The anesthesiologist personally provided the anesthesia care.
The anesthesiologist personally provided the anesthesia care. The patient’s physical status was -P4. LOCATION: Inpatient, Hospital PATIENT: Kelsey Ducsavage PHYSICIAN: Gary I. Sanchez, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Crigler-Najjar Syndrome. POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURES:
1. Orthotopic liver transplant.
2. Temporary portacaval shunt.
ANESTHESIA: General ESTIMATED BLOOD LOSS: Less than 100 ml.
INDICATIONS: This patient is a 10-year-old boy with Crigler-Najjar syndrome. He was listed for transplantation about 4 months ago. A donor became available. The liver was procured and sent to our center. I performed a back table dissection in the immediate preoperative period. The hepatic artery and arterial anatomy were normal. The liver was comfortable size to the recipient.
DESCRIPTION OF PROCEDURE: He was placed on the table in supine position and general anesthesia was induced. The abdomen was prepped and draped in a sterile manner. We made a standard bilateral subcostal incision with a vertical extension. We entered the abdominal cavity. There was no evidence of ascites or retention present. We then placed the appropriate retractors in the subcostal position. The liver itself had a relatively unremarkable appearance and without evidence of chronic disease, which was not unexpected. His disease consists primarily of a metabolic syndrome. Therefore, the liver was grossly unremarkable. We began by performing a portal dissection. We identified the junction of the cystic duct and common duct. The cystic duct was ligated, and we transected the common duct just above this. We identified left and right branches of hepatic artery and dissected this back. The gastroduodenal also came off at this site. Therefore, the branches were trifurcated. We ligated the right and left branches leaving the gastroduodenal intact. The portal vein was then dissected off for a length of about 3 cm. We clamped the portal vein at the hilum and transected it by oversewing the hepatic side. We then rotated the vein down for an end-to-side portacaval shunt. This was done with a 5-0 Prolene. After completion of the shunt, we performed the recipient hepatectomy. The right and left lobes were mobilized, and the liver was taken off the vena cava with numerous small branches ligated, large accessory right hepatic vein branch was sutured. We then placed a cross-clamp at the hepatic veins and removed the liver. We were able to open the cuff of all 3 hepatic veins into a single orifice, which did perfectly in size to the donor suprahepatic cava. The liver was then brought into the field, and the suprahepatic cava anastomosis was done using a 4-0 Prolene. We then ligated the portacaval shunt and shortened the donor portal vein appropriately and performed an end-to-end portal vein anastomosis with a 5-0 Prolene. We flushed the liver with lactated Ringer’s just prior to completing the anastomosis. We then reperfused the liver allowing the initial pass of blood out the infrahepatic cava, which was then ligated with a 0 silk tie. It was extremely stable during the reperfusion. We then pursued immediately to hepatic artery anastomosis. The gastroduodenal branch was ligated, and we clamped the native hepatic artery and transected it proximal to the various branches. The diameter of the native artery was surprisingly small. We dilated this pretty gently. It corresponded in size to the common hepatic artery of the donor. Therefore, we resected the celiac trunk and all the other branches and performed an end-to-end anastomosis of donor to recipient common hepatic arteries. This was done with interrupted 7-0 Prolene sutures. We then released the clamp. There was good flow in liver. We applied some topical vasodilators with good results. We took a very short break at this point, during which patient was monitored, and returned in about 10 minutes. There was adequate hemostasis. We proceeded immediately to the bile duct anastomosis. The donor and recipient ducts were approximately same diameter. The donor duct was shortened appropriately, and then, we performed an end-to-end anastomosis with a running 6-0 PDS. At this point, we checked the operative site for hemostasis, which continued to be excellent. Sponge and lap counts were verified. We closed the abdomen with a 0 Prolene for fascia. We placed 1 closed suction drain in the subhepatic space. The skin was closed with staples. Overall, he tolerated the procedure extremely well. Estimated blood loss for the entire operation was less than 100 ml. He was taken to intensive care unit in stable condition.
Pathology pending.
2 The anesthesiologist is medically supervising a CRNA, with a total of 4 concurrent cases. The patient’s physical status was -P2. LOCATION: Outpatient, Hospital PATIENT: Jacob Newton PHYSICIAN: Larry P. Friendly, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
INDICATIONS:
1. Persistent vomiting.
2. Delayed gastric emptying
ENDOSCOPIC IMPRESSION: Abnormal EGD
1. Gastric outlet obstruction secondary to pyloric web.
2. Suspect esophagitis (peptic vs. eosinophilic)
INDICATIONS: Patient seen for persistent vomiting. Discussed options, answered questions and patient consented to proceed with EGD.
