CRNA provided the anesthesia care without medical direction.
CRNA provided the anesthesia care without medical direction. The patient’s physical status was -P3. The base for this procedure is 6 units. The anesthesia time is 0736 to 0816. Time units are based on 15-minute increments. Round up after 7-½ minutes. What are the total units for this case? LOCATION: Inpatient, Hospital PATIENT: Gretel Valance PHYSICIAN: Gregory Dawson, M.D. ANESTHESIOLOGIST: CRNA.
PREOPERATIVE DIAGNOSIS: Malignant right pleural effusion. POSTOPERATIVE DIAGNOSIS: Same.
INDICATIONS: The patient is an elderly lady with a history of cervical or endometrial cancer. She has now been found to have a large malignant pleural effusion and positive cytology. She presents to have definitive drainage of this. While additional procedures, such as open biopsy of enlarged lymph nodes in the groin and insertion of a Mediport catheter have been discussed with her, she preferred to have only the placement of the Pleurx catheter at this time.
OPERATION: Insertion of right Pleurx catheter under local anesthesia and sedation.
HISTORY AND FINDINGS: The patient is an elderly lady with a history of cervical or endometrial cancer, who has now been found to have a large malignant pleural effusion and positive cytology. She enters the operating room to have definitive drainage of this.
At surgery, 1000 ml of bloody fluid was easily removed from her chest. She tolerated this very well.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and sedated with intravenous sedation. She was kept supine and the right chest carefully prepped and draped in a standard manner. An area just caudal to the right breast was carefully selected, and this area was first numbed with 1% local Xylocaine. A 22-gauge needle was used to aspirate this space and revealed bloody pleural effusion. A wheal of anesthetic was carried out in this location and a long subcutaneous tunnel extending anteriorly along the lateral and anterior chest wall. A second skin wheal was made 6 cm anterior to this first opening. Two 1-cm incisions were now made in these 2 areas of skin wheals. The chest was entered with a finder needle and Angiocath posteriorly and then guidewire placed into the pleural cavity. Through the anterior wound, a tunnel was now created to connect through to the posterior wound, and then the Pleurx catheter was introduced with its blunt introducer through the anterior wound and threaded to the posterior wound, leaving the Velcro cuff in the subcutaneous position. The guided introducer sheath was now placed over the introducer wire into the chest. Once the introducer was removed, then the Pleurx catheter was threaded through the introducer sheath into the pleural cavity and the peel-away sheath removed. Function of the Pleurx catheter was assured by attaching it to suction, and it seemed that this functioned normally. Bloody fluid 1000 ml was drained and submitted for cytology and additional cytogenetic studies. Then the 2 small openings were closed using 3-0 Vicryl for the subcutaneous tissues and a 4-0 intracuticular Vicryl for the skin. Dermabond was placed onto the posterior opening, and a 3-0 silk suture was used to secure the Pleurx catheter anteriorly. A sterile dressing was applied, and the Pleurx catheter was capped.
The patient was now in stable condition and was fairly awake. She was transferred back to her room on the 4th floor in stable condition.
Pathology Report Later Confirmed: Large malignant pleural effusion and positive cytology.
2. The anesthesia service was provided by the CRNA with anesthesiologist medically directing 3 concurrent cases. The patient’s physical status was -P2. LOCATION: Inpatient, Hospital PATIENT: Carol Tigerton PHYSICIAN: Mohomad Almaz, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Right hallux valgus.
2. Right second metatarsophalangeal joint degenerative arthrosis.
3. Right metatarsalgia.
POSTOPERATIVE DIAGNOSES: Same.
PROCEDURES PERFORMED:
1. Right chevron osteotomy.
2. Right distal soft tissue procedure.
3. Right second MTP joint arthrotomy with synovectomy, debridement, and removal of multiple loose bodies.
4. Right second proximal phalanx base resection with excision of osteophytes from the second metatarsal head.
ANESTHESIA: Right ankle block plus intravenous sedation.
INDICATIONS: This patient is a 77-year-old woman with a long history of a painful bunion on her right foot associated with second metatarsophalangeal joint arthrosis with metatarsalgia. Patient has pain, loss of motion, and difficulty with shoe wear. She has failed conservative therapy and is functionally limited by her symptoms, and she is requesting operative intervention. The risks, benefits, indications, alternatives, and limitations of surgery were discussed with the patient, and all of her questions were answered. Informed consent was obtained for the above procedures. Patient had a preoperative history and physical and was cleared for surgery by anesthesia prior to the surgical date. Patient understands the elective nature of the procedure, and she wishes to proceed. She understands the risks of surgery, which include but are not limited to damage to blood vessels and nerves; wound complications and infection; nonunion or malunion; recurrence; persistent or worsening pain, deformity, or stiffness; and the possible need for future surgery.
