Author:
Kai Knudsen
Updated:
2 May, 2025
The following are recommended anesthesia models for elective procedures in general surgery, gynecology, urology, ENT surgery, oncology, and orthopedic procedures. Methods described here can be seen as recommendations for anesthesia techniques. Several other models are fully possible and may be just as effective as our suggestions. Local deviations and routines may occur. The proposed anesthesia model is presented in a condensed tabular format. Premedication is described using abbreviations.
Content:
- Recommended anesthesia methods
- Anesthesia methods and premedication for elective surgical procedures
- Anesthesia Methods for Gynecological and Urological Procedures
- Ortopedic Anesthesia Procedures
- Orthopedic Anesthesia for extremities
- Anesthesia Methods for ENT Procedures
- Anesthesia methods for Neurosurgery
- Anesthesia methods for Neuro / radiological Interventions
- Anesthesia methods for Craniofacial Surgery
Recommended anesthesia methods
Be careful to ensure that patients are fasting, receive prescribed premedication, correct other regular medication and correct antibiotic prophylaxis. Check regular pain relief and plan for continued adequate postoperative pain relief. Deviations from the form of anesthesia or premedication are made individually based on medical indication, e.g. heart disease, severe airway, PONV, obesity, allergies, etc. Keep in mind the usual contraindications.
Anesthesia methods and premedication for elective surgical procedures
Recommended methods of anesthesia. Consider usual contraindications. Be careful to ensure that patients receive their regular pain relief. Deviations from anesthesia or premedication are made on medical indication, e.g. heart disease, severe airway, PONV, obesity. P= Paracetamol O= Oxycontin COX= Etoricoxib OXA= Oxazepam Bet= Betametason Ond= Ondansetron Ev. Parecoxib (Dynastat) at the end of the operation after discussion with the surgeon
| Surgical procedure or Intervention | Airway | Anesthesia model | Epidural / Spinal | Premedication | Remark |
|---|---|---|---|---|---|
| Adrenalectomy open or via laparoscope | Intubation | Sevoflurane/Remifentanil | Epi if open surgery | P +O | |
| If the indication is primary aldosteronism, give oral potassium chloride (KCl) in appropriate dose. Check serum potassium (S-K) the same day | |||||
| Bone marrow aspiration | Sevoflurane/Remifentanil | P+O+COX | |||
| Hernia plastic surgery | Intubation or LM | Sevoflurane/Remifentanil | P+O+COX | ||
| Breast surgery minor | Laryngeal mask | Propofol/Remifentanil or Propofol/Alfentanil | P+O+COX+Bet+ Ond | ||
| Fast track + minor surgery, ASA 1, <65 years, no need for blood sampling (tests, chart review). No opioids for day surgery | |||||
| Breast surgery major | Laryngeal mask | ||||
| Direct reconstruction → PECS block by anesthesiologist before induction | |||||
| Carcinoid surgery | Intubation | Sevoflurane/Fentanyl | Epi if open surgery | P+OXA | |
| ECG, NT-ProBNP. Possibly echocardiography (UCG), watch for carcinoid heart disease | |||||
| Cava thrombosis | Intubation | Sevoflurane/Fentanyl | Epi | P+O | |
| Cholecystectomy open or via laparoscopy | Intubation | Sevoflurane/Remifentanil | Epi if open surgery | P+O+COX | |
| Cystectomy+possible establishment of ileum reservoir | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | P+O | |
| Diagnostic laparoscopy | Intubation | Sevoflurane/Remifentanil | P+O+COX | ||
| Esophagectomy, thoracoabdominal | Intubation | Sevoflurane/remifentanil during the abdominal phase Propofol/remifentanil during the thoracic phase | Epidural anesthesia (Epi) if open surgery | ||
| RSI? DLT. Note: the surgeon must establish an intraoperative substitution plan for oral medications | |||||
| EMR - EUS - ERCP - Gast+ dil | Intubation | Propofol/Remifentanil | |||
| Pheochromocytoma | Intubation | Sevoflurane/Fentanyl | Epi if open surgery | P+O+OXA | |
| Fundoplication - open or via laparoscope | Intubation | Sevoflurane/Remifentanil | Epi if open surgery | P+O | |
| Gastrectomy - ventricular resection | Intubation | Sevoflurane/Fentanyl | Epi | P+O | |
| Gastric pacemaker via laparoscope | Intubation | Sevoflurane/Remifentanil | P+O | ||
| Gastroplasty open or via laparoscope | Intubation | Sevoflurane/Remifentanil | Epi if open surgery | P | |
| Minor neck surgeries (PTH, hemithyr, tot.thyr) | Intubation | Propofol/Remifentanil | P+O+COX+ Bet+Ond | ||
| Note: potentially difficult airway, possibly videolaryngoscope, NIM, avoid neuromuscular blockers (muscle relaxants) | |||||
| Major neck surgeries (sternothomi) | Intubation | Propofol/Remifentanil | P+O | ||
| Note: potentially difficult airway, possibly videolaryngoscope, NIM, avoid neuromuscular blockers (muscle relaxants) | |||||
| Hyperthermic perfusion extremity | Intubation | Sevoflurane/Fentanyl | P+O | ||
| Note: possible immunotherapy, do not give Betametason (corticosteroids), watch for side effects | |||||
| Liver perfusion | Intubation | Sevoflurane/Fentanyl | Epi | O | |
| Liver resection | Intubation | Sevoflurane/Fentanyl | Epi ev | O | |
| Liver transplantion | Intubation | Sevoflurane/Fentanyl | Epi ev | ||
| Nephrectomy/kidney resection | Intubation | Sevoflurane/Fentanyl | Epi | P+O | |
| Kidney donation (living donor) | Intubation | Sevoflurane/Remifentanil | P+O | ||
| Kidney transplantion | Intubation | Sevoflurane/Fentanyl | P+O | ||
| Note gastroparesis – RSI? Monitor plasma potassium (P-K). Preoperative dialysis? Dry weight + chest X-ray if needed. | |||||
| Kidney and auxiliary liver transplantation | Intubation | Sevoflurane/Fentanyl | |||
| Pancreas and kidney transplantation | Intubation | Sevoflurane/Fentanyl | Epi | P+O | |
| Percutaneous stone extraction | Intubation | Sevoflurane/Remifentanil | P+O | ||
| RSI. Note: liquid diet for 5 days and nothing by mouth (NPO) for more than 8 hours. | Intubation | Propofol/Remifentanil | |||
| Splenectomy | Intubation | Sevoflurane/Fentanyl | Epi if open surgery | P+O | |
| Thoraco-abdominal esophageal resection | Intubation | Sevoflurane/Fentanyl Propofol/Remifentanil when using double lumen tube (DLT) | Epi | P+O | |
