Review Note

Last Update: 03/30/2025 10:53 PM

Current Deck: ACG Part 2::Plastic Surgery and Burns

New Card (Unpublished)

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Front

Commit #312121

SS_PB 1.3 Discuss the issues involved with and the anaesthetic management of patients having surgery for tissue flaps. Including:
- Prolonged anaesthesia

Back

Commit #312121

Prolonged Anaesthesia: Considerations for Complicated Reconstructive Procedures

Vascular Access: Ensure that line placement does not interfere with the surgical site. An arterial line is desirable; a central venous line (CVL) aids in estimating intravascular volume and provides reliable venous access post-operatively. At least one large-bore IVL (14-16G) for fluids and a smaller IV catheter (20-22G) for other infusions such as TCI & PCA.

Blood Loss: Ensure blood is crossmatched. The initial dissection typically involves the most blood loss, and moderate hypotension may help limit this. Afterward, blood loss will be subtle and ongoing—track via swab weighing, visual estimation, and regular ABG to monitor Hb & Hct.

Fluid Balance: An indwelling catheter (IDC) is essential. Monitor fluid balance, especially in patients with poor cardiorespiratory reserve.

Body Temperature: Monitor core temperature (nasopharyngeal). Maintain temperature using low FGFs, HME filters, warmed IV fluids, a warm theatre environment (24°C), heated mattresses, and external warming blankets (e.g., Bair Hugger). Avoid overheating.

Positioning: Ensure proper alignment of the C-spine and brachial plexus. Protect pressure areas with cotton wool over bony prominences and foam pads under heels.

DVT Prophylaxis: All patients should receive daily LMWH, TEDS, and SCDs during theatre.

NGT: Consider emptying the stomach, especially in children, who are prone to gastric distension during prolonged procedures.

Eye Care: Apply ointment, tape, and pads for protection. Avoid excessive padding that could lead to corneal abrasion, which may result in permanent visual loss from exposure.

ETT Cuff Pressure: The cuff pressure may increase if N2O is used. High cuff pressures can cause mucosal ischemia and long-term tracheal strictures. Recheck cuff pressure regularly during the procedure.

Repeat Prophylactic Antibiotics: Administer every 4 hours.

Post-operative Care: Either HDU/ICU (for closer observation, ABG, invasive monitoring, and airway support) or plastics ward (for better wound care and nursing observation of flaps).