PROCEDURE: The patient was seen in the preoperative holding area and was felt to be stable to undergo operative intervention. The appropriate operative limb was marked. She was given preoperative antibiotics. The patient was then brought to the block room, where a right ankle block was performed by the anesthesia service under sterile conditions, which she tolerated well, with no complications.
The patient was brought into the operating theater and placed supine on the operating table. All bony prominences were appropriately padded. Intravenous sedation was administered and monitored by the anesthesia service during the case. The right lower extremity was sterilely prepped and draped in the usual, standard fashion. An Esmarch bandage was used to exsanguinate the foot and was left wrapped above the ankle to provide a tourniquet effect during the case.
An incision was made dorsally in the 1st web space. This began just medial to the base of the second proximal phalanx and was extended down to the medial aspect of the second metatarsophalangeal joint, where it was curved more medially to overlay the web space. The incision was carried through the skin and subcutaneous tissue, with care being taken to avoid damage to small blood vessels and nerves. Hemostasis was controlled using Bovie electrocautery.
Attention was then directed to the first web space. The dissection was carried medially until the first web space was exposed. Dissection was carried through the adventitial bursa, which was released. Once this was performed, the transverse and oblique heads of the adductor tendon were noted. These were then released from their insertions.
Next, the transverse metatarsal ligament was identified and divided in its midline. Care was taken to prevent damage to the underlying neurovascular structures. The lateral capsule was then piecrusted, and the interval between the lateral sesamoid and 1st metatarsal head was incised open and mobilized. Once this was performed, the sesamoid complex was able to be passively reduced onto the 1st metatarsal head. No additional tight soft tissue structures were noted.
Attention was then directed to the medial aspect of the hallux metatarsophalangeal joint. An incision was made over the medial aspect of the joint beginning at the base of the proximal phalanx and extending to the neck of the first metatarsal. The incision was carried through the skin and subcutaneous tissue, with care being taken to avoid damage to small blood vessels and nerves. Hemostasis was controlled using Bovie electrocautery. Dissection was carried full thickness down to the capsule and dorsal and plantar flaps were elevated off of the capsule, with care being taken to avoid damage to small blood vessels and nerves. The dorsomedial cutaneous nerve was identified, mobilized, and retracted out of the surgical field. Once the capsule was fully exposed, a distally based, inverted L-shaped capsulotomy was performed. The vertical limb was created approximately 2 to 3 mm from the joint. It was begun on the dorsal aspect of the joint and carried down to the level of the abductor tendon. The dorsal limb was then extended proximally. The capsule was then dissected off of the metatarsal head.
At this point, the lst metatarsophalangeal joint was inspected. There was some synovitis, which was debrided with a rongeur. The articular cartilage was intact, without unstable cartilage or loose bodies. There were no full-thickness lesions, although the cartilage was thinned out centrally. Next, the medial eminence was excised approximately 1 to 2 mm medial to the sagittal sulcus from a distal to proximal direction using a Synthes flexible chisel. Once this was performed, the center of the metatarsal head was marked with a K-wire. Next, a 60-degree chevron cut was made using a sagittal saw. The apex was at the center of the metatarsal head. Once the cuts were made, the distal fragment was displaced approximately 4 to 5 mm laterally. This was then impacted manually. This was then stabilized using a 0.045 mm K-wire introduced from a dorsal to plantar direction. Position of the osteotomy and K-wire was checked using fluoroscopy in multiple planes, including an AP/lateral and oblique of the foot, and were felt to be good. The K-wire was removed and replaced with a 14-mm Ace breakaway screw. Once the screw was fully inserted, this resulted in excellent fixation and compression across the osteotomy. Final position of the osteotomy and hardware was checked using fluoroscopy in multiple planes, as above, and was felt to be excellent. The prominent medial bone was then debrided with a rongeur and smoothed off with a rasp.
Attention was then directed to the second metatarsophalangeal joint. A longitudinal capsulotomy was made just medial to the extensor digitorum longus tendon. This was carried through the extensor mechanism and dorsal capsule down to the skeletal plane. The joint was then exposed using subperiosteal and subcapsular dissection. In the dorsal joint space, 2 large loose bodies were noted, and these were excised. There were massive hypertrophic exostoses on both the head of the second metatarsal and the base of the proximal phalanx. These were excised using a Synthes flexible chisel. Once the joint was fully debrided of these osteophytes, the joint could be inspected. There was complete loss of articular cartilage on both the base of the proximal phalanx and the head of the second metatarsal. At this point, it was decided to proceed with resection arthroplasty of the joint. The base of the proximal phalanx was then excised using a sagittal saw. The cut was angled from a dorsal and distal to plantar and proximal direction, such that the plantar plate was left intact.