| Thoracoplasty | Intubation | Propofol/Remifentanil | Epi ev | P+O | Note any other traumatic injuries |
| TUR-B trans urethral resection of bladder tumour | Laryngeal mask | Propofol/Remifentanil | Spinal | P+O | |
| TUR-P trans urethral resection of prostatic tumour | Spontaneous airway | Spinal | P+O | ||
| Ureteroscopy | Laryngeal mask | Propofol/Remifentanil | P+O+COX | ||
| Whipple | Intubation | Sevoflurane/remifentanil | Epidural anesthesia (EDA) | P | |
| Whipple and pancreatic resection | Intubation | Sevoflurane/Remifentanil | Epidural anesthesia (EDA) | P, (O) | |
| Whipple total pancreatectomy, laparoscopy/robot | Intubation | Sevoflurane/remifentanil | Epidural anesthesia (EDA) | P, (O) | |
| Pancreatic resection, distal | Intubation | Sevoflurane/remifentanil | EDA if open | P, (O) | |
VASCULAR SURGERYPreoperative vascular surgical evaluation. NOTE: Antiplatelet therapy is particularly important pre-/perioperatively for certain vascular procedures (and neurointervention). In these cases, any perioperative adjustments (e.g., for regional anesthesia) must always be done in consultation with the operating specialty. |
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| Open aorta | Intubation | Sevoflurane/Fentanyl | P+O | ||
| Echocardiography (UCG) + NT-ProBNP + spirometry. NOTE comorbidities. Dysphagia/contraindication for TEE? | |||||
| EVAR | Intubation | Sevoflurane/remifentanil or Sevoflurane/Fentanyl | P+O | ||
| Lower short-term mortality/morbidity (compared to open). Benefit > risk in elderly with multiple comorbidities? UCG + NT-ProBNP + possible spirometry. Possible sedation in severe comorbidity. | |||||
| EVAR with sedation | Spontaneous breathing | remifentanil or Dexmedetomidine | P+Oxa | ||
| Lower short-term mortality/morbidity (compared to open). Benefit > risk in elderly with multiple comorbidities? UCG + NT-ProBNP + possible spirometry. Possible sedation in severe comorbidity. | |||||
| Carotid | Intubation | Sevoflurane/remifentanil | P+O NT-ProBNP. NOTE BP – side difference? | ||
| Peripheral vascular surgery | Intubation or Sevoflurane/remifentanil or Sevoflurane/Fentanyl | Epidural for major procedures or spinal epidural (SpEDA) | |||
Anesthesia Methods for Gynecological and Urological Procedures
| Type of Procedure | Airway | Anesthesia Model | Epidural/Spinal | Premedication | Remarks |
|---|---|---|---|---|---|
Gynecology |
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| Abdominal wall endometriosis | Intubation | Sevoflurane/Fentanyl | Spinal with morphine (in consultation with surgeon) | O+P+Cox+Bet+Ond | |
| Endometriosis laparoscopy – NHV full-day procedure | Intubation | Sevoflurane/Remifentanil | Spinal with morphine (in consultation with surgeon) | O+P+Cox+Bet+Ond (possibly Postafen/Lergigan + Gabapentin) | |
| Exenteration – anterior and total (hysterectomy + BSO + cystectomy + rectal amputation, creation of Kock’s pouch and Bricker diversion) | Intubation | Sevoflurane/Fentanyl | Thoracic Epidural Th10–12 or Spinal (morphine) or bilateral rectus catheters or PCA/Oxycodone | O+P+Cox+Bet+Ond (possibly Postafen 25 mg or Lergigan 25 mg, Gabapentin 600 mg) | |
| Short gynecological procedures (e.g. curettage, evacuation, VEX, hysteroscopy, Bartholin cyst) | Face mask or LM | Propofol/Remifentanil or Propofol/Alfentanil | O+P+Cox+Bet+Ond | ||
| Conization / loop diathermy | LM / Face mask | Propofol/Remifentanil | O+P+Cox+Bet+Ond | First choice: PCB by gynecologist + Alfentanil at start/sedation with Remifentanil | |
| Laparoscopic procedures: total/subtotal hysterectomy ± BSO, cystectomy, myomectomy | Intubation | Sevoflurane/Remifentanil | Spinal with morphine | O+P+Cox | |
| Palpation under anesthesia | Mask or LM | Propofol/Alfentanil | Optional: Spinal (Ampres -Chloroprocain) | Bet+Ond | First choice: Mask anesthesia; alternative: LM, TCI technique. Day-surgery spinal: Ampres. |
| Peritonectomy ("stripping") for ovarian cancer | Intubation | Sevoflurane/Fentanyl | Thoracic epidural Th8-10 first choice, or bilateral rectus catheters/PCA + Oxycodone | O+P+Cox+Bet+Ond | |
| Robot-assisted hysterectomy | Intubation | Sevoflurane/Remifentanil | Spinal with morphine | O+P+Cox+Bet+Ond + Pepcid 10 mg (Omeprazole 40 mg if previously prescribed) | |
| Robot-assisted trachelectomy | Intubation | Sevoflurane/Remifentanil | Spinal with morphine | O+P+Cox+Bet+Ond + Pepcid 10 mg (Omeprazole 40 mg if previously prescribed) | |
| Vaginal hysterectomy | Intubation (?) | Sevoflurane/Remifentanil | Spinal heavy Bupivacaine (Marcain) ± Fentanyl 15-20 mcg | O+P+Cox+Bet+Ond | |
| Vulvar resection/vulvectomy | LM | Propofol/Remifentanil | Spinal heavy Takipril or heavy Bupivacaine (Marcain) ± Fentanyl 15-20 mcg | O+P+Cox+Bet+Ond | For major procedures: Intrathecal morphine combined with anesthesia if needed. |
| Wertheim hysterectomy | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | O+P+Cox+Bet+Ond | |
| Open gynecological surgeries (hysterectomy±BSO, myomectomy) | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | O+P+Cox+Bet+Ond | |
Urology |
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| Artificial sphincter or Advance sling | Intubation | Sevoflurane/Remifentanil | O+P+Cox+Bet+Ond | ||
| Endoluminal ureterolithotomy | LM | Propofol/Remifentanil | O+P+Cox+Bet+Ond | ||
| Nephrectomy, nephroureterectomy, kidney resection | Intubation | Sevoflurane/Fentanyl | Thoracic epidural (preferred) | O+P+Bet+Ond | TEDA Th9-11 for flank incision; Th6-10 for abdominal incision; TAP block/PCA if lower midline incision. |
| Orchiectomy - Ablatio testis | LM | Propofol/Remifentanil | Heavy spinal (Prilocaine (Takipril) or Bupivacaine (Marcain) ± Fentanyl 15-20 mcg | O+P+Cox+Ond | Local anesthesia + sedation with remifentanil in case of reduced general condition |
| Bricker diversion + possible cystectomy (ERAS) - open | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | O+P+Cox+Bet+Ond | |
| Bricker diversion + possible cystectomy (ERAS) - robot-assisted | Intubation | Sevoflurane/Remifentanil | Spinal with morphine | O+P+Cox+Bet+Ond + Pepcid 10 mg (or Omeprazole 40 mg) | |
| Percutaneous endoscopic nephropyelolithotomy | Intubation | Sevoflurane/Fentanyl | O+P+Bet+Ond | ||
