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Elective: Patients with intermittent, abnormal vaginal bleeding, uterine fibroids, or polyps may undergo D & C as an elective procedure. These procedures are typically used to determine the cause of bleeding and, in some cases, the benign or malignant nature of a uterine growth. These patients can undergo pre-operative testing based on the presence or absence of co-morbidities. 2. Preoperative evaluation During the preoperative evaluation, it is important to assess the pregnancy status of the patient, as dilatation and curettage is contraindicated in patient with a viable and desired intrauterine pregnancy. Medically unstable conditions warranting further evaluation include major cardiac or pulmonary disease or clotting disorders. Patients with pelvic infections are at risk for bacteremia and perforation as a result of the fragile uterine tissue.
lithotomy), thus limiting the feasibility of these procedures. Patients with pre-existing cardiac, gastrointestinal, or pulmonary issues may benefit from regional or paracervical blocks. It would be important to evaluate these patients preoperatively for coagulation disorders or infection near the block site. 3. What are the implications of co-existing disease on perioperative care? Patients with acute or chronic bleeding should have a baseline CBC. If bleeding has been significant (>=1.5 liters acutely, or multiple recent bleeds), then consider a DIC screen.
3. What are the implications of co-existing disease on perioperative care? Patients with acute or chronic bleeding should have a baseline CBC. If bleeding has been significant (>=1.5 liters acutely, or multiple recent bleeds), then consider a DIC screen. b. Cardiovascular system Acute ongoing hemorrhage may exacerbate underlying cardiac ischemia, further necessitating prompt resuscitation and identification of the underlying cause of bleeding. Baseline coronary artery disease or cardiac dysfunction Goals of management: If the patient’s pain and bleeding are well controlled, then the D & C or D & E should lead to minimal hemodynamic derangement. However, inadequate anesthesia and major hemorrhage can precipitate ischemia through increased utilization and decreased availability of oxygen.
Perioperative Risk Reduction Strategies These targeted patients should continue their ongoing medication regimens, assuming they are optimized. Patients with COPD may benefit from short term preoperative inhaled or systemic corticosteroids. Anesthetic techniques that avoid instrumenting the airway, such as a paracervical block with sedation or neuraxial anesthetics, are preferable to general anesthesia. Patients with a history of smoking or excessive alcohol consumption should be advised to practice smoking and alcohol cessation at least 4-8 weeks prior to surgery. Reactive Airway Disease (i.e., Asthma) The status and severity of the patient’s disease should be assessed, including identifying common triggers, the response to bronchodilators, history of recent hospitalizations, prior steroid therapy, or intubations for exacerbations. Perioperative Risk Reduction Strategies Ideally, patients would not undergo a procedure during an asthma or COPD exacerbation, but rather they would first be medically optimized. If the procedure is emergent, the anesthetic technique of choice would be to allow the patient to breathe spontaneously and avoid instrumentation of the airway (e.g.
Perioperative Risk Reduction Strategies Ideally, patients would not undergo a procedure during an asthma or COPD exacerbation, but rather they would first be medically optimized. If the procedure is emergent, the anesthetic technique of choice would be to allow the patient to breathe spontaneously and avoid instrumentation of the airway (e.g. paracervical block with sedation/MAC or spinal). If general anesthesia is necessary, then initial use of a volatile agent to aid in bronchodilation, decreased to 0.5 MAC after induction to promote uterine contraction post-procedure, would be beneficial. Preoperative and intraoperative treatment with inhaled bronchodilator therapy may also benefit these patients. In situations with excessive bleeding, carboprost (Hemabate) should be avoided or used cautiously as it can cause bronchospasm in susceptible individuals. Alternative uterotonic agents such as oxytocin, methergine, or misoprostol should be used instead.
In situations with excessive bleeding, carboprost (Hemabate) should be avoided or used cautiously as it can cause bronchospasm in susceptible individuals. Alternative uterotonic agents such as oxytocin, methergine, or misoprostol should be used instead. Active respiratory therapy is advisable. As per ASA guidelines, patients undergoing non-urgent or emergent D & C should be NPO for 6-8 hours for solid food and 2 hours for clear liquids prior to the procedure. Those with symptomatic reflux should be identified, and should undergo light sedation that preserves airway reflexes (+ paracervical block or neuraxial anesthetic) or rapid sequence induction with general endotracheal anesthesia after H2 blocker therapy. g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient) Patients with a history of or active cervical or uterine cancer should be evaluated preoperatively and managed carefully as heavy bleeding or perforation can occur. The anesthesiologist should be prepared with proper IV access and blood products on standby.