At this point, it was felt that the joint was adequately decompressed. Further debridement of the second metatarsal head was performed with a rongeur. The joint was then copiously irrigated with sterile saline. Note should be made that there was abundant fibrous tissue as well as hypertrophic synovium within the joint which was excised sharply. Next, the joint was stabilized using a 0.0625 mm K-wire. The K-wire was introduced into the base of the proximal phalanx and driven out the tip of the toe. Distraction was then made at the joint, and the K-wire was advanced across the metatarsophalangeal joint and into the second metatarsal. Clinically, the alignment of the toe was good, and this was confirmed fluoroscopically in multiple planes.
The hallux was positioned in slight varus overcorrection and in neutral dorsiflexion and rotation. Redundant capsule was excised sharply, and the capsule was repaired and imbricated using 2-0 Vicryl sutures. Once this was performed, the hallux was felt to be in good position clinically, and this was confirmed fluoroscopically in multiple planes, as above.
The second metatarsophalangeal joint capsule as well as the extensor hood were repaired with 2-0 Vicryl sutures. At this point, the tourniquet was released. Total tourniquet time was approximately 100 minutes. Please see the anesthesia and nursing records for the exact tourniquet time. Hemostasis was then controlled using Bovie electrocautery and digital pressure. All of the toes were pink and warm with brisk capillary refill after release of the tourniquet. At this point, clinically, the alignment of the first and second toes was felt to be good, with stable-appearing hardware. This was confirmed fluoroscopically in multiple planes, as above.
The wounds were then copiously irrigated with sterile saline. The wounds were then closed in layers using 4-0 Vicryl sutures to approximate the subcutaneous tissue and 4-0 nylon interrupted, simple sutures to reapproximate the skin. The wounds were then dressed with Xeroform, sterile 4 x 4’s, and sterile Webril. A soft forefoot dressing was applied and overwrapped with an Ace wrap, and the patient was placed into a postoperative shoe. The patient was then transferred to her hospital bed and was brought to the recovery room in stable condition without difficulty.
All sponge and needle counts were correct at the end of the case, and there were no perioperative or intraoperative complications.
Pathology Report Later Indicated: Bony osteophytes and tissue inflammation, benign.
3. The CRNA provided the anesthesia care with medical direction of the anesthesiologist who was directing this case and 3 other concurrent cases. The patient’s physical status was -P1. LOCATION: Inpatient, Hospital PATIENT: Sarah Simmers PHYSICIAN: Andy Martinez, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSIS: Chronic pelvic pain with history of adhesiolysis.
POSTOPERATIVE DIAGNOSES:
1. Chronic pelvic pain with history of adhesiolysis.
2. Thin pelvic adhesions.
PROCEDURE PERFORMED: Diagnostic laparoscopy with adhesiolysis. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Less than 1 ml. FLUIDS: 1200. URINE OUTPUT: 50 COMPLICATIONS: None.
INDICATIONS: Patient presents with chronic pelvic pain failed conservative management. Due to history of pelvic adhesions patient presents for diagnostic laparoscopy and treatment of adhesions if found. Risks were discussed and patient wishes to proceed.
FINDINGS: Thin film adhesions in the pelvis and the small-bowel which were lysed and then the omentum was adherent to the anterior abdominal wall.
PROCEDURE: The patient was prepped and draped in the lithotomy position under general endotracheal anesthesia and the bladder was straight catheterized. A sponge stick was placed in the vagina. A 1-cm transverse infraumbilical incision was made. The Veress needle was placed in the abdominal cavity. The abdominal cavity was insufflated with 3 liters of CO2. The Veress needle was removed and the sharp trocar and sheath placed in the abdominal cavity under direct visualization. Sharp trocar was removed. A lighted scope was reinserted in the abdominal cavity. Pelvic contents were inspected.
Findings were the omentum was then adherent to the anterior abdominal wall. However the small-bowel appeared normal. A 0.5-cm transverse mid abdominal incision was made and the sharp trocar and sheath were placed in the abdominal cavity under direct visualization. Sharp trocar was removed and the blunt probe was placed in the abdominal cavity and pelvic contents inspected. Findings documented in the photographs.