| Quadratus lumborum block (QL block): performed on an anesthetized and positioned patient, preferably before incision. For QL block: use ultrasound with abdominal probe, a 12 cm nerve block needle, and 30 ml of 0.5% Ropivacaine | |||||
| Radical prostatectomy - open | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | O+P+Cox+Bet+Ond | |
| Robot-assisted laparoscopic prostatectomy (RALP) | Intubation | Sevoflurane/Fentanyl | Optional: Spinal with morphine | O+P+Cox+Bet+Ond | If spinal morphine is desired: use intubation, Sevoflurane/Remifentanil, and spinal morphine. Add Pepcid 10 mg (or Omeprazole 40 mg if the patient was already on it) |
| Robot-assisted nephrectomy/kidney resection/pyeloplasty | Intubation | Sevoflurane/Remifentanil | Thoracic epidural – if high conversion risk (consult surgeon) | O+P+Bet+Ond | |
| Robot-assisted para-aortic lymph node dissection for testicular cancer | Intubation | Sevoflurane/Remifentanil | Spinal with morphine | O+P+Cox+Bet+Ond | Note: Bleomycin treatment! Maximum FiO₂ 30%. Pepcid 10 mg (or Omeprazole 40 mg if previously prescribed). |
| Staging with retroperitoneal lymph node dissection for testicular cancer – open | Intubation | Sevoflurane/Fentanyl | Thoracic epidural Th9–10 (preferred) or TAP block/PCA + Oxycodone | O+P+Cox+Bet+Ond | Note: Bleomycin treatment! Maximum FiO₂ 30%. |
| Transurethral resection of the prostate (TUR-P) | Possibly LM | Heavy spinal with Bupivacaine (Marcain) ± Fentanyl 15–20 mcg | O+P+Cox+Ond | Note: With bipolar diathermy and 0.9% NaCl irrigation fluid, risk of hypernatremia/hypervolemia with large losses. | |
| Transurethral resection of bladder tumor (TUR-B) | LM | Propofol/Remifentanil | Day-surgery spinal with Prilocaine (Takipril) in high-risk patients | O+P+Ond | General anesthesia: Mivacron 0.15–0.2 mg/kg (15–20 min duration) if high risk of obturator nerve stimulation. Do not use neostigmine to reverse. Consider obturator nerve block with spinal. |
| Transvesical adenoma enucleation of the prostate | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | O+P+Cox+Bet+Ond | Note: Post-op bladder irrigation: monitor input and output closely. |
| Urethral diverticulum | Intubation (?) | Sevoflurane/Remifentanil | O+P+Cox+Bet+Ond | Note: TIVA not suitable – risk of erectile dysfunction. | |
| Urethroplasty with free skin graft | Intubation (?) | Sevoflurane/Remifentanil | O+P+Cox+Bet+Ond | Note: TIVA not suitable – erectile dysfunction risk. Nasal intubation if using oral mucosa. | |
| Ureteroscopy | LM | Propofol/Remifentanil | O+P+Cox+Bet+Ond | Give two PONV prophylactic drugs, e.g., Betapred 4–8 mg, Ondansetron 8 mg. | |
| Ureteral reimplantation | Intubation | Sevoflurane/Fentanyl | Spinal with morphine | O+P+Cox+Bet+Ond | |
Oncological Anesthesia |
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| Brachytherapy for cervical cancer | Intubation | Propofol/Remifentanil | Possibly spinal | O+P+Cox+Bet+Ond | |
| Brachytherapy for prostate cancer | Sevoflurane/Remifentanil | Heavy spinal with Bupivacaine (Marcain) 18–20 mg ± Fentanyl 15–20 mcg | O+P+Cox+Bet+Ond | First choice: Spinal. Note: Bleomycin treatment — max FiO₂ 30%. | |
| Endoluminal brachytherapy | Intubation | Propofol/Remifentanil | O+P+Cox+Bet+Ond | For esophageal cancer: Intubation + Propofol/Remifentanil TCI. For trachea/bronchus/lung: LMA with Propofol/Remifentanil TCI. | |
Special Patient Groups |
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| Robot-assisted surgery for morbid obesity (BMI > 40) | Intubation | Desflurane/Remifentanil | O+P+Cox+Bet+Ond | Ultrasound-guided arterial line. C-MAC, metal stylet, fiberoptic scope for difficult airways. Consider awake fiberoptic intubation. Pepcid 10 mg or Omeprazole 40 mg if already prescribed. | |
| Patients at high risk for PONV | Propofol/Remifentanil | O+P+Cox+GABA+Bet+Ond | Keep Ondansetron and Dridol for treating manifest PONV. Consider: OxyContin 0.1 mg/kg, Alvedon 1 g, Arcoxia 120 mg, Gabapentin 600–900 mg, Betapred 8 mg, Postafen 25 mg, or Lergigan 25 mg. | ||
Ortopedic Anesthesia Procedures
| Type of Procedure | Airway | Maintenance Anesthesia | Epidural / Spinal | Ketanest Infusion | Premedication |
|---|---|---|---|---|---|
| Minor spine (herniated disc/endoscopic, decompression) | Intubation | Sevo/remifentanil | P+O+COX+Steroid+Ond+Prescr. | ||
| Minor spine (anterior lumbar/cervical fusion 2 levels) | Intubation | Sevo/remifentanil | P+O+COX+Steroid+Ond+Prescr. | ||
| Major spine (posterior fusion) | Intubation | 1. Sevo/fentanyl 2. Propofol/remifentanil during neurostimulation | Possibly Ketanest infusion | P+O+GAB+Prescr. | |
| Major spine (anterior lumbar/cervical fusion 3 levels) | Intubation | 1. Sevo/fentanyl 2. Propofol/remifentanil during neurostimulation | Possibly Ketanest infusion | P+O+GAB+Prescr. | |
| Major spine (corpectomy, osteotomy) | Intubation | 1. Sevo/fentanyl 2. Propofol/remifentanil during neurostimulation | Possibly Ketanest infusion | P+O+GAB+Prescr. | |
| Major spine (trauma, infections) | Intubation | 1. Sevo/fentanyl 2. Propofol/remifentanil during neurostimulation | Possibly Ketanest infusion | P+O+GAB+Prescr. | |
| Major spine (tumor) | Intubation | 1. Sevo/fentanyl 2. Propofol/remifentanil during neurostimulation | Possibly Ketanest infusion | P+O+GAB+Prescr. | |
| Major spine (reoperations) | Intubation | 1. Sevo/fentanyl 2. Propofol/remifentanil during neurostimulation | Possibly Ketanest infusion | P+O+GAB+Prescr. | |
| Scoliosis idiopathic | Intubation | Propofol/remifentanil | Intraoperative spinal | According to fast-track protocol | |
| Scoliosis neuromuscular | Intubation | Sevo/fentanyl | Possibly intraop | Possibly Ketanest infusion | Individualized |
| Thoracic wall resection including ribs | Intubation | Propofol/remifentanil | Thoracic Epi | P+O | |
| Sacrum amputation | Intubation | Sevo/fentanyl | Epi | P+O | |
| Hemipelvectomy | Intubation | Sevo/fentanyl | Epi | P+O | |
| Mutars prosthesis – reconstructive prosthesis knee/hip | Intubation | Sevo/fentanyl | Epi | P+O | |
| Bone lengthening | Intubation | Sevo/fentanyl | Possibly Epi | P+O | |
| Tumor minor procedure, soft tissue surgery | Laryngeal Mask | Propofol/remifentanil | P+O+COX+Steroid+Ond | ||