Those with symptomatic reflux should be identified, and should undergo light sedation that preserves airway reflexes (+ paracervical block or neuraxial anesthetic) or rapid sequence induction with general endotracheal anesthesia after H2 blocker therapy. g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient) Patients with a history of or active cervical or uterine cancer should be evaluated preoperatively and managed carefully as heavy bleeding or perforation can occur. The anesthesiologist should be prepared with proper IV access and blood products on standby. 4. What are the patient's medications and how should they be managed in the perioperative period? h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern? If patients are taking anti-coagulants or anti-platelet agents, they should consult with their physicians at least a week prior to surgery for further instructions, as some of these medications have an extremely long half-life.
Use regional technique or paracervical block if possible. These are not considered to be MH triggering agents, and therefore can be used in patients at risk for malignant hyperthermia. It is important to ask patients if they are allergic to local anesthetics or sunscreen containing PABA (relevant for ester local anesthetics) before administering local anesthetic. 5. What laboratory tests should be obtained and has everything been reviewed? For young healthy patients not at risk of significant bleeding, no pre-operative labs are needed unless there is significant hemorrhage. Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique? The anesthetic options for dilation and curettage include conscious sedation or MAC (monitored anesthesia care) +/- paracervical block, neuraxial, and general anesthesia. The optimal anesthetic choice depends on the patient and: a) the degree of hemorrhage/hemodynamic stability, b) the patient and provider preference, c) and cervical dilation, which may affect the feasibility of doing a paracervical block. The Cochrane Database Review (2009) examined 17 studies, including over 1,855 participants, regarding cervical dilation and uterine intervention with paracervical block when compared with no treatment, placebo, and other regional anesthesia, systemic sedation, or GA. Some studies reported that women experienced severe pain (mean scores of 7-/10) during uterine intervention, irrespective of the analgesia technique used. No technique provided reliable pain control. The available evidence fails to show whether paracervical block is inferior, equivalent to, or superior to alternative analgesia techniques in terms of efficacy and safety for women undergoing uterine interventions.
The anesthetic options for dilation and curettage include conscious sedation or MAC (monitored anesthesia care) +/- paracervical block, neuraxial, and general anesthesia. The optimal anesthetic choice depends on the patient and: a) the degree of hemorrhage/hemodynamic stability, b) the patient and provider preference, c) and cervical dilation, which may affect the feasibility of doing a paracervical block. The Cochrane Database Review (2009) examined 17 studies, including over 1,855 participants, regarding cervical dilation and uterine intervention with paracervical block when compared with no treatment, placebo, and other regional anesthesia, systemic sedation, or GA. Some studies reported that women experienced severe pain (mean scores of 7-/10) during uterine intervention, irrespective of the analgesia technique used. No technique provided reliable pain control. The available evidence fails to show whether paracervical block is inferior, equivalent to, or superior to alternative analgesia techniques in terms of efficacy and safety for women undergoing uterine interventions. a.
a. Regional anesthesia Regional anesthesia, including Paracervical block (+/- sedation), +/- intrauterine local anesthetic and neuraxial (+/- sedation) have been reported for D & C and D & E. Benefits: anecdotally, patients typically feel the least discomfort. Drawbacks: low, but non-zero, risk of post-dural puncture headache (PDPH) and transient radicular irritation (TRI) in setting of outpatient procedure and lithotomy position. Consider using hyperbaric bupivacaine 0.75% (1-1.5 ccs) with fentanyl (10-20 mics) or, if less than 1 hour of procedure time is anticipated, mepivacaine 1.5% (45-60 mg) with preservative-free dextrose (approximately 1 cc) or chloroprocaine 40-60mg. Recovery time varies and the patient may have to recover in hospital before being discharged. 2. Peripheral Nerve Block e.g., paracervical (consider Nesacaine 1%) Benefits: less invasive and better analgesia than sedation alone.