PROCEDURE: EGD with biopsy and fluoroscopy study COMPLICATIONS: No complications
ESTIMATED BLOOD LOSS: Minimal
DESCRIPTION of PROCEDURE and FINDINGS: The patient was brought to the operating room and anesthetized. The patient remained positioned in the supine position. The Pentax EG1870 A110046 gastroscope was passed into the upper esophagus under direct vision. Endoscopic appearance of the esophagus was abnormal as there was swelling of the mucosa without erythema or erosions. There were longitudinal furrows, but no exudates. The stomach was entered and insufflated with air to flatten the folds. Endoscopic appearance of the body and retroflex view of the cardia and fundus were unremarkable. The pylorus was abnormal as the pylorus is obscured by circumferential hypertrophied antroduodenal folds. The diameter at the pylorus was diminutive, 6 mm and offered resistance to the passage of the scope with an OD of 6 mm. The duodenal bulb is generous and has a slight change in caliber at its first fold. The second and third portion of the duodenum and most proximal jejunum had normal caliber and no anatomical abnormalities. Fluoroscopic examination of the first portion of the small bowel and antropyloric area reveals there is not thickening, of the pylorus and there is an uniform caliber of the duodenum. Random biopsies were obtained from the duodenum and antrum. Biopsies were obtained from the distal and proximal esophagus. The endoscope was advanced into the stomach a final time to evacuate the air/fluids and it was withdrawn, terminating the procedure. The patient tolerated the procedure well, was awakened, and returned to the recovery room in good condition.
TREATMENT PLAN: Await biopsy results and surgical consultation. A surgical intervention is likely to be our next step.
DISPOSITION: Discharge home/after care instructions provided
3 The CRNA provided the anesthesia care without medical direction. The patient’s physical status was -P2. LOCATION: Outpatient, Hospital PATIENT: Denise Kohlmeir PHYSICIAN: Mohomad Almaz, M.D. ANESTHESIOLOGIST: Karen Demers, CRNA PREOPERATIVE DIAGNOSIS: Loose body, right knee. POSTOPERATIVE DIAGNOSIS: Same.
OPERATIVE PROCEDURE: Right knee arthroscopy with removal of loose body. POSITION: Supine. ANESTHESIA: General.
INDICATIONS: The patient is a 26-year-old young lady who underwent right knee arthroscopy with bone grafting of an osteochondritis dissecans lesion in May. The patient had removal of loose bodies and cancellous autograft placement into the base of her osteochondritis dissecans lesion at that time. Postoperatively, she has been doing extremely well, but recently developed some catching and locking in her knee. A new MRI was obtained which shows a loose body sitting in the suprapatellar pouch. She presents electively today for right knee arthroscopy.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and placed supine on the operating table. After administration of general anesthesia and receiving Ancef antibiotic, her right lower extremity was prepped and draped in the normal sterile fashion with a tourniquet about her right proximal thigh. The left lower extremity was draped over a well-leg holder, well padded and secured.
The procedure began with exsanguination of the right lower extremity and inflation of the thigh tourniquet to 250 mmHg. Three arthroscopic portals were made; the superolateral portal was used for outflow and medial and lateral parapatellar tendon portals were used for arthroscopic tool placement. Evaluation of the patient’s knee joint showed she had normal articular cartilage on the medial and lateral facets of the patella, the apex of the patella, and the femoral trochlea. Evaluation of the femoral notch showed a normal anterior and posterior cruciate ligament. Evaluation of the medial compartment showed that the patient had excellent healing and shape to the medial femoral condyle. There was slight bulging in the area of the fibrocartilage, but there was no fraying or flapping on the fibrocartilage and there was good fill with reasonable contour of the medial femoral condyle. Evaluation of the lateral compartment showed normal articular cartilage on the femur and tibia with a normal lateral meniscus.
Attention was turned to the medial and lateral gutter where the loose body was identified. It was directed up into the suprapatellar pouch and was easily removed using an arthroscopic grasper.
At this time, all arthroscopic tools were removed. A drain was placed in the superolateral portal. The portals were closed with 4-0 Vicryl and covered with Steri-Strips. A sterile dressing was applied and held in place with a Kerlix. A TED stocking was placed on the patient’s leg and an ice pack applied to the knee. The tourniquet was released.
The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Pathology Report Later Indicated: tissue from knee benign.
