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THE OTTAWA HOSPITAL GENERAL CAMPUS

DEPARTMENT OF ANESTHESIOLOGY

Version: Aug 27, 2014

 

PERIOPERATIVE ANESTHESIA CARE FOR ROBOTIC SURGERY

(PROSTATECTOMY AND HYSTERECTOMY)

PAU  

General medical assessment.  RN and Anesthesiology consultation.

Bloodwork as per medical directives.

Review specific patient considerations which may have concerns associated with prolonged pneumoperitoneum or extreme Trendelenberg positioning . (Severe cardiopulmonary disease, intracranial pathology,  severe ocular disease)

Review anticipated Length of Stay, discharge on POD 1

Order preoperative multimodal analgesia (if no contraindication: Allergy, Hepatic/Renal Dysfunction, Congestive Heart Failure).

·         Tylenol 975 mg po

·         Celebrex 200-400 mg po

DOS

SDA

Multimodal analgesia as ordered in PAU .

Antibiotic on chart (Ancef 1-2 g, Vancomycin if allergic).

Heparin on chart (5000 u sc to be given in OR, review with Surgeon)

OR

1.       Anesthesia technique :

·         General Anesthesia as per attending

·         Neuraxial techniques not recommended as routine.

·         Avoid opioid loading  (patients have low postoperative opioid requirements)

·         Low dose opioid intraoperative infusions acceptable; suggest early discontinuation in anticipation of emergence

2.       Venous Access

·         Ensure large bore venous access with extension tubing. Unnecessary to add PCA connector (not anticipated postop).  Ensure IV clamps not directly on skin which can indent patient (pad or remove clamps).  Once patient positioned, access to patient and lines is difficult, therefore confirm that IV functioning well.

 

3. Monitoring

·         Arterial line placement will be at discretion of Anesthesiologist.  (Unnecessary for majority of patients.  At discretion of Anesthesiologist if technical problems with NIBP and tucked arms, or based on patient considerations.)

·         Place all other monitors necessary (NMT, Temp probe) prior to final positioning, as access will be difficult.  Ensure O2 sat probe functions well after tucking arms (have ear O2 sat probe immediately available in room)

4.       Positioning (standardized with  all surgeons)

·         Patient will be placed directly on Megadyne to prevent slippage during procedure (Suggest Prewarming with Bair Hugger before transfer. 

·         Arms both tucked at sides with sleds or lapstrap.  Positioning has been standardized for all patients, please follow lead from Surgery and Nursing.

       NB.access after positioning difficult

·         Ensure ETT well secured, as access to face may be poor.

·         Ensure face, eyes clear of equipment, and padding appropriate

·         Maximum Trendelenberg will be used (anticipate  physiologic effects in conjunction with prolonged pneumoperitoneum).

·         For final positioning, drop the bed to the lowest position first, then put patient in maximum Trendelenberg (if not at lowest position, robot will not be able to be positioned properly)

·         “Test” positioning for adequacy of patient securing, prior to final positioning of robot.

·         Shoulder braces will be placed on table, but primarily for preventing fall, not to support patient in Trendelenberg.  Regular checks during procedure should ensure hand can fit between shoulder supports and shoulders, many need repositioning.

 

NB: IF SURGICAL OR ANESTHETIC EMERGENCY,  DO NOT MOVE PATIENT BED UNTIL ROBOT UNDOCKED AS THIS MAY RESULT IN PATIENT INJURY

 

5.       Ventilation  

·         At discretion of Anesthesiologist.  Anticpitate high likelihood of endobronchial intubation and poor compliance with pneumoperitoneum and postioning

6.       Orogastric Tube

·         Orogastric tube requested post induction for Robotic Hysterectomies only.  Remove prior to emergence.

7.       Fluid Management

·         Excessive fluids can contribute to excessive facial edema with prolonged steep trendelenberg positioning, and could possibly prevent safe extubation, and may contribute to prolonged PACU  stay.

·         Suggestion:  1 L crystalloid for period prior to urethrovesical anastomosis, limit if possible to 2 L crystalloid for entire case. (Studies and our local experience suggest minimal blood loss ijn majority of robotic Prostatectomies and Hysterectomies.)

8.       Thromboprophylaxis

·         TED stockings

·         SCD’s

·         Heparin 5000u s/c post induction (unless contraindication eg. HIT) may be requested by surgeon

 

9.       Antiemetic Prophylaxis

·         Goal is to fast track patients and avoid prolonged PACU stay.

·         Suggest:

i.   Dexamethasone 8 mg IV start of case

ii.            Ondansetron 4mg IV prior to emergence

10.   Local Anesthetic – Intraperitoneal Local used for Robotics

Pharmacy to provide Ropivacaine 0.15% (1.5mg/ml) in 100 ml bag.  Nursing will obtain this solution from the Omnicell.

             

·         Trocar site infiltration:  5-10 ml  (=10-20mg)

·         Cervical infiltration: 5-10ml  (=10-20mg)

·         Intraperitoneal installation through trocar (beginning and end of procedure)

o        Before initiating pneumoperitoneum:  40 ml  (=80mg)

o        Before removal trocar: 40 ml  (=80mg)

 

NB: Maximum dose 3mg/kg = 2ml/kg .

For 50 kg patient, 100 ml is maximum volume.  Adjust volume for patients less than 50 kg to prevent toxicity

 

NB . Avoid Intravenous Lidocaine with induction or continuous infusions of Lidocaine because of  cumulative toxicity

 

 

11.   Neuromuscular Blockade

·         Adequate neuromuscular blockade necessary during procedure to prevent patient movement with positioning of rigid robotic arms

·         Monitoring of blockade suggested

·         Consider infusion of muscle relaxant

PACU

Extended Length of  Stay expected: 

Gyne patients Overnight SDCU, may be same discharge if meet criteria

Urology patients planned discharge POD1 ~ 17:00. 

Postop

APS

Postoperative Analgesia will follow Robotic Surgery pathway.

·         Acetaminophen 650 mg po q4h

·         Celebrex 200 mg po q 12h

·         Hydromorphone 2-4 mg po q 4 h prn

·         Hydromorphone 1-2 mg s/c q 2 h prn.

 

 

 

It is anticipated most patients will not require PCA.  Decision will be made by Anesthesiologist and Surgeon on day of surgery (possible PCA if procedure changes (eg. Conversion to Open), or if patient has anticipated problematic postop pain (eg. Chronic pain syndrome/preop narcotic usage)

 

 

 

PAU : Preoperative Assessment Unit      OR: Operating Room

DOS: Day of Surgery                             APS: Acute Pain Service

SDA: Same Day Admission Unit           CAS: Canadian Anesthesiologist Society

PACU: Post-Anesthesia Care Unit

 

 

 

 

 

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