| Tumor major procedure, skeletal surgery, prosthesis surgery | Intubation | Sevo/fentanyl | Epi possibly block | P+O |
TEDA: Thoracic epidural anesthesia
Orthopedic Anesthesia for extremities
| Type of Procedure | Airway | Block | Maintenance Anesthesia | Epidural / Spinal | Ketanest Infusion | Premedication | Notes |
|---|---|---|---|---|---|---|---|
Upper Extremities |
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| Shoulder and humerus procedures | Intubation | Interscalene block | 1. Remifentanil + Sevoflurane 2. Fentanyl + Sevoflurane | P+COX+O | 1. Remifentanil + Sevoflurane for patients with block and/or no chronic pain. 2. Fentanyl + Sevoflurane for non-blocked patients or pain patients. | ||
| Procedures often in 'beach chair' with seated patient, high risk of hypotension. Prefer weak norepinephrine 0.01 mg/ml infusion. Consider arterial line and strong norepinephrine infusion 0.1 mg/ml. Special cases - ASA 4 - may be operated with block and sedation. Consult pain specialist. Ensure 2–3 IV lines before incision. | |||||||
| Elbow procedures | LMA (supine), intubation (lateral with arm hanging) | Supraclavicular/Infraclavicular block | Fentanyl + Sevoflurane | P+COX+O | |||
| Forearm, wrist and hand procedures | LMA | Supraclavicular/Axillary block, IVRA or selective peripheral nerve blocks | Fentanyl + Sevoflurane | P+COX+O | |||
Lower Extremities |
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| Pelvic procedures | Intubation | Fentanyl + Sevoflurane | Epi | Possibly | |||
| Hip fracture* | Possibly LMA, otherwise GA if spinal contraindicated | Femoral/FIC block followed by spinal | Fentanyl + Sevoflurane (if GA) | Spinal | P+COX+O | ||
| *Often elderly and frail. Note frailty using Clinical Frailty Scale. Check anticoagulant use and timing. Consult ward doctor and orthopedic surgeon for acute cases. Consider perioperative HFG. | |||||||
| Primary hip/knee prosthesis | Spontaneous breathing | If GA: Fentanyl + Sevoflurane | Spinal | P+COX+O | Standard: Give Tranexamic Acid (Cyklokapron) and Betametason (Betapred) 8 mg IV | ||
| Secondary hip/knee prosthesis | Spontaneous breathing, possibly intubation | Possibly Fentanyl + Sevoflurane | Spinal + Epi | P+COX+O | Can bleed 1–3 L. Ensure good IV access. Usually Sp + Epi or GA + Epi. Spinal alone may suffice for minor procedures. | ||
| Femur fracture | Preferably intubation | Femoral/FIC block followed by spinal | Spinal or GA | P | Block/Epi depending on injury and procedure. Spinal with Morphine + Bupivacaine (Marcain) may be suitable. | ||
| Lower leg fracture | LMA | Fentanyl + Sevoflurane | Spinal or GA | Possibly clonidine and ketamine | P+COX+O | Tibia fractures carry risk of compartment syndrome. Regional anesthesia may be used with caution. | |
| Ankle fracture | LMA | Possibly Popliteal/Saphenous block | Fentanyl + Sevoflurane | Spinal or GA | P+COX+O | Unimalleolar – spinal or GA only. Bi-/Trimalleolar – Popliteal/Saphenous block. | |
| Calcaneus, talus, midfoot fracture | LMA. Intubation if lateral or prone | Possibly Popliteal/Saphenous block | Fentanyl + Sevoflurane | Spinal or GA | P+COX+O | ||
| Amputations | LMA | Fentanyl + Sevoflurane | Usually SP+Epi, alternatively Epi+ GA | P+COX+O | |||
Anesthesia Methods for ENT Procedures
| Type of Procedure | Airway | Maintenance Anesthesia | Premedication | Postop Pain Relief | Notes |
|---|---|---|---|---|---|
| Acute mastoiditis (Mastoidectomy) | Intubation | Propofol/Remifentanil | Ond/Bet/P/COX | Clonidine. Possibly oxycodone | |
| Cochlear implant | Intubation | Ond/Bet/P/COX | Children: also clonidine, Dynastat and Perfalgan | No muscle relaxant after induction due to nerve stimulator. Avoid coughing. | |
| BAHA (bone-anchored hearing aid) | LA + sedation | Sevo/Fentanyl if child | Ond/Bet/P/COX | LA. Children: also clonidine, Dynastat and Perfalgan | |
| CAT and Radical ear | Intubation | Propofol/Remifentanil or Sevo/Remifentanil | Ond/Bet/P/COX | Clonidine. Possibly oxycodone | |
| MIUS with or without tube insertion/removal | Mask | Propofol/Alfentanil | Perfalgan for children | ||
| Brainstem audiometry | Laryngeal mask | Propofol/Remifentanil | P | Perfalgan for children | |
| Tympanoplasty | Intubation | Propofol/Remifentanil | Ond/Bet/P/COX | Avoid opioids | |
| Ossiculoplasty | Intubation | Propofol/Remifentanil | Ond/Bet/P/COX | Children: also clonidine, Dynastat and Perfalgan | Avoid opioids |
| Stapedotomy/Stapedectomy | Possibly muscle relaxant | Propofol/Remifentanil | Ond/Bet/P/COX | Children: also clonidine, Dynastat and Perfalgan | Avoid opioids |
Nose surgery |
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| FESS – Functional Endoscopic Sinus Surgery | Oral intubation, throat pack, TIVA to reduce bleeding | Propofol/Remifentanil | O/Ond/Bet/P/COX | Clonidine and possibly oxycodone. Children: also Dynastat and Perfalgan | |
| Frontal sinus trephination | Oral intubation, throat pack | Propofol/Remifentanil | O/Ond/Bet/P/COX | ||
| Lateral rhinotomy | Oral intubation, throat pack | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and possibly oxycodone | |
| Epistaxis | Oral intubation, throat pack | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | Max 40% O2 if laser. RSI if bleeding. |
| Nasal repositioning | Intubation if fracture >7 days | Propofol/Alfentanil | Ond/Bet/P/COX | Children: also clonidine, Dynastat and Perfalgan | Short but potentially painful. Possibly throat pack. |
| Septoplasty and Turbinoplasty | Oral intubation, throat pack | Propofol/Remifentanil | O/Ond/Bet/P/COX | Clonidine and possibly oxycodone. Children: also Dynastat and Perfalgan | |
| Total nasal and Rhinoplasty | Oral intubation, throat pack, TIVA | Propofol/Remifentanil | O/Ond/Bet/P/COX | Clonidine and possibly oxycodone. Children: also Dynastat and Perfalgan | |
Scopy |
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| Microlaryngoscopy | Jet ventilation / Intubation / EVONE / trach tube | Propofol/Remifentanil | Ond/Bet/P/COX | LA local. Possibly oxycodone | Laser: Max 40% O2. No N2O. |
| Rigid bronchoscopy | Manual or jet ventilation | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | Consult surgeon about ventilation method. |
