Anesthetic Considerations for Placenta Accreta
Robert M. Silver in Placenta Accreta Syndrome, 2017
The arterial line allows for continuous blood pressure monitoring and frequent laboratory draws, which become indispensable in cases with large blood loss and fluid shifts requiring massive resuscitation. Hypocalcemia, common in the setting of massive transfusion, is associated with coagulopathies, decreased systemic vascular resistance, and arrhythmias. Metabolic acidosis due to poor organ perfusion is associated with myocardial depression, vasodilation, arrhythmias, decreased thrombin generation, and impaired coagulation.41 Goal-directed transfusion medicine directed by laboratory results may improve outcomes and reduce blood product administration.42–45 Having an arterial line makes it easy to trend laboratory results such as calcium, pH, hemoglobin, platelets, coagulation panel, fibrinogen, and the thromboelastogram.
Invasive hemodynamic monitoring in obstetrics
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
The preparation for arterial line (A-line) placement begins with sterile preparation of the site, local anesthesia of the insertion site, and positioning of the patient’s wrist on a hand board in the dorsiflexed position (14). The radial artery is located 1 to 2 cm from the wrist, between the bony head of the distal radius and the flexor carpi radialis tendon. The two techniques for A-line placement (over-the-wire and over-the-needle) begin with palpation of the artery and location of the radial pulse followed by entry of the needle at a 30’–45’ angle. In the over-the-wire technique, the catheter is advanced through the artery until a flash of blood is noted. At this point, both the needle and the catheter are advanced 1 cm deeper in order to completely transect the artery. After this, the needle is removed and the catheter is lowered until it is almost parallel with the skin. The catheter is pulled gently until pulsatile blood is noted. At this point, the guidewire is introduced, and then the catheter is advanced into the artery through the guidewire. Finally, pressure should be placed proximal to the catheter and the wire removed. For the over-the-needle technique, the needle is advanced slowly through the skin until a flash of blood is seen. The needle is then lowered 10’–15’, and the catheter is advanced into the artery. The catheter is then secured in place.
Diagnosis and Treatment of Inhalation Injury in Burn Patients
Jacob Loke in Pathophysiology and Treatment of Inhalation Injuries, 2020
Since ventilator settings in these critically ill individuals are guided by the results of arterial blood gases, a vascular access to facilitate sampling as well as monitoring may be gained through an arterial line. The use of an arterial line eliminates the trauma of repeated arterial puncture, a particular consideration in the elderly in whom intimal injury and perivascular extravasation of blood may aggravate a pre-existing compromised flow through an arteriosclerotic vessel and cause limb ischemia. Additionally, perivascular hematomas have the potential for becoming infected. In critically ill patients, the results of arterial blood gases correlate well with those obtained by noninvasive devices that detect transcutaneous oxygen and carbon dioxide tensions. With certain limitations, such as slow response time and inaccuracy of results at low flow states (Tremper et al., 1980a), these electronic sensors are a viable alternative to direct blood gas measurements in monitoring pulmonary function (Hansen and Tooley, 1979; Tremper et al., 1979, 1980b;Rowe and Weinburg, 1979; Salmenpera and Heinonen, 1984).
A 29-year-old woman presenting for urgent cesarean hysterectomy: a multidisciplinary care challenge
Published in Baylor University Medical Center Proceedings, 2023
Claudia Serrano, Jessica C. Ehrig, Michael P. Hofkamp
The placenta accreta team was rapidly assembled, consisting of an accreta surgeon; members from urology, anesthesiology, and neonatology services; and operating room circulator nurses and surgical technicians. A standardized cesarean hysterectomy checklist was used to direct care. When the patient arrived in the operating room, an arterial line was placed for continuous blood pressure monitoring. More than 12 hours had elapsed since her last dose of enoxaparin, and she received a combined spinal epidural with 11.25 mg hyperbaric bupivacaine 0.75%, 15 mcg of fentanyl, and 0.2 mg of preservative-free morphine administered in the intrathecal space. Bilateral ureteral stents were then placed by an urologist. An abdominal incision was made and the fascia and recti muscles were separated. Ultrasound mapping of the uterus using a sterile probe cover was performed to identify a site for uterine incision that would avoid the placenta. The neonate was delivered and neonatal care was provided by the neonatology team in attendance. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. After delivery of the neonate, general endotracheal anesthesia was induced. A supracervical hysterectomy was performed and was complicated by extensive adhesions from the anterior abdominal wall to anterior uterus. The patient received a bilateral transversus abdominus plane block under ultrasound guidance prior to emergence to facilitate postoperative analgesia.
Symptomatic Response to Transcatheter Mitral Valve Repair According to Baseline Left Atrial Pressure
Published in Structural Heart, 2021
Thomas J. Breen, Rick A. Nishimura, Guy S. Reeder, Mohamad Alkhouli, Mayra Guerrero, Charanjit S. Rihal, Mackram F. Eleid
The procedure for TMVr has been previously described.7,11 Following transseptal puncture, the baseline LAP was recorded and two guidewires were advanced into the left superior pulmonary vein. A 4 French multipurpose catheter was advanced over the first guidewire, while the MitraClip steerable guiding catheter was advanced over the second guidewire into the left atrium. The multipurpose catheter was then pulled back into the left atrium for continuous monitoring. After the final MitraClip was deployed, a post-procedure LAP was obtained and served as the final pressure. The mean LAP was measured during end-expiration at the mid-A wave or, if the patient was in atrial fibrillation, mid-C wave. Concomitant arterial pressure measurements were obtained with all LAPs via radial arterial line. All TMVr procedures were performed under general anesthesia and with intra-procedural transesophageal (TEE) guidance.
Optimization of radiation settings for angiography using 3D fluoroscopy for imaging of intracranial aneurysms
Published in Computer Assisted Surgery, 2021
Thomas Linsenmann, Alexander März, Vera Dufner, Christian Stetter, Judith Weiland, Thomas Westermaier
Under general anesthesia, the patients received a central venous catheter in the right jugular vein for infusions of fluid, medication and contrast agent. Arterial blood pressure was continuously monitored via an arterial line in the left radial artery. Since all patients of this series had an aneurysm in the anterior circulation, all patients were placed in a supine position with their head fixed in a carbon Mayfield clamp. Prior to surgery, baseline imaging was performed. The positioning of the O-arm™ Imaging system (Medtronic, Littleton MA) was verified by biplanar fluoroscopy. Subsequently, a 360° rotational native fluoroscopy scan was performed. Thereafter, a second, contrast-enhanced scan was performed using 60 ml of iodine contrast agent (Imeron® 350, Bracco Imaging, Konstanz, Germany). Contrast injection was performed by an automated injector (Acutron CT, Medtron, Saarbrücken, Germany) The contrast agent was infused via the 16 gauge line of a 5-lumen central venous catheter over a period of 24 s. With a delay of 12 s, the 3D scan was started. For image acquisition, the ‘high definition mode’ or ‘enhanced cranial mode’, respectively, of the O-arm™ Imaging system (digital flat panel detector 40 × 30 cm, camera resolution 2000 × 1500, reconstruction matrix 512 × 512 x 192) was applied both requiring an image acquisition time of 24 s for the 360-degree gantry rotation. After placement of the clips, all metallic surgical devices and spatula that were potential causes of artifacts were removed and the imaging procedure was repeated. The intraoperative setting is depicted in Figure 1. The timing protocol of fluoroscopy and contrast injection is depicted in Figure 2.
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- Radial Artery