthetic considerations for robotic surgery

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).

Rectus Sheath Catheters

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

Peri-op lidocaine infusion

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

ECT

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

Lobectomy recipe

+/- 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

Radical Cystectomy Recipe

Issues:

Long/major-op
Laparotomy – usually umbilicus to pubis, may be longer
Potential major blood loss
Anastomoses
Prolonged ileus

Recipe:
Xmatch 4 units/fluid warmer/cell salvage
Large bore IV
Awake epidural @ T10. Test does 3ml of mix (of 20ml 0.25% levobupivicaine + 100mcg/2ml fentanyl)
GA/ETT ( – 2mcg/ml fentanyl, less propofol)
Asleep art line/CVC +/- CO monitor

Dex/paracetamol
Des
Just before KTS: Top-up epidural with 5ml mix/5ml H20/5ml mixRun epidural infusion 0.125% l-bupivicaine + 2mcg/ml fentanyl 4-8ml/hr.

At end bolus 5 ml of epidural infusion.
Ondansetron
Alternative:
Run remi intra-op then epidural at end/extubation
Adv: can switch off if major haemorrhage to avoid hypotension
Dis: May be difficult to wean remi->epidural and establish post-op analgesia reliably