| Flexible bronchoscopy | Oral tube or LMA | Propofol/Remifentanil | Ond/Bet/P/COX | Paracetamol and Dynastat. Possibly oxycodone | |
| Flexible esophagoscopy | Intubation | Propofol/Remifentanil | No oral premed | Paracetamol and Dynastat. Possibly oxycodone | |
| Rigid esophagoscopy | Intubation | Propofol/Remifentanil | No oral premed | Possibly oxycodone | |
| PEG placement | LA + sedation or intubation | Sevo/Remifentanil | Often not possible orally | Paracetamol, individual | Often combined with other surgeries |
| Hypopharyngoscopy | Via scope | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | |
| TOUSS (TransOral endoscopic UltraSonic Surgery) | Nasal intubation | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | Nafazoline-lidocaine nasal before induction |
| Total endoscopy incl. bronchoscopy | Intubation/scope | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | For malignancy workup. Coordinate with surgeon. |
| Laryngeal laser procedures | Various airway options | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | |
| Epipharyngoscopy | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | ||
| Laterofixation | Oral intubation / trach tube / jet ventilation | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | Vocal cord palsy may make ventilation difficult. Long #5 tube. Consider Evone®. |
| Awake fiber intubation | Various: oral/nasal, midazolam/fentanyl/alfentanil for scope | Propofol/Fentanyl or TIVA | Ond/Bet/P/COX | Possibly oxycodone | Careful topical anesthesia with inhaled xylocaine, LA in throat, and nasal Nafazoline-lidocaine. |
Head and neck surgery |
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| Abrasio | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and possibly oxycodone. Children: also Dynastat, Betamethasone, and Perfalgan | |
| Epiglottitis | Usually awake nasal fiberintubation | Sevo/Fentanyl | IV premed on OR table | Surgical trach readiness in OR. Sedatives: Midazolam/Fentanyl/Alfentanil/Propofol in consultation with anesthesiologist. | |
| Tonsillectomy/-otomy | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and possibly oxycodone. Children: also Dynastat, Betamethasone, Perfalgan | Hot tonsillectomy may need fiberoptic intubation. |
| Tracheotomy | Oral/nasal fiberintubation, LA+sedation, existing ICU tube | Propofol/Remifentanil | Individual, often sedated from ICU | Individual, often sedated from ICU | Customized anesthesia. Long ICU stay, difficult airway. Already intubated patients common. |
| Skin laser treatment (children) | Laryngeal Mask | Propofol/Remifentanil | Ond/Bet/P | Perfalgan and possibly clonidine | Short procedure |
| Lateral neck cyst | Intubation | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | |
| Submandibular gland excision | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
| Radical neck + supraomohyoid dissection | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
| Lymph node excision | Oral intubation or LA + sedation | Propofol/Remifentanil | Ond/Bet/P/COX | Clonidine and oxycodone | |
| Hemiglossectomy | Nasal intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and oxycodone | Nasal intubation |
| Tongue/floor of mouth biopsy | Oral or nasal intubation | Propofol/Remifentanil | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
| Iridium implant removal | Awake fiber intubation | Propofol/Remifentanil | Ond/Bet/P/COX | Possibly oxycodone | Careful anesthesia with inhaled xylocaine and nasal lidocaine |
| Laryngectomy | Oral intubation or tracheostomy | Propofol/Fentanyl or Sevo | O/Ond/Bet/P/COX | Clonidine and oxycodone | Difficult airway, often trached. U-tube may be placed intraoperatively. |
| Parotidectomy | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and oxycodone | Avoid muscle relaxants after induction if nerve stimulator used. |
| Suprahyoid neck dissection | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
Plastic Surgery |
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| Otoplasty | Intubation | Propofol/Remifentanil | Ond/Bet/P/COX | LA. Children: also clonidine, Dynastat and Perfalgan | |
Maxillofacial fracture surgery |
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| Mandible fracture | Intubation | Sevo/Remifentanil | O/Ond/Bet/P/COX | Clonidine and oxycodone | May need fiberoptic intubation. Nasal intubation. Throat pack. |
| Orbital floor repositioning | Intubation | Propofol/Remifentanil | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
| Zygomatic fracture (Gilles) | Intubation | Propofol/Remifentanil | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
| Hemi-maxillectomy / Hemi-mandibulectomy | Nasal intubation | Sevo/Remifentanil | O/Ond/Bet/P/COX | LA and possibly oxycodone. Children: also Betamethasone, Clonidine, Dynastat, Perfalgan | Nasal intubation |
| Orthognathic/craniofacial surgery (Le Fort II-III) | Nasal intubation | O/Ond/Bet/P/COX | Clonidine and oxycodone. Children: also Betamethasone, Clonidine, Dynastat, Perfalgan | MAP ~60. Risk of oculocardiac reflex. Pre-op dexamethasone and Cyklokapron. | |
| Minor jaw surgery (Sagittal split, Le Fort I) | Nasal intubation | Propofol/Remifentanil | O/Ond/Bet/P/COX | LA and possibly oxycodone | Nasal intubation. Pain relief includes LA, oxycodone. Children: also Betamethasone, Clonidine, Dynastat, Perfalgan. |
Miscellaneous surgery |
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| Eye evisceration | Intubation | Sevo/Fentanyl | O/Ond/Bet/P/COX | Clonidine and oxycodone | |
| Bone marrow harvest | Laryngeal Mask | Propofol/Remifentanil (high dose ~4 mg/kg for prone) | IV premed: P+Dyn+Bet+Ond | Oxycodone. Possibly Cyklokapron if BP stable | Donor often sore at iliac crest postop |
*Muscle relaxants are prescribed depending on the time of surgery: celocurin or rocuronium. In cases where muscle relaxants are not necessary for the procedure, intubation with local anesthesia of the larynx with 3-4 ml Xylocaine 40 mg/ml can be considered. Applies to procedures shorter than approximately 3 hours. Crystalloid fluids are used as standard intraoperatively unless otherwise prescribed by the attending physician.
