Appendix XI
UAB Nurse Anesthesia Program
School of Health Related Professions
Anesthesia Management Plan
Date: August 6, 2002
Student Name:
x Prospective
Retrospective
Patient DX: Desires Sterilization
Proposed Procedure: Laparoscopic BTL
Age: 34
Sex: F
Allergies: NKDA
Medications: None
Height: 5’1”
Weight: 74kg
ASA Status: 1
Medical/Surgical History
Significant Review of Systems
Med. Hx: Para 3003
All deliveries uncomplicated vaginal
Surgical Hx: None
Social Hx: Smokes ½ ppd. Occasional ETOH.
Denies drug use.
Dental: Good. No loose teeth or Partials.
Neuro: Alert and oriented x3. No gross deficit.
Resp: BBS CTA. Chest x-ray without opacities or gross
Abnormalities.
CV: S1 and S2. RRR. No ectopy. .
GU: H/o UTI’s
Airway: Class 2; FROM of head and neck.
Lab Values
Na: 139 Hgb: 13.2
Cl: 106
BUN: 10
K: 4.1
Plt: 212
Cr: 0.6
CO2: 25
HCT: 39.5
Glu: 98
Fluid Management
Maint: 148 cc/hr
Deficit: 1780 cc
3rd Space: minimal
ABL: 960cc
Evaluation Anesthetic Management
Adequate anesthetic depth attained as evidenced by stable vital signs throughout the procedure and during
induction and emergence. Adequate muscle relaxation as monitored per nerve stimulator.
Postoperative Evaluation
To PACU with HOB elevated Extubated without difficulty after sustained lift following reversal. VSS and
O2 saturation holds at 97% on 40% OFM.
- Sample -
Scheduled Procedure: Laparoscopic BTL
Position: Supine with arms on bilateral padded armboards < ninety degrees from sides.
Exposure: Zyphoid to pubis. Table to table
Incision: 1-4 incisions approximately 1-2 cm long below the umbilicus.
Blood bank: Type & screen
EBL: < 10 cc
Surgical time: 10-30 minutes
Nerves: Cutaneous branches of T10-12.
Overview
Laparoscopy is a technique widely used to visualize abdominal and pelvic structures without a large
incision thus promoting quicker recovery from surgery. It involves several small incisions through which
trocars are inserted for insufflation of CO2 into the peritoneal cavity, and rigid instrumentation support.The
laparoscope is a rigid long camera with a fiberoptic lightsource attached to the end that is inserted through
one of the trocars to provide visualization. Several procedures may be performed with the use of the
laparoscope, one of which is tubal ligation for sterilization.
Lithotomy is used to allow for uterine manipulation from a vaginal approach.
The procedure is usually performed under GETA but may also be done with regional techniques.
This patient preferred General.
Reglan 10mg IV slow with Pepcid 20mg IV slow were given preoperatively for aspiration prophylaxis.
Pre-op Assessment
Complete history including assessment for GERD. This pt’s history was relatively benign with the
exception of fibroadenomatous reproductive organs. She had irregular periods with some heavy bleeding
and pain.
Her exercise tolerance was good and her BP was within normal limits.
Anesthesia Implications
With the insufflation of large quantities of air into the peritoneum, ventilation can become more
challenging. Residual volume decreases and peak inspiratory pressures increase. O2 saturations may
decrease a bit and you may need to deliver smaller tidal volumes with higher respiratory rates to keep the
patient from becoming hypercapneic. There may also be some intraperitoneal absorption of CO2 which
may also contribute.
Dysrhythmias such as ST or SB may occur with CO2 insufflation as well.
Postoperatively, the pt may have some abdominal discomfort that may radiate to the shoulders due
primarily to quantities of CO2 in the peritoneum and or gut.
Anesthetic Management
Upon entering the room and monitor attachment, 2mg Versed and 100mcg Fentanyl were given. We also
administered a defasciculating dose of 5mg Zemuron at this time.
Induction was performed with 80mg Propofol and 120mg Anectine.
A 7.0 Fr ETT was placed without difficulty of trauma and Isoflurane with O2 /N2O were utilized for
maintenance. Zemuron 15-20mg boluses for continuous relaxation as monitored per PNS.
1 liter of LR was given intraoperatively via #18 PIV.
Reversal attained with Neostigmine 3mg and Robinul .6mg as evidenced by Full 4/4 TOF and sustained
DBS.
Isoflurane turned off with closing of fascial layer and N2O with O2 utilized to aid in blowing off volatile
until skin is closed.
Ventilator turned off at .27% ET agent and pt. allowed to begin spontaneous respirations. Oropharynx
suctioned and pt. extubated with + Pressure after sustained head lift displayed and following commands.
Little BP or HR lability intraop. With smooth induction and emergence.