Appendix XIa
UAB Nurse Anesthesia Program
School of Health Related Professions
Anesthesia Management Plan
Date: August 6, 2002
__Prospective
Student Name:
x _Retrospective
Patient DX: Hemorroids
Proposed Procedure: Hemorrhoidectomy
Age: 40
Sex: M
Allergies: NKDA
Medications: None
Height: 5’10”
Weight: 84kg
ASA Status: 2
Medical/Surgical History
Significant Review of Systems
Med. Hx: Left foot fracture, hemorrhoids
Surgical Hx: Hemorrhoidectomy ’94 with GA
NAC
Social Hx: Smokes ½ ppd, denies ETOH,
H/O cocaine use.
Works as a furniture mover.
Dental: Intact
Neuro: No gross deficit
Resp: BBS CTA
CV: S1 and S2 with RRR. Normal heart sounds. No 12
lead ECG recorded.
Airway: Class 1 FROM head and neck.
Lab Values
Hct: 46
Hgb: 16
Fluid Management
Maint: 170 cc/hr
Deficit: 2040cc
3rd Space: 84 cc/hr
ABL: 1260cc
Evaluation Anesthetic Management
Spinal Anesthetic Block used for this procedure. T4 level assessed at onset of procedure. No complications
with ventilation or hemodynamics intraop.
Postoperative Evaluation
Level of block receded to T7 upon transfer to PACU. All VSS. No c/o pain or shortness of breath.
- Sample -
Scheduled Procedure: Hemorrhoidectomy
Position: Prone jacknife in this instance
Exposure: Anus and surrounding perineum.
Incision: A series or longitudinal incisions is made from the anal verge to the top of the anal columns
Blood bank: No order necessary usually
EBL: < 100cc
Surgical time: 45-90 minutes
Nerves: Pudendal Nerves
Overview
Hemorrhoids are naturally occurring tissues made up of venous vasculature that protrude into the rectal and
anal lumens sometimes can become incarcerated externally. The primary symptoms are pain and bleeding.
The primary reason for the manifestation of hemorrhoids is degeneration of the structures that support
them.
The surgical correction involves insertion of an anoscope and grasping and excision of the hemorrhoid
deep to the natural plane of the hemmorrhoidal tissue. All redundent tissue is removed and the tissue is
closed making sure that enough mucosa is left between adjacent hemorroidal columns.
The majority of hemorrhoidectomies are performed with local anesthesia unless specifically requested by
the patient.
Pre-op Assessment
.
Resp: Careful assessment of the respiratory system is required. Any h/o COPD or decreased respiratory
reserve should be noted.
CV: Usual assessment of CV status including h/o HTN, CAD, MI etc.
Neuro: Assessment for gross deficit required.
GI: Assess for h/o constipation and other GI disturbances.
Labs: H & H unless history indicates otherwise.
PreMeds: 10mg Reglan and 300mg Tagamet po
Anesthesia Implications
If pt. has limited ventilatory reserve as with COPD, lithotomy position may be tolerated better than prone
jacknife.
If considerable pain is associated with sitting then spinal may be performed in the lateral decubitus
position.
If pt is on ASA, NSAIDS or dipyridamole, PT/PTT may be needed prior to performance of regional
anesthesia.
Chest rolls will be needed to maximize chest expansion while in jacknife position and genitalia need to be
checked for pinching in the bed as well as padding all pressure points in the lower and upper extremities.
Adequate preload with a good large IV should be given prior to injection of intrathecal LA to avoid
hypotension and bradycardia. The level of the block should be monitored closely and communication with
the patient should be continuous as respiratory distress and agitation may result if the block extends into the
upper thoracic or lower cervical level.
Nausea is common with blocks that cause significant hypotension. Ephedrine should be readily available
and not withheld if signs of hypotension are present.
Anesthetic Management
1mg Versed prior to SAB. Sat up for procedure. Back prepped x 3 and allowed to dry. Local anesthetic SQ
at L2-3. #25g Whitacre through introducer without difficulty at L2-3 to LOR and +CSF return. No blood
aspirated or paresthesia elicited. 2cc 5% Lidocaine with 20mcg Fentanyl intrathecal without difficulty and
+ CSF return. Pt carefully prone with all pressure pts. checked and ok. Genitalia checked and ok.
T4 level assessed at onset of surgery.
Pt placed on 3L nc O2and 80mcg of Fentanyl were given prior to start of surgery.
Pt. without complaints during procedure.