Anesthesia methods for Neurosurgery
| Type of Procedure | Airway | Maintenance Anesthesia | Arterial Line | Immobilization | Premedication | Postop Pain Relief | Notes |
|---|---|---|---|---|---|---|---|
| Acoustic neuroma | Intubation | Sevo/Remi | Yes | Often PONV/postop pain | Possibly clonidine | NIM monitor. Muscle relaxant at induction is OK. | |
| Acrylic reconstruction | Intubation | Sevo/Fentanyl | P, Ond, Oxy | ||||
| Aneurysm/AVM | Intubation | Sevo/Remi | Yes | Yes | High ICP: Use TIVA. | ||
| Baclofen pump – dose change | Sedation/Intubation or LMA | Propofol/Remi (sometimes LA + sedation) | P, Ond | Sometimes feasible under LA + sedation. LMA optional. | |||
| Baclofen pump – implantation | Intubation | Sevo/Fentanyl | P, Ond | ||||
| Balloon compression 'Trig' | Intubation | Sevo/Fentanyl | P, Ond | Rapifen + Atropine on standby. | |||
| Carotid TEA | Intubation | Sevo/Remi | Yes | P, Ond, Oxy | NIRS. Invasive BP from arm with higher pressure before induction. | ||
| DBS | Intubation | Propofol/Remi | Yes | Yes | Maintain same pCO2 during MRI and biopsy. | ||
| Cervical disc herniation | Intubation | Sevo/Fentanyl | P, Oxy, Ond | Risk of bleeding: consider A-line, CVP if Mayfield used. Possibly clonidine/gabapentin/ketamine. | |||
| Epidural hematoma, acute | Intubation | Propofol/Remi | Yes | Often high ICP/impending herniation. Avoid hypotension! | |||
| Epilepsy surgery | Intubation | Propofol/Remi | Yes | Yes | Continue regular antiepileptics | Do not suction via NG tube! | |
| Floating 1 | Sedation | P | |||||
| Floating 2 | LMA | Sevo/Fentanyl | P, Ond | ||||
| Pituitary surgery | Intubation | Propofol/Remi | Yes | Yes | Assess hormonal status. Ensure hormone replacement (Solu-Cortef, Minirin). | ||
| Subdural hematoma, chronic | Sedation/Intubation | Sevo/Remi or Prop/Remi | P, Ond | Sedation if unilateral and suitable patient. TIVA if consciousness affected. | |||
| Subdural hematoma, acute | Intubation | Propofol/Remi | Yes | Often high ICP/impending herniation. Avoid hypotension! | |||
| Shunt placement | Intubation | Sevo/Fentanyl | P, Oxy, Ond | ||||
| Stereotactic biopsy | Intubation | Propofol/Remi | Yes | Yes | Maintain same pCO2 during MRI and biopsy. | ||
| Tumor biopsy | Intubation | Sevo/Remi | Yes | Yes | P, Oxy, Ond | ||
| Posterior fossa + Chiari | Intubation | Sevo/Remi | Yes | Yes | Possibly clonidine | Often PONV/postop pain | |
| Supratentorial tumor | Intubation | Sevo/Remi | Yes | Yes | Craniotomy size correlates with postop pain. | ||
| Tethered cord / TMS | Intubation | Sevo/Remi | Yes | Possibly clonidine. Consider gabapentin 300–600 mg for chronic pain | Consider CVP if Mayfield used. Postop pain common especially with multilevel surgery. | ||
| Vagus nerve stimulation | Intubation | Propofol/Remi | P, Oxy, Ond | ||||
| Awake surgery | LMA/Sedation | Yes | P, Ond, T Betapred if no protocol/diabetes, T Omeprazol 40 mg | Must consult responsible anesthesiologist. | |||
| Ventricular drain | Intubation | Sevo/Remi or Prop/Remi | High ICP: Use TIVA. | ||||
| Endoscopic third ventriculostomy | Intubation | Sevo/Remi | Yes | ||||
| Neurosurgery – children ≤12 yrs | Assessed by anesthesiologist in charge. | ||||||
| NG tube: For intracranial surgery >3h, prone, or aspiration risk | |||||||
| PONV prophylaxis: liberal for intracranial surgery. Dridol (0.625–1.25 mg) allowed | |||||||
Anesthesia methods for Neuro / radiological Interventions
| Type of Procedure | Airway | Maintenance Anesthesia | Awake | Arterial Line | Central Line | Other Notes | Premedication |
|---|---|---|---|---|---|---|---|
| Elective cerebral angiography with planned intervention | Intubation | Sevo/Remifentanil | Yes | NOTE! Antiplatelet therapy prescribed by neurosurgeon in consultation with neurointerventionist | P | ||
| Test occlusion of carotid / carotid stent | Yes | Yes | Invos | P | |||
| Venous malformation (outside head/neck) | LMA | Propofol/Remifentanil | No Betapred (reduces treatment effect) | P + COX (children: see note below) | |||
| Venous malformation (head/neck) | Intubation | Propofol/Remifentanil | No Betapred. Consider ICU bed if intraoral procedure | P + COX (children: see note below) | |||
Abdominal/vascular intervention |
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| Chemoembolization (TACE) | Intubation or LMA | Sevo/Remifentanil | P* + Ond + Bet | ||||
| Hepatic artery embolization | Intubation | Sevo/Remifentanil | Yes | Possible CVK. Carcinoid syndrome – follow protocol | P* + O + Ond + Bet | ||
| Renal artery embolization | Intubation | Sevo/Remifentanil | Consider TEDA. Consult interventionist/urologist regarding expected pain | P + O + Ond + Bet | |||
| PTC (percutaneous transhepatic cholangiography) | Intubation | Sevo/Remifentanil | P + Ond | ||||
| RF / Microwave ablation (liver/kidney) | Intubation | Propofol/Remifentanil | Liver = jet ventilation | P + O + Ond | |||
| TIPS | Intubation | Sevo/Remifentanil | Yes | P | |||
| Vena cava stent | Intubation | Sevo/Remifentanil | Yes | Watch for vena cava syndrome | P | ||
| PTA (percutaneous transluminal angioplasty) | LMA | Sevo/Remifentanil | Prefer regional block | P + O | |||
| EVAR | Intubation | Sevo/Remifentanil | Yes | Yes | If uncomplicated EVAR, good peripheral IV can replace CVK | P | |
Diagnostic radiology (MRI, CT) |
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| MRI and CT – diagnostic only | Intubation or LMA | Propofol/Remifentanil | For neurodiverse patients, always inform anesthesiologist | All regular medications | |||
| CT-guided biopsy | LMA | Sevo/Fentanyl | P + O + COX | ||||
| CT scan child (e.g., 3-year follow-up post-cranioplasty) | Sedation | Sedation | DEX intranasal 3 µg/kg | ||||
In case of pediatric anesthesia < 6 years - inform the responsible anesthesiologist. Always consider Emla before PVK. Premedication with nasal DEX 2-3 ug/kg. (Other alternatives are po midazolam/atropine, po ketalar or po clonidine). Paracetamol and Dynastat are given perop (>6 months).