4 The anesthesia service was performed by the CRNA with an anesthesiologist medically directing 2 concurrent cases. The patient’s physical status was a -P1. LOCATION: Outpatient, Hospital PATIENT: Gabby Brown PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Right perineal abscess. POSTOPERATIVE DIAGNOSIS: Right perineal abscess x2. PROCEDURE: Incision and drainage of right perineal abscess.
ANESTHESIA: General. ESTIMATED BLOOD LOSS: Less than 3 ml. COMPLICATIONS: None.
INDICATIONS: This is a 14-year-old African-American female who has a 1-week history of a tender mass in right labial region. Per history, the mass has begun to bleed and drained over the past 24 hours. The patient was noted to be on Bactrim prior to admission.
FINDINGS: as below
DESCRIPTION OF PROCEDURE: After informed consent, we proceeded to the operating room. A general mask anesthesia was noted for the patient. A time out was made prior to the procedure beginning. The patient currently was receiving intravenous clindamycin. The prep was performed and sterile towels and drapes were placed over the perineum. A 1-cm stab incision was made near the edge of the right labia and into the buttocks region. Copious amount of purulence was noted with gentle expression of the cavity. The cavity was then irrigated with normal saline solution, approximately 80 ml. The cavity was then packed with quarter-inch iodoform gauze and covered by 4 x 4.
4 The anesthesia service was performed by the CRNA with the anesthesiologist medically directing 4 concurrent cases. The patient’s physical status is -P2. LOCATION: Outpatient, Hospital PATIENT: Evan Ziebach PHYSICIAN: Larry P. Friendly, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Radiation proctitis.
2. Rule out anal stenosis.
POSTOPERATIVE DIAGNOSIS: Radiation proctitis.
PROCEDURES PERFORMED: Exam under anesthesia with rigid proctoscopy. ANESTHESIA: General anesthesia.
CLINICAL SUMMARY: This patient has a longstanding history of radiation proctitis and has had significant difficulties with his defecation patterns. Because of this, he was referred to rule out an anal stenosis. He was extremely tender and would not allow examination in the clinic.
DESCRIPTION OF OPERATION: The patient was placed in a supine position and underwent anesthesia. He was then placed in a low lithotomy position and prepped and draped in the usual fashion. Digital examination revealed a slightly woody and abnormal anal exam but without significant stenosis. Rigid proctoscopy confirmed that there was no additional pathology within the rectum with the exception of the hypervascularity associated with radiation injury. Following this, the patient was returned to the supine position and returned to the recovery room in good condition.
6 The anesthesia service was provided by a CRNA with an anesthesiologist medically directing 3 concurrent cases. The CRNA performed an axillary block in the holding room 45 minutes prior to the start of anesthesia time. Patient is a stable diabetic. The patient’s physical status was -P2. The axillary block is the type of anesthesia used for this case.
What is the total anesthesia time for this case?
The axillary block time: 0900 to 0917.
The anesthesia time: 1002 to 1108.
LOCATION: Outpatient, Hospital PATIENT: Inga Somers PHYSICIAN: Timothy L. Pleasant, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Same. OPERATIVE PROCEDURE: Right carpal tunnel release.
ANESTHESIA: Axillary block with sedation. COMPLICATIONS: None.
INDICATIONS: Patient with right carpal tunnel syndrome. Failed conservative management and presents for surgical intervention. I have met with the patient and discussed the planned procedure, indications, and risks. Her questions have been answered, she understood and agreed to proceed.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was taken to the Operating Room and placed in the supine position. The right upper extremity was then prepped and draped in the standard fashion.
A standard incision was performed parallel to the thenar crease; this incision measured approximately 3 cm. The palmar fascia was incised. The transverse carpal ligament was identified and released both proximally and distally. The nerve was assessed; the nerve did look very compressed. There were no masses. At this point, the tourniquet was released. Hemostasis was achieved.
The wound was irrigated and closed with interrupted horizontal mattress sutures. There were no complications during the procedure.
The patient was taken to the recovery room for close observation, in stable condition.
7 A CRNA provided anesthesia under Dr. Larson’s medical direction while she was directing 3 concurrent cases. The patient is a normal healthy female. The patient’s physical status was -P1. LOCATION: Inpatient, Hospital PATIENT: Patricia Keystone PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Symptomatic macromastia. POSTOPERATIVE DIAGNOSIS: Same.
Patricia is a 25-year-old woman who has requested a breast reduction due to her macromastia. All of her questions and concerns have been answered and she wishes to proceed with the procedure.