Drawbacks: low, but non-zero, risk of post-dural puncture headache (PDPH) and transient radicular irritation (TRI) in setting of outpatient procedure and lithotomy position. Consider using hyperbaric bupivacaine 0.75% (1-1.5 ccs) with fentanyl (10-20 mics) or, if less than 1 hour of procedure time is anticipated, mepivacaine 1.5% (45-60 mg) with preservative-free dextrose (approximately 1 cc) or chloroprocaine 40-60mg. Recovery time varies and the patient may have to recover in hospital before being discharged. 2. Peripheral Nerve Block e.g., paracervical (consider Nesacaine 1%) Benefits: less invasive and better analgesia than sedation alone. Drawbacks: reports of pain regardless of the agent used if paracervical block is done without sedation. Benefits: less invasive.
Consider using hyperbaric bupivacaine 0.75% (1-1.5 ccs) with fentanyl (10-20 mics) or, if less than 1 hour of procedure time is anticipated, mepivacaine 1.5% (45-60 mg) with preservative-free dextrose (approximately 1 cc) or chloroprocaine 40-60mg. Recovery time varies and the patient may have to recover in hospital before being discharged. 2. Peripheral Nerve Block e.g., paracervical (consider Nesacaine 1%) Benefits: less invasive and better analgesia than sedation alone. Drawbacks: reports of pain regardless of the agent used if paracervical block is done without sedation. Benefits: less invasive. Some investigations have shown that 5 cc’s of 2% lidocaine can be as effective as paracervical block or po NSAID.
Peripheral Nerve Block e.g., paracervical (consider Nesacaine 1%) Benefits: less invasive and better analgesia than sedation alone. Drawbacks: reports of pain regardless of the agent used if paracervical block is done without sedation. Benefits: less invasive. Some investigations have shown that 5 cc’s of 2% lidocaine can be as effective as paracervical block or po NSAID. As with paracervical block, use in conjunction with conscious sedation for best results. b. General Anesthesia Benefits: secured airway, anecdotally more reliable pain management, and less intra-op patient movement.
Increased risk of postoperative nausea and vomiting. c. Monitored Anesthesia Care D & C is often done under sedation or Monitored Anesthesia Care (MAC) with paracervical block. There are many analgesia and anesthetic agents that can be used in bolus dosing or as continuous infusions (e.g., Fentanyl and Versed, Propofol and Remifentanil). In one randomized, controlled trial, propofol (target concentration of 5 mics/ml) was recommended for D & C when administered with Fentanyl 1 mic/kg and N02 (66%) as compared with 4 and 6 mics/cc. Close monitoring and appropriate respiratory management were deemed necessary for safe administration. Benefits include that it takes the patient less time to wake up when compared with general anesthesia, potentially less need to instrument the airway, if the patient continues to breath spontaneously, and the avoidance of post-dural puncture headache. Drawbacks include the risk of respiratory depression, which could lead to depressed airway reflexes, aspiration, and/or apnea, the potential for patient movement, increasing the chance of uterine perforation, and a greater chance of inadequate pain relief when compared to neuraxial or general anesthesia.
Close monitoring and appropriate respiratory management were deemed necessary for safe administration. Benefits include that it takes the patient less time to wake up when compared with general anesthesia, potentially less need to instrument the airway, if the patient continues to breath spontaneously, and the avoidance of post-dural puncture headache. Drawbacks include the risk of respiratory depression, which could lead to depressed airway reflexes, aspiration, and/or apnea, the potential for patient movement, increasing the chance of uterine perforation, and a greater chance of inadequate pain relief when compared to neuraxial or general anesthesia. 6. What is the author's preferred method of anesthesia technique and why? When obstetric providers expect that the procedure will be straightforward (that is, there is no molar pregnancy or malplacentation) for first trimester incomplete or therapeutic abortions or the removal of retained products of conception, then our anesthetic of choice is a paracervical block placed by the surgeons (using 1% Nesacaine) and MAC. We use various combinations of anesthetics for sedation during the MAC, including bolus fentanyl and versed or propofol and remifentanil infusions.
