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1

Anesthesia considerations for AV Fistula or thrombectomy

  • IV access on opposite side
  • NS is fluid of choice
  • induce with prop/etomidate, cisatracurium, and fentanyl
  • RA possible with decreased LA doses
    • may facilitate cannula introduction d/t vasodilation

2

What is a cystoscope?

Retrograde pyelography?

  • Cystoscope
    • scope introduced into urethra and advanced into bladder to allow for inspection
    • most common ly performed urologic procedure
  • retrograde pyelography
    • small catheters introduced into uretera orifices and advanced up to kidneys
    • most pts have temorary stent in place post-op

3

What are the anesthetic options for a cystoscope or pyelogram?

  • Neuraxial
    • T8-T10 required
    • Spinal: 0.75% bupivicaine
      • 10-12 mg if > 1 hour, 7.5 mg if <1 hr
    • epidural: 1.5-2% lido w/epi
      • 15-25 ml
      • supplement with 5-10 mL boluses as needed
  • GA
    • ETT vs LMA (relaxation usually not required)
    • minimal narcotic required
    • +/- toradol, check with surgeon
  • Can also be done under MAC or local with IV sedation

4

What are the other considerations for cystoscopy?

  • Lithotomy position
    • nerve injury risks
    • decrease FRC and atelectasis
    • increase in venous return that can exacerbate CHF
  • bladder perforation (HTN, tachycardia, or hypotension)
  • bacteremia
  • bleeding

5

What is the TURP procedure?

What are the different types?

How much irrigation fluid is absorbed?

What is EBL for a TURP procedure?

  • Alleviates urinary obstruction from BPH
  • resectoscope inserted into urethra/bladder allowing for cutting and coagulation of tissues and vessels
  • Types of Turp:
    • monopolar- requires hypoosmolar irrigation solution which can absorb and cause turp syndrome
    • bipolar turp- can use normal osmolarity fluids so absorption wont be as bad
    • Laser turp
  • Absorption: 20 ml/min of resection time
    • height of irrigation fluid should be no more than 60 cm above table
  • EBL = 2-4 ml/min of resection time (about 500)

6

What can the fluid absorption during TURP procedure lead to?

  • pulmonary edema
  • hyponatremia
  • cardic and retinal toxic effects
  • increased blood volume
  • hyperglycemia
  • TURP syndrome- hyponatremia, hypoosmolality
  • hypothermia

7

What are the signs and symptoms of TURP syndrome?

  • HTN leading to bradycardia or tachyarrhythmias and eventually MI
  • CHF, decreased contractility leading to Pulmonary edema and hypoxemia
  • CNS disturbances (HA, restlessness, confusion, transient blindness)
  • hemolysis
  • Hyponatremia:
    • <120 CNS effects apparent
    • <115 somnolence, hypotension, EKG changes
    • <102 sz, coma

8

How is TURP syndrome treated?

  • Early recognition
  • fluid restriction
  • loop diuretics
  • hypertonic saline
  • CV support

9

What are the anesthetic options for a TURP procedure?

  • No difference in M&M btwn GA and RA
  • GA- turp syndrome may delay emergence
  • RA- technique of choice for M-TURP to maintain neuro exam throughout case
    • T10 needed
    • decreases post-op venous thrombosis and intra-op EBL

10

What is ESWL?

  • Procedure using shock waves focused on calculi in kidneys or upper 2/3 or ureters to disintigrate them
    • high energy (1st generation); pt must be immersed in water bath
    • low energy (2nd, 3rd gen); no water bath, uses tightly focused sound beam
  • Tissue has same acoustic density as water, so waves travel without damaging tissue
    • damages stone
    • fragments can travel down (stent placed)
    • tissue destruction can occur to lung/intestine if in the way
    • shock is delivered in ventricular refractory period

11

What are the contraindications for ESWL?

absolute?

relative

  • Absolute contraindications
    • pregnancy
    • untreated bleeding disorders
  • Relative
    • AICD (must turn off)
    • pacemaker (put on non-demand mode and have backup available)
    • large calcified aortic or renal artery aneurysms
    • morbid obesity

12

What are the anesthetic options for ESWL?