The liver and gallbladder could not be visualized because of adhesions of the omentum with the anterior abdominal wall. Appendix is surgically absent. The patient had thin film adhesions of the small-bowel to the vaginal apex. These were lysed with a blunt probe without difficulty and the operative site was hemostatic at the completion of the procedure. The CO2 was evacuated from the abdominal cavity. Instruments were removed from the abdominal cavity under direct visualization.
Skin incisions were closed with 4-0 plain suture. Incisions were injected with 0.5% Marcaine with epinephrine, 10 ml. Bandages were applied. Sponge stick was removed from the vagina. All sponges and needles were accounted for at the completion of the procedure. Patient left the operating room in apparent good condition after tolerating the procedure well.
4. The anesthesia service was provided by a CRNA with the anesthesiologist medically directing 2 concurrent cases. The patient’s physical status was -P3. The BVU for this case is 6. LOCATION: Outpatient Hospital PATIENT: Carmen Pitmen SURGEON: Loren White, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D.
PREOPERATIVE DIAGNOSES:
1. Sacral ulcer.
2. Osteomyetitis of sacrum/coccyx.
POSTOPERATIVE DIAGNOSES:
1. Sacral ulcer.
2. Pending.
INDICATIONS: Patient with history of sacral ulcer that has failed conservative management. The planned procedure was discussed in detail. Risks and benefits explained and questions answered. Patient elects to proceed with surgical intervention at this time.
PROCEDURES PERFORMED: 1. Excision of sacral ulcer. 2. Excision of coccyx.
SURGICAL FINDINGS: There was about a 4 cm deep pressure ulcer that went all the way down to the coccyx. The coccyx was separated from the sacrum and had very sclerotic bone in it. It was very vascular around the coccyx.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 150 cc. DRAINS: One #10 Jackson-Pratt.
PROCEDURE: The patient was intubated and turned to the prone position. The buttocks were prepped with Betadine scrub and solution and draped in routine sterile fashion. The ulcer was excised elliptically by following a hemostat to the bottom of the wound which ended in the lower end of the sacrum/upper end of the coccyx. We took a piece of the coccyx and placed it in a culture tube. I then removed the coccyx which was quite vascular, clamping bleeders with 2-0 Vicryl and putting in one stick tie of 2-0 Vicryl. The coccyx was removed and submitted for specimen. A piece of Gelfoam with some topical thrombin spray was placed in the depth of the wound, and the wound was closed in two layers with interrupted 0 Monocryl for the deepest fascial layer over the drain and over the bed from which the coccyx had been dissected. We also closed the skin with #2 Protene. The drain was sutured in with 0 Monocryl. Dressing consisted of Kertix fluffs and Elastoptast. The patient tolerated the procedure well and left the operating room in good condition.
Pathology Report Later Indicated: Sclerotic bone, coccyx.
5. The anesthesiologist was medically directing 4 concurrent cases including this CRNA. The patient’s physical status was -P1. LOCATION: Outpatient, Hospita PATIENT: Kayla Adams PHYSICIAN: Mohomad Almaz, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Right fifth toe metatarsophalangeal joint dislocation. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Open reduction of right fifth toe metatarsophalangeal joint dislocation with application of long leg cast. ANESTHESIA: General.
INDICATIONS: The patient is an 8-year-old girl who injured her right fifth toe while jumping on a small trampoline. She had an attempt at closed reduction of the dislocation in the office, which was unsuccessful. I have recommended open reduction. I have discussed the situation with the mother. She wished to proceed as recommended. I have discussed the possibility of repeat dislocation, need for fixation implant, and neurovascular injury, scarring, stiffness, and pain. I have discussed the options for treatment including continued nonoperative management.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. Once general anesthesia was administered and the patient was intubated, the right leg and foot were prepped and draped in usual sterile manner. A curvilinear incision was made over the dorsal aspect of the right fifth toe overlying the metatarsophalangeal joint. The dissection was carried down on to the proximal metatarsophalangeal joint. The metacarpal head was identified. There was soft tissue interposed, which was not allowing reduction at the metatarsophalangeal joint. Once this was removed and the proximal portion of the proximal phalanx was identified, the joint was then reduced. It was felt that the joint would be very difficult to pin because the joint surfaces were so small: Therefore, no pin fixation was performed. It was felt that the location of the joint was now appropriate and was relatively stable. The wound was irrigated with normal saline. Routine wound closure was performed using interrupted 4-0 nylon sutures. Routine soft dressings were applied. The tourniquet was deflated and the toe had excellent capillary refill. She was placed in a long leg cast. She tolerated the procedure well and left the operating room in stable condition. Postop plan is to have the patient return for removal of sutures. The cast will be windowed for this procedure. The cast will be on for a minimum of 4 weeks.
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