P= Paracetamol O= Oxycontin COX=Arcoxia. *= In case of liver resection, the liver surgeon is responsible for prescribing paracetamol. Deviations from the form of anesthesia or premedication are made on medical indication, e.g. heart disease, difficult airway, PONV, obesity.
Anesthesia methods for Craniofacial Surgery
| Type of Procedure | Airway | Maintenance Anesthesia | Premedication | Lines (CVL/Art Line) | Postop Pain Relief | Notes |
|---|---|---|---|---|---|---|
| Cranial reconstruction for metopic synostosis (child >6 months) | Intubation | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line + CVL | Clonidine and morphine. Possibly Dynastat | |
| PI-plasty for sagittal synostosis (from ~6 months) | Intubation, possibly nasal | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line + CVL | Clonidine and morphine. Possibly Dynastat | |
| Strip craniectomy with springs for sagittal synostosis (~3–6 months) | Intubation, possibly nasal | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line | Clonidine and morphine. Possibly Dynastat | |
| Head ring (Stille) + green gel ring. Prone position. Marking and local anesthesia. W-shaped incision above the suture. | ||||||
| Cranial reconstruction with springs for metopic synostosis (~4–6 months) | Intubation, possibly nasal | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line | Clonidine and morphine. Possibly Dynastat | |
| Marking, local anesthesia, and bicoronal zigzag incision. Subperiosteal dissection forward. Urinary catheter (Foley) inserted. | ||||||
| Cranial reconstruction with acrylic | Intubation, possibly nasal | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line | Clonidine and morphine. Possibly Dynastat | Coronal incision |
| LeFort III osteotomy with external distractor | Oral intubation/Tracheostomy | Sevo/Fentanyl | Ond/Bet/P | Art line + CVL | Clonidine and morphine. Possibly Dynastat | Used for craniofacial syndromes (e.g., Crouzon, Apert) |
| A Le Fort III osteotomy is a surgical procedure used to correct severe facial and jaw deformities, where the midface is characterized by very poor growth, for example in patients with craniofacial syndromes such as Crouzon, Apert, and Pfeiffer syndromes. | ||||||
| Unicoronal synostosis with Arnaud's distractor | Intubation | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line + CVL | Clonidine and morphine. Possibly Dynastat | |
| The distractor is screwed into the skull bone. A urinary catheter (Foley) is placed. In unicoronal synostosis, the forehead appears flat on the affected side and the eye looks more open. On the healthy side, the forehead bulges compensatorily and the eye appears compressed. | ||||||
| Unicoronal synostosis at approximately 6 months | Airway: Intubation | Maintenance anesthesia: Sevoflurane/Fentany | Premedication: EMLA (2 doses for children <1 year/10 kg, 3 doses for children >1 year/10 kg). Clonidine orally if >1–2 years as needed. | Lines: Arterial line + central venous catheter (CVL) | Postoperative pain relief: Clonidine and morphine. Possibly Dynastat. | |
| The procedure is performed in the supine position. The scalp is anesthetized with 0.25% Carbocaine with adrenaline. A zigzag incision is made from ear to ear. A bone graft is cut from the frontoparietal area. The deformed forehead is also cut out, and the orbital roof on the healthy side is elevated. The orbital rim on the affected side is angled forward. The old and new forehead segments are swapped and fixed in place with slowly resorbable sutures. | ||||||
| Cranial reconstruction & spring/distractor removal | Intubation (TIVA if ↑ICP) | Sevo/Fentanyl + muscle relaxant | Emla. Clonidine or midazolam-atropine per age | Art line + CVL | Paracetamol + Clonidine + Morphine ± Dynastat | Benelyte 2–5 ml/kg/h. Tranexamic acid 15 mg/kg. Pain management protocol varies. |
| Benelyte via infusion pump at 2–5 ml/kg/hour. For children under 10 kg, consider giving 10 ml/kg during the first hour. Always administer tranexamic acid 15 mg/kg before the start of surgery. Pain management includes paracetamol and clonidine for all procedures; minor surgeries receive morphine bolus and often Dynastat, while major surgeries receive morphine via infusion pump but usually no Dynastat. | ||||||
| Monobloc + canthopexy + springs / glasses plasty / LeFort III | Intubation (TIVA if ↑ICP) | Sevo/Fentanyl + muscle relaxant | Emla. Clonidine or midazolam-atropine per age | Art line + CVL | Paracetamol + Clonidine ± Morphine/Dynastat | Large surgery – morphine infusion used. Small surgery – morphine bolus. |
| Pain management includes paracetamol and clonidine for all procedures. Minor surgeries receive a morphine bolus and usually Dynastat, while major surgeries receive morphine via infusion pump but usually no Dynastat. | ||||||
| Bicoronal synostosis with springs (~6 months) | Intubation, possibly nasal | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line | Clonidine and morphine. Possibly Dynastat | |
| Supine position with head ring. A zigzag-shaped bicoronal incision is made after anesthesia with 0.25% Carbocaine with adrenaline (2 ml/kg). A urinary catheter (Foley) is inserted. | ||||||
| Spring removal | Intubation, possibly nasal | Sevo/Fentanyl | Emla. Clonidine orally if >1–2 yrs | Art line | Clonidine and morphine. Possibly Dynastat | |
| The spring is located and marked with a surgical marker. A small incision is usually made at the site of the previous incision, approximately where the spring has been located. The soft tissue and spring are dissected, and the spring is removed either intact or in pieces. | ||||||
| Lambdoid synostosis (unilateral/bilateral) with springs/resorbable plates | Intubation, possibly nasal | Sevo/Fentanyl | P | Art line | Clonidine and morphine. Possibly Dynastat | |
| Spring surgery: The suture is released from the periosteum and cut through using a high-speed drill. Up to six springs are inserted into drilled holes and secured in place. | ||||||
| Skull/facial trauma | Intubation, possibly nasal | Sevo/Fentanyl | Optional: O/Ond/Bet/P | Art line | Optional: Clonidine and oxycodone | Often emergencies. May require special induction (e.g., ketamine) |