  • GA with controlled ventilation- provides immobilization and avoids noise exposure
    • control of diaphragm movement (can use HFJV)
    • only light GA required
  • RA (T6 required)
    • unable to control diaphragm and immovilize
    • avoid air injection w/epidural
  • MAC ok for low energy but still need immobilization
  • **bradycardia will increase procedure length
  • adequate hydration will have stone pass after

13

Laser lithotripsy:

What is it?

Anesthetic options?

Risks?

  • Laser beam carried through rigid ureteroscope to brake ureteral stones
    • staff must wear protective eyewear
  • GA w NMB advised
    • T8-T10 required if choose to do RA
  • Risk of ARF (post-renal)
    • obstruction d/t stones, clots
    • function can be restored if cause is found within hours
    • pt may require percutaneous nephrostomy

14

Radical nephrectomy:

What is removed?

Considerations?

  • removal of kidney, adrenal gland, and perinephric fat
  • Considerations:
    • majority of pts are anemic, may need pre-op tx
    • extensive blood loss expected d/t vascular and large tumors
    • large bore PIV x2 + art line
    • consider CVC
      • L IJ, avoid R IJ d/t high proability of IVC involvement (5-10% of tumors extend into IVC and RA)
    • NS/LR 4-5 ml/kg/hr
    • anticipate hypotension w/ retraction of IVC

15

Radical prostatectomy:

What is removed?

How is pt positioned?

  • Removal of prostate, seminal vesicles, ejaculatory ducts, and part of the bladder neck
    • remaining bladder neck is anastomosed to urethra over indwelling foley catheter
  • Positioning:
    • hyperextended supine position with abdominal incision
      • iliac crest over break in OR table
    • thoracoabdominal incision position
      • hyperextended
      • knee on non-op side flexed 90
      • shoulder on op side brought over chest on arm rest
    • Roboti assisted with steep T-berg
    • Lithotomy for perineal approach

16

What are some additional considertions for a pt undergoing a radical prostatectomy?

  • Large EBL- +/- autologous blood donation
  • Large bore IV access + invasive monitoring
  • NS4-6 ml/kg/hr
  • nerve, soft tissue injuries
  • VAE
  • disease of elderly, consider comorbidities

17

What are the anesthetic options for a radical prostatectomy?

  • Neuraxial
    • decreased VAE and EBL if used w/or w/out GA
    • T8 required
  • GA
    • more commone, esp d/t uncomfortable positioning
    • standard induction and maintenance

18

What complications are seen with radical prostatectomy?

  • hemorrhage
  • hypothermia
  • VAE
  • common peroneal nerve injury d/t lithotomy position
  • DVT--> PE
  • pain is significante, consider epidural or PCA

19

Pelvic lymph node disection:

Why is it done?

How is it done?

Anesthetic?

Considerations

  • Pelvic lymph node disection to stage prostate cancer
  • DaVinci Robotic laparoscopic
  • GA (no N2O)
  • Consideration:
    • steep T berg + rotation for exposure can make ventilation difficult
    • risk for hypothermia d/t irrigation fluids

20

Bilateral Orchiectomy:

What is it?

Duration of procedure?

Anesthetic?

  • Removal of testicles to control metastatic adenocarcinoma of the prostate
  • Procedure time = 20 minutes
  • single midline scrotal incision
  • Most pts prefer GA w/ LMA, but can be done under local

21

Bladder Cancer

How is the bladder removed?

What is removed with it in Males?

Females?

  • Radical cystectomy- midline incision from pubis to xiphoid process
    • urinary diversion required
  • Removed in males:
    • bladder
    • lower ureters
    • prostate
    • seminal vesicles
  • Removed in females
    • bladder
    • uterus
    • ovaries
    • anterior vaginal wall

22

Anesthetic considerations for a pt with bladder cancer

  • Pt may have received radiation pre-op
  • 4-6 hr procedure
  • large EBL; may use controlled hypotension
  • art line, +/- CVL
  • GA w/NMB
  • RA as adjunct for post-op pain
    • can cause hyperperistalsis which makes it difficult to create the urinary diversion
  • difficult but important to assess UOP
    • look at urine on field

23