PROCEDURE: Bilateral breast reduction using a vertical parenchymal shaping with horizontal skin excision technique.
This young woman has symptomatic macromastia as determined in her preoperative chart. Risks and benefits of surgery were discussed with the patient prior to coming to the operating room but, in review, included but not limited to infection, bleeding, hematoma, seroma, scar formation, changes in nipple sensitivity, devascularization of the nipple/areolar complex, asymmetry, bruising, and the need for reoperation.
With this in mind, the patient was marked 1 day preoperatively in a seated and upright position with the intention of placing the top of her new areola at 22 cm from the sternal notch.
Preoperatively, her marks were rechecked. She was treated with bilateral compression boots, Ancef, and a forced air warming blanket for 30 minutes prior to going to surgery. She was taken to the operating room and placed in a supine and padded position, the arms tucked, the ulnar nerves padded, and the chest prepped and draped in a sterile fashion following the infusion of 500 cc of tumescent solution into each breast. Specifically, that fluid was infused in a manner to provide hemostasis throughout dissection planes.
With this done, surgery began on the right, side where a 48-mm areola was designed. The superomedial pedicle which had been preoperatively marked was de-epithelialized. The superomedial pedicle was then defined with a 10 blade superiorly, inferiorly, and laterally. Cat’s paw retractors were put into the level of the proposed new inframammary fold. The inferior breast was evacuated off of the skin using a Bovie set at 20. At this point, we performed resection of inferior and lateral breast tissue in a crescentic shape. We then did a tailor-tack technique to determine final skin excision volumes and amounts, put the patient into a seated and upright position, and determined that a horizontal skin excision would be also necessary to improve shape of the breasts. With this done, that final skin excision was made, and the total amount of breast tissue removed from the right side was 675 g. Some minor shaping liposuction was performed in the axilla and the pectoral tendon region.
The same precise procedure was then performed on the contralateral side, removing from the left breast 517 g total. While the amount of tissue removed was different, it was the preoperative assessment that the right side was, in fact, significantly larger than the left.
At this time, both breasts were reopened. Careful attention was paid to hemostasis bilaterally. A 7-mm Clot Stop drain was deployed, 1 into each breast. Ethibond 2-0 was used to fix the superomedial pedicle into a rotated position by reapproximating the breast pillars. The skin was then closed using a combination of deep 3-0 PDS suture and subcuticular 3-0 PDS suture, followed by Mastisol and Steri-Strips.
At the conclusion of the procedure, the patient was put into a seated and upright position. Breast symmetry, nipple/areolar position, and inframammary fold position all were quite symmetric.
All breast tissue was separately labeled left versus right and sent to pathology for examination. The patient was then turned over to the care of the anesthesia service, having tolerated the procedure well.
Pathology Report Later Indicated: Breast tissue normal, no pathology.
8 The anesthesia service was performed by the CRNA under Dr. Larson’s medical direction while she was providing medical direction for 4 concurrent cases. The patient’s physical status was -P1. LOCATION: Inpatient, Hospital PATIENT: Loren Baldur PHYSICIAN: Gary I. Sanchez, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSES: Reducible left inguinal hernia. POSTOPERATIVE DIAGNOSES: Same.
NAME OF PROCEDURE: Left inguinal hernia repair with ilionguinal nerve block for post-operative pain management.
ANESTHESIA: General endotracheal ESTIMATED BLOOD LOSS: Minimal DRAINS: None
SPECIMENS: Left inguinal hernia sac
COMPLICATIONS: There were no complications.
FINDINGS: There was an indirect left inguinal hernia sac with an intact floor. There were no complications.