Drawbacks include the risk of respiratory depression, which could lead to depressed airway reflexes, aspiration, and/or apnea, the potential for patient movement, increasing the chance of uterine perforation, and a greater chance of inadequate pain relief when compared to neuraxial or general anesthesia. 6. What is the author's preferred method of anesthesia technique and why? When obstetric providers expect that the procedure will be straightforward (that is, there is no molar pregnancy or malplacentation) for first trimester incomplete or therapeutic abortions or the removal of retained products of conception, then our anesthetic of choice is a paracervical block placed by the surgeons (using 1% Nesacaine) and MAC. We use various combinations of anesthetics for sedation during the MAC, including bolus fentanyl and versed or propofol and remifentanil infusions. For second trimester D & Es, our anesthetic of choice is typically either spinal or general (endotracheal) anesthesia, and occasionally MAC plus paracervical block The MAC with paracervical block option requires careful case selection (e.g., absence of symptomatic reflux in the patient, anticipation of a straightforward procedure). If significant bleeding has occurred or is expected, or if the patient is hemodynamically unstable, then we proceed with resuscitation and general endotracheal anesthesia.
Patients are continued on NSAIDs postoperatively on an as-needed basis for pain control. What prophylactic antibiotics should be administered? According to the ACOG guidelines, despite the lack of data, antibiotic prophylaxis is indicated for elective and missed suction curettage abortion. Although the optimal antibiotic regimen is unclear, Doxycycline (100 mg prior to the procedure and 200 mg post-procedure) was shown in a meta-analysis to be effective and inexpensive. In a prospective, randomized, controlled trial, antibiotic prophylaxis showed no benefit before the treatment of incomplete abortion. What do I need to know about the surgical technique to optimize my anesthetic care? Will there be manual dilation of the cervix?
“Antibiotic Prophylaxis for Gynecologic Procedures”. Obstetrics and Gynecology. vol. 113. 2009. pp. 1180-1189. (This document summarizes the recommendations for first and second line prophylaxis [including exclusion criteria] for D & E and other gynecologic procedures.)
Agostini, A, Provansal, M. “Comparison of ropivacaine and lidocaine for paracervical block during surgical abortion”. Contraception. vol. 77. 2008. pp. 382-385. (In this randomized, double-blind study, intraoperative pain was better, although still elevated, when ropivacaine was used for paracervical block compared with lidocaine.
Contraception. vol. 77. 2008. pp. 382-385. (In this randomized, double-blind study, intraoperative pain was better, although still elevated, when ropivacaine was used for paracervical block compared with lidocaine. Postoperative pain was not different between the two groups.)
vol. 77. 2008. pp. 382-385. (In this randomized, double-blind study, intraoperative pain was better, although still elevated, when ropivacaine was used for paracervical block compared with lidocaine. Postoperative pain was not different between the two groups.) Api, O, Ergen, B.
“Comparison of oral nonsteroidal analgesic and intrauterine local anesthetic for pain relief in uterine fractional curettage: a randomized, double-blind, placebo-controlled trial”. Am J Obstet Gynecol. vol. 203. 2010. pp. 28 e21-27. (Either intrauterine lidocaine (5 cc's 2% lidocaine) or oral dexketoprofen were effective in relieving fractional curettage-related pain, although a combination of the two medications did not demonstrate a clinically relevant increase in analgesia.)
Am J Obstet Gynecol. vol. 203. 2010. pp. 28 e21-27. (Either intrauterine lidocaine (5 cc's 2% lidocaine) or oral dexketoprofen were effective in relieving fractional curettage-related pain, although a combination of the two medications did not demonstrate a clinically relevant increase in analgesia.) Castillo, T, Avellanal, M. “Bolus application of remifentanil with propofol for dilatation and curettage”.
vol. 203. 2010. pp. 28 e21-27. (Either intrauterine lidocaine (5 cc's 2% lidocaine) or oral dexketoprofen were effective in relieving fractional curettage-related pain, although a combination of the two medications did not demonstrate a clinically relevant increase in analgesia.) Castillo, T, Avellanal, M. “Bolus application of remifentanil with propofol for dilatation and curettage”. Eur J Anaesthesiol.
203. 2010. pp. 28 e21-27. (Either intrauterine lidocaine (5 cc's 2% lidocaine) or oral dexketoprofen were effective in relieving fractional curettage-related pain, although a combination of the two medications did not demonstrate a clinically relevant increase in analgesia.) Castillo, T, Avellanal, M. “Bolus application of remifentanil with propofol for dilatation and curettage”. Eur J Anaesthesiol. vol.
Castillo, T, Avellanal, M. “Bolus application of remifentanil with propofol for dilatation and curettage”. Eur J Anaesthesiol. vol. 21. 2004. pp. 408-411. (The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v.