| Usually an emergency case. May require special induction, for example with ketamine. | ||||||
| Sternocleidomastoid (division) | Intubation | Sevo/Fentanyl | Ond/Bet/P | Oxycodone | ||
| Ptosis correction | ? | |||||
| Hidradenitis | LMA or Intubation | Sevo/Remifentanil | O/Ond/Bet/P | Oxycodone | Possibly skin graft and flap surgery. | |
| Lipofilling to palate | Nasal intubation (possibly) | Sevo/Fentanyl | Ond/Bet/P | Fat harvested from abdomen and injected into palate/pharyngeal flap. | ||
| Fat is harvested from a part of the body, usually the abdomen around the navel, and injected into the palate/pharyngeal flap. | ||||||
| Split-thickness skin graft | LMA/Sedation - LA | Remifentanil/Propofol | Ond/Bet/P | Use 0.5% Carbocaine w/ adrenaline. Adjust dilution depending on technique. | ||
| 0.5% Carbocaine with adrenaline is mixed with sodium bicarbonate if the procedure is performed under local anesthesia; otherwise, it is diluted with NaCl to a concentration of 0.25% for injection. Adrenaline 1 mg/ml, 0.5 ml, is mixed with 500 ml NaCl to moisten the gauze that is then placed on the donor site. | ||||||
| Pectus excavatum | Intubation | Sevo/Fentanyl | P | Art line | Clonidine and morphine. Possibly Dynastat | Silicone implant placed after pocket is dissected. |
| A prosthetic pocket is carefully dissected, and the custom-molded silicone prosthesis is placed in the correct position. | ||||||
| Expander prosthesis insertion/removal (naevus) | LMA or Intubation | Remifentanil/Propofol | Midazolam/Atropine rectal or EMLA for small children. Older children: Clonidine or DEX. Adults: Alvedon, Arcoxia, Oxycontin, Betapred, Ondansetron | P + Clonidine | TIVA/TCI for children; adults typically receive TCI with Propofol/Remifentanil. | |
| Children: TIVA or TCI with Propofol and Remifentanil, or alternatively Sevoflurane and Fentanyl. Adults: TCI with Propofol and Remifentanil. |
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| Nerve graft for facial palsy | Intubation, possibly nasal | Remifentanil/Propofol | O/Ond/COX/Bet/P | Short-acting muscle relaxant or Remifentanil for intubation. Nerve function tested intraop. | ||
| Use short-acting muscle relaxants, or alternatively intubate with Remifentanil (the surgeon tests nerve function during the operation). | ||||||
| Microsurgery – free flap | Intubation | Remifentanil/Propofol | O/Ond/COX/Bet/P/Gab | Art line | Minimum two good IV lines in feet. Monitor urine output and perfusion carefully. | |
| At least two good peripheral IV lines in the feet. Monitor arterial pressure. Insert a urinary catheter with hourly output measurement. Administer norepinephrine as needed. Use Plasmalyte via infusion pump at 1–2 (up to 3) ml/kg/hour. Aim to avoid hypoperfusion or edema in the flap—maintain normovolemia. Medications: Paracetamol 1000 mg, Arcoxia 90 mg, OxyContin 10–20 mg, Gabapentin 300 mg, Betapred 8 mg, Ondansetron 8 mg. |
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| Head and neck – tracheostomy | Intubation | Sevo/Remifentanil + Fentanyl if needed | Oxascand 5–20 mg if needed | Art line + CVL | Clonidine and morphine. Possibly Dynastat | Use Plasmalyte 1–2 (or 3) ml/kg/hr. Aim for normovolemia. Noradrenaline infusion. |
| Plasmalyte via infusion pump at 1–2 (up to 3) ml/kg/hour, aiming to maintain normovolemia. Administer norepinephrine as needed. | ||||||
| Le Fort I/II/Sagittal Split/Bimax | Nasal intubation | Remifentanil/Propofol | O/Ond/COX/Bet/P | Art line | Clonidine and morphine. Possibly Dynastat | Pre-bent tube, nasal gastric tube, secure all lines to forehead. |
| Nasal intubation with a pre-bent tube, straight filter, and breathing circuit. A nasogastric tube is also placed. Everything is taped up over the forehead and secured with a headband around the patient’s head. | ||||||
| Chin surgery | Nasal intubation | Sevo/Remifentanil + Fentanyl as needed | O/Ond/COX/Bet/P | Art line | Clonidine and morphine. Possibly Dynastat | Pre-bent tube. Throat pack. Nasal gastric tube. |
| Breast surgery (reduction/implants/latissimus/mastectomy) | LMA or Intubation | Remifentanil/Propofol (+ Fentanyl and Ketanest for mastectomy) | O/Ond/COX/Bet/P | PECS block recommended for mastectomy. Complex positioning for latissimus flap. | ||
| For latissimus dorsi procedures, the surgery is performed in two stages: the patient is first positioned in lateral decubitus on a beanbag, then turned to the supine position. The patient must be re-prepped and re-draped before continuing the operation. It is important to ensure accessible peripheral IV lines in the arms and hands before positioning. | ||||||
| Rhinoplasty | Oral intubation with pre-bent tube | O/Ond/COX/Bet/P. Children: Clonidine orally 1 hr preop | Children: Perfalgan, Morphine, Dynastat. Adults: Oxycodone | Tampons or cut tubes in nostrils may cause nasal obstruction. Possible nasal splint. | ||
| The patient may receive nasal packing or tubes (cut endotracheal tubes) in the nostrils. This can make nasal breathing difficult. A nasal splint may also be applied on the bridge of the nose. | ||||||
| TMJ discectomy | Nasal intubation with pre-bent tube | Sevo/Remifentanil | O/Ond/COX/Bet/P | Oxycodone and Clonidine | Difficult intubation possible. Use fiber scope or videolaryngoscope. Avoid nasal compression. | |
| These patients may be difficult to intubate due to limited mouth opening. Fiberoptic intubation or videolaryngoscopy may be required. Use a throat pack and insert a nasogastric tube. Both the tube and the NG tube should be taped and secured. Breathing circuits should be positioned upward using a purple nasotracheal tube holder. Important: avoid compression or traction on the nasal tip—the tubing must not shift cranially. | ||||||
| PI-plasty for sagittal synostosis from approximately 6 months of age | Airway: Intubation, possibly nasal | Maintenance anesthesia: Sevoflurane/Fentanyl | Premedication: EMLA (2 doses for children <1 year/10 kg, 3 doses for children >1 year/10 kg). Clonidine orally if >1–2 years as needed. | Lines: Arterial line + central venous catheter (CVL) | Postoperative pain relief: Clonidine and morphine. Possibly Dynastat. | |
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