INDICATIONS: Loren is a healthy 18-year-old who presented in my office with an intermittent left inguinal bulge. He had an obvious reducible left inguinal hernia without clinical signs of hernia on the contralateral side. Repair was indicated to prevent incarceration, strangulation or obstruction in the future.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position where a time-out was performed correctly identifying the patient and the planned procedure. General anesthesia was achieved without difficulty. The abdomen and genitalia were prepped and draped in the standard fashion. An oblique incision was made just lateral to his left pubic tubercle with a #15 blade; it was carried down through the subcutaneous tissues and Scarpa’s fascia with cautery. The external oblique aponeurosis identified and sharply dissected free from the subcutaneous fat working from a superior and lateral to an inferior and medial direction which exposed the external ring. The external oblique aponeurosis was incised lateral with a #15 blade and this was elongated through the external ring with a Metzenbaum scissors. The ilioinguinal nerve was identified and preserved throughout the case. The cremasterics of the cord were gently spread with a hemostat exposing the hernia sac which was grasped. The hernia sac and cord structures were dissected free from the cremasterics with care. A hemostat was placed beneath the hernia sac and cord structures to elevate them. The hernia sac, which was identified in the anterior medial aspect of the cord, was dissected free from all other cord structures. With the vas clearly identified, an Allis was placed around the cord structures to retain retraction. A hemostat was placed on the hernia sac proximal and distal and the hernia sac was divided. The hernia sac was dissected free from the cord structures all the way above the internal ring. It was then twisted several times and ligated with 2 separate 2-0 Vicryl stick ties and the distal portion of the sac was amputated. The internal ring was reapproximated with a 2-0 Vicryl stitch. The testicle was returned back down into the scrotum in the dependent position. The external oblique aponeurosis was closed with interrupted Vicryl sutures. The skin was anesthetized with local analgesia as was the ilioinguinal nerve to provide a block postoperatively. Scarpa’s tissue was reapproximated with interrupted 3-0 Vicryls and the skin closed with Monocryl. Steri-Strips were applied. The patient was extubated and taken to the recovery room in stable condition. There were no complications. Sponge and needle counts were correct at the end of the case.
Pathology Report Later Indicated: Normal hernia sac, benign pathology.
9 The anesthesia service was performed by the CRNA under the anesthesiologist’s medical direction of three concurrent procedures. This was a normal healthy patient with physical status of -P1. LOCATION: Outpatient, Hospital PATIENT: Kaitlyn Grossman PHYSICIAN: Jeff King, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Recurrent otitis media with effusion.
2. Eustachian tube disorder.
POSTOPERATIVE DIAGNOSES: Same. PROCEDURE PERFORMED: Bilateral myringotomy and tube insertion. ANESTHESIA: General COMPLICATIONS: None ESTIMATED BLOOD LOSS: None
FINDINGS: Bilateral thick mucoid effusions.
INDICATIONS: This is a 12-month-old female with multiple ear infections in the last several months and persistent effusion.
DESCRIPTION OF PROCEDURE: After identifying the patient in the preoperative holding area and reviewing the surgical plan, the patient was taken to the operating room. After successful initiation of general anesthesia, the right ear was addressed first. The external ear, external auditory canal and tympanic membrane were normal. The middle ear appeared to have a mucoid effusion. An anterior-inferior myrinqotomy was made. An Armstrong beveled grommet tube was inserted without difficulty. Floxin drops were placed.
The procedure was repeated on the left side with the same result. An anterior-inferior myringotomy was made and an Armstrong beveled grommet tube was inserted. Floxin drops were placed.
The patient tolerated the procedure quite well and was awakened after general anesthesia in good condition.
Pathology Report Later Indicated: Mucoid fluid.
10 The anesthesiologist personally provided monitored anesthesia care. The patient is 68 years old and the physical status was -P5. LOCATION: Inpatient, Hospital PATIENT: Frances Lynn PHYSICIAN: Gregory Dawson, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSIS:
1. Acute aspiration pneumonitis.
2. Acute hypoxemic respiratory failure.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURES PERFORMED:
1. Direct laryngoscopy.
2. Endotracheal intubation.
INDICATIONS: The patient was in severe respiratory distress secondary to acute aspiration pneumonitis maintaining her saturations on nonrebreather mask. The patient was still retching and having severe nausea so BiPAP was initially tried but she was not a good candidate for BiPAP due to persistent nausea. Family discussion was held and they wanted the patient to be intubated.
PROCEDURE DESCRIPTION: The patient was laid supine on the bed and bag valve ventilation was performed and we were still not able to get saturations above 88% despite adding external PEEP. The patient was given 4 mg of Versed IV and 10 mg of etomidate. MAC 3 blade was used for direct laryngoscopy. The patient did have thick secretions in the posterior oropharynx. Vocal cords were visualized, grade 1 view. Subsequently size 8 endotracheal tube was passed under direct visualization and left at 22 cm at the lip and tube was secured in place. Tube position was confirmed by auscultation and end tidal CO2 monitoring. The patient’s expiration improved immediately to 94 to 95% after intubation.
COMPLICATIONS: There were no immediate complications.
The patient tolerated the procedure well. The postprocedure chest x-ray was reviewed. Endotracheal tube was at the level of main carina. We pushed it back by at least 2 cm. The patient still has bilateral breath sounds present, and continues to maintain good saturation levels.
IMPRESSION: Technically successful direct laryngoscopy and endotracheal intubation.
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