Eur J Anaesthesiol. vol. 21. 2004. pp. 408-411. (The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v. with propofol 2 mg kg(-1) i.v.
vol. 21. 2004. pp. 408-411. (The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v. with propofol 2 mg kg(-1) i.v. and 60% nitrous oxide in oxygen.)
21. 2004. pp. 408-411. (The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v. with propofol 2 mg kg(-1) i.v. and 60% nitrous oxide in oxygen.) Fox, M. C, Hayes, J. L.. “Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation”.
2004. pp. 408-411. (The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v. with propofol 2 mg kg(-1) i.v. and 60% nitrous oxide in oxygen.) Fox, M. C, Hayes, J. L.. “Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation”. Contraception.
408-411. (The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v. with propofol 2 mg kg(-1) i.v. and 60% nitrous oxide in oxygen.) Fox, M. C, Hayes, J. L.. “Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation”. Contraception. vol.
(The most favorable intra-op anesthetic conditions and post-operative recovery times were found with Remifentanil 1.5 mic/ kg(-1) i.v. with propofol 2 mg kg(-1) i.v. and 60% nitrous oxide in oxygen.) Fox, M. C, Hayes, J. L.. “Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation”. Contraception. vol. 76.
Fox, M. C, Hayes, J. L.. “Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation”. Contraception. vol. 76. 2007. pp. 486-495. (These clinical guidelines explore the role of cervical preparation for D & E prior to 20 weeks’ gestation, specifically addressing the available osmotic dilators.)
Contraception. vol. 76. 2007. pp. 486-495. (These clinical guidelines explore the role of cervical preparation for D & E prior to 20 weeks’ gestation, specifically addressing the available osmotic dilators.) Mankowski, J. L, Kingston, J.
vol. 76. 2007. pp. 486-495. (These clinical guidelines explore the role of cervical preparation for D & E prior to 20 weeks’ gestation, specifically addressing the available osmotic dilators.) Mankowski, J. L, Kingston, J. “Paracervical compared with intracervical lidocaine for suction curettage: a randomized controlled trial”.
76. 2007. pp. 486-495. (These clinical guidelines explore the role of cervical preparation for D & E prior to 20 weeks’ gestation, specifically addressing the available osmotic dilators.) Mankowski, J. L, Kingston, J. “Paracervical compared with intracervical lidocaine for suction curettage: a randomized controlled trial”. Obstet Gynecol.
“Paracervical compared with intracervical lidocaine for suction curettage: a randomized controlled trial”. Obstet Gynecol. vol. 113. 2009. pp. 1052-1057. (According to this investigation, either of these techniques, coupled with conscious sedation, provides effective and acceptable analgesia for first trimester suction curettage.)
Rattanachaiyanont, M, Leerasiri, P. “Effectiveness of intrauterine anesthesia for pain relief during fractional curettage”. Obstet Gynecol. vol. 106. 2005. pp. 533-539. (This randomized, double-blind, controlled study showed that the addition of intrauterine anesthesia (in this case 5ml 2%lidocaine in addition to the paracervical block) further reduced pain during D & C without increasing side effects.)
vol. 106. 2005. pp. 533-539. (This randomized, double-blind, controlled study showed that the addition of intrauterine anesthesia (in this case 5ml 2%lidocaine in addition to the paracervical block) further reduced pain during D & C without increasing side effects.) Sotiriadis, A, Makrydimas, G. “Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis”. Obstet Gynecol.
106. 2005. pp. 533-539. (This randomized, double-blind, controlled study showed that the addition of intrauterine anesthesia (in this case 5ml 2%lidocaine in addition to the paracervical block) further reduced pain during D & C without increasing side effects.) Sotiriadis, A, Makrydimas, G. “Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis”. Obstet Gynecol. vol.
Sotiriadis, A, Makrydimas, G. “Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis”. Obstet Gynecol. vol. 105. 2005. pp. 1104-1113. (Complete evacuation of the uterus was more common if surgical management was undertaken than if there was medical management of first trimester or incomplete miscarriage.
vol. 105. 2005. pp. 1104-1113. (Complete evacuation of the uterus was more common if surgical management was undertaken than if there was medical management of first trimester or incomplete miscarriage. Expectant management had very variable success rates.) Tangsiriwatthana, T, Sangkomkamhang, U. S. “Paracervical local anaesthesia for cervical dilatation and uterine intervention”.
Tangsiriwatthana, T, Sangkomkamhang, U. S. “Paracervical local anaesthesia for cervical dilatation and uterine intervention”. Cochrane Database Syst Rev. 2009. pp. CD005056(The Cochrane Database Review (2009) examined 17 studies, including over 1,855 participants, regarding cervical dilation and uterine intervention with paracervical block when compared with no treatment, placebo, and other regional anesthesia, systemic sedation, or GA. Some studies reported that women experienced severe pain (mean scores of 7-/10) during uterine intervention, irrespective of the analgesia technique used. No technique provided reliable pain control.) Tuncalp, O, Gulmezoglu, A. M. “Surgical procedures for evacuating incomplete miscarriage”.
Cochrane Database Syst Rev. 2009. pp. CD005056(The Cochrane Database Review (2009) examined 17 studies, including over 1,855 participants, regarding cervical dilation and uterine intervention with paracervical block when compared with no treatment, placebo, and other regional anesthesia, systemic sedation, or GA. Some studies reported that women experienced severe pain (mean scores of 7-/10) during uterine intervention, irrespective of the analgesia technique used. No technique provided reliable pain control.) Tuncalp, O, Gulmezoglu, A. M. “Surgical procedures for evacuating incomplete miscarriage”. Cochrane Database Syst Rev.
Tuncalp, O, Gulmezoglu, A. M. “Surgical procedures for evacuating incomplete miscarriage”. Cochrane Database Syst Rev. vol. 9. 2010. pp. CD001993(This paper indicates that serious complications (e.g. uterine perforation and other morbidity) were rare, but the trial sample sizes were not large enough to evaluate small or moderate differences.)
Cochrane Database Syst Rev. vol. 9. 2010. pp. CD001993(This paper indicates that serious complications (e.g. uterine perforation and other morbidity) were rare, but the trial sample sizes were not large enough to evaluate small or moderate differences.) Uerpairojkit, K, Urusopone, P. “A randomized controlled study of three targets of propofol plasma concentration in patients undergoing uterine dilation and curettage”.
Uerpairojkit, K, Urusopone, P. “A randomized controlled study of three targets of propofol plasma concentration in patients undergoing uterine dilation and curettage”. J Obstet Gynaecol Res. vol. 29. 2003. pp. 79-83. (The authors conclude that a target propofol concentration of 5 mics/ml in conjunction with Fentanyl 1mic/kg and nitrous oxide 66% minimized patient movement, hypotension, and respiratory depression during D & C.) Silvanus, MT, Groeben, H, Peters, J.
J Obstet Gynaecol Res. vol. 29. 2003. pp. 79-83. (The authors conclude that a target propofol concentration of 5 mics/ml in conjunction with Fentanyl 1mic/kg and nitrous oxide 66% minimized patient movement, hypotension, and respiratory depression during D & C.) Silvanus, MT, Groeben, H, Peters, J. “Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation”.
vol. 29. 2003. pp. 79-83. (The authors conclude that a target propofol concentration of 5 mics/ml in conjunction with Fentanyl 1mic/kg and nitrous oxide 66% minimized patient movement, hypotension, and respiratory depression during D & C.) Silvanus, MT, Groeben, H, Peters, J. “Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation”. Anesthesiology.
29. 2003. pp. 79-83. (The authors conclude that a target propofol concentration of 5 mics/ml in conjunction with Fentanyl 1mic/kg and nitrous oxide 66% minimized patient movement, hypotension, and respiratory depression during D & C.) Silvanus, MT, Groeben, H, Peters, J. “Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation”. Anesthesiology. vol.
“Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation”. Anesthesiology. vol. 100. 2004. pp. 1052-7. Warner, MA, Offord, KP, Warner, ME, Lennon, RL, Conover, MA, Jansson-Schumacher, U.
Anesthesiology. vol. 100. 2004. pp. 1052-7. Warner, MA, Offord, KP, Warner, ME, Lennon, RL, Conover, MA, Jansson-Schumacher, U. “Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients”.
vol. 100. 2004. pp. 1052-7. Warner, MA, Offord, KP, Warner, ME, Lennon, RL, Conover, MA, Jansson-Schumacher, U. “Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients”. Mayo Clin Proc.
“Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients”. Mayo Clin Proc. vol. 64. 1989. pp. 609-616. Nelson, G, Altman, AD, Nick, A, Meyer, LA.
vol. 64. 1989. pp. 609-616. Nelson, G, Altman, AD, Nick, A, Meyer, LA. “Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – Part I”. Gynecologic Oncology.
“Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – Part I”. Gynecologic Oncology. vol. 140. 2016. pp. 313-322. Copyright © 2017, 2013 Decision Support in Medicine, LLC.
Gynecologic Oncology. vol. 140. 2016. pp. 313-322. Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
vol. 140. 2016. pp. 313-322. Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC.
140. 2016. pp. 313-322. Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM. - What the Anesthesiologist Should Know before the Operative Procedure - 1. What is the urgency of the surgery? - What is the risk of delay in order to obtain additional preoperative information? - 2.
- What the Anesthesiologist Should Know before the Operative Procedure - 1. What is the urgency of the surgery? - What is the risk of delay in order to obtain additional preoperative information? - 2. Preoperative evaluation - 3. What are the implications of co-existing disease on perioperative care? - b. Cardiovascular system - c. Pulmonary - d. Renal-GI: - e. Neurologic: - f. Endocrine: - g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient) - 4.
What is the urgency of the surgery? - What is the risk of delay in order to obtain additional preoperative information? - 2. Preoperative evaluation - 3. What are the implications of co-existing disease on perioperative care? - b. Cardiovascular system - c. Pulmonary - d. Renal-GI: - e. Neurologic: - f. Endocrine: - g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient) - 4. What are the patient's medications and how should they be managed in the perioperative period?
- 2. Preoperative evaluation - 3. What are the implications of co-existing disease on perioperative care? - b. Cardiovascular system - c. Pulmonary - d. Renal-GI: - e. Neurologic: - f. Endocrine: - g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient) - 4. What are the patient's medications and how should they be managed in the perioperative period? - h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern? - i.
versus anaphylactic reaction, prepare the operating room with latex-free products. - l. Does the patient have any antibiotic allergies? - m. Does the patient have a history of allergy to anesthesia? - 5. What laboratory tests should be obtained and has everything been reviewed? - Intraoperative Management: What are the options for anesthetic management and how to determine the best technique? - 6.
- 5. What laboratory tests should be obtained and has everything been reviewed? - Intraoperative Management: What are the options for anesthetic management and how to determine the best technique? - 6. What is the author's preferred method of anesthesia technique and why? - What prophylactic antibiotics should be administered? - What do I need to know about the surgical technique to optimize my anesthetic care?
Other signs include end-inspiratory crackles (sounds heard at the end of a deep breath) on auscultation and the presence of a third heart sound. Classically it is cardiogenic (left ventricular) but fluid may also accumulate due to damage to the lung. This damage may be direct injury or injury mediated by high pressures within the pulmonary circulation. When directly or indirectly caused by increased left ventricular pressure pulmonary edema may form when mean pulmonary pressure rises from the normal of 15 mmHg to above 25 mmHg. Broadly, the causes of pulmonary edema can be divided into cardiogenic and non-cardiogenic. By convention cardiogenic refers to left ventricular causes. - Congestive heart failure which is due to the heart's inability to pump the blood out of the pulmonary circulation at a sufficient rate resulting in elevation in wedge pressure and pulmonary edema – this may be due to left ventricular failure, arrhythmias, or fluid overload, e.g., from kidney failure or intravenous therapy.
Blood tests are performed for electrolytes (sodium, potassium) and markers of renal function (creatinine, urea). Liver enzymes, inflammatory markers (usually C-reactive protein) and a complete blood count as well as coagulation studies (PT, aPTT) are also typically requested. B-type natriuretic peptide (BNP) is available in many hospitals, sometimes even as a point-of-care test. Low levels of BNP (<100 pg/ml) suggest a cardiac cause is unlikely. In those with underlying heart disease, effective control of congestive symptoms prevents pulmonary edema. Dexamethasone is in widespread use for the prevention of high altitude pulmonary edema. Sildenafil is used as a preventive treatment for altitude-induced pulmonary edema and pulmonary hypertension, the mechanism of action is via phosphodiesterase inhibition which raises cGMP, resulting in pulmonary arterial vasodilation and inhibition of smooth muscle cell proliferation.
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