What is the recommended anesthetic plan for a salpingectomy?

Anesthetic Plan for Salpingectomy

General Anesthesia is Recommended

For salpingectomy procedures, general anesthesia with endotracheal intubation using short-acting agents is the standard approach, allowing for rapid emergence and early recovery. 1

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Preoperative Management

Fasting and Premedication

• Allow clear fluids up to 2 hours before induction and solid food up to 6 hours before anesthesia 1
• Avoid routine preoperative sedatives, particularly long-acting benzodiazepines, as they delay postoperative recovery and mobilization 1, 2
• Administer preoperative carbohydrate loading (400ml with 50g carbohydrate) 2 hours before surgery in non-diabetic patients to reduce insulin resistance 1

Prophylaxis

• Give single-dose intravenous antibiotic prophylaxis 30-60 minutes before skin incision with coverage for aerobic and anaerobic bacteria 1
• Apply well-fitting compression stockings and administer pharmacological thromboprophylaxis with LMWH 1
• Prepare skin with chlorhexidine-alcohol solution (noting fire risk with diathermy) 1

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Intraoperative Anesthetic Technique

Induction

• Use propofol (2-2.5 mg/kg) for induction combined with a short-acting opioid 1, 3
• Administer fentanyl (1.5-2.0 mcg/kg), alfentanil, or remifentanil infusion for analgesia 1
• Use short-acting muscle relaxants titrated with neuromuscular monitoring to facilitate surgical access 1

Maintenance

• Maintain anesthesia with sevoflurane or desflurane in oxygen-enriched air 1, 3
• Alternatively, use total intravenous anesthesia (TIVA) with target-controlled infusion, particularly beneficial for patients at high risk for postoperative nausea and vomiting 1
• Avoid deep anesthesia levels (BIS <30), especially in elderly patients, as excessive depth increases postoperative confusion risk 1
• Consider BIS monitoring to titrate anesthetic depth to minimum effective levels 1

Intraoperative Adjuncts

• Add intraoperative ketamine as a co-analgesic to reduce opioid requirements 1
• Consider dexamethasone or methylprednisolone to reduce postoperative inflammation and nausea 1
• Administer alpha-2 agonists intraoperatively for additional analgesia 1

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Monitoring

• Standard ASA monitoring including ECG, pulse oximetry, non-invasive blood pressure, capnography, temperature, and neuromuscular monitoring 1
• Maintain normothermia (≥36°C) using active warming devices and warmed intravenous fluids throughout the procedure 1
• Monitor depth of anesthesia with BIS in elderly patients to avoid excessive depth 1

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Fluid Management

• Use goal-directed fluid therapy targeting cardiac output to optimize hemodynamics and avoid fluid overload 1
• Target near-zero fluid balance to prevent postoperative complications 1
• Use vasopressors (after confirming normovolemia) to maintain mean arterial pressure rather than excessive fluid administration 1

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Pain Management Strategy

Regional Anesthesia Options

For laparoscopic salpingectomy:

• Regional anesthesia is generally not required as the procedure is minimally invasive 1
• Consider intravenous lidocaine infusion as an opioid-sparing adjunct 1

For open salpingectomy (if performed):

• Thoracic epidural analgesia (T7-10) with local anesthetics and low-dose opioids is superior to systemic opioids for pain control and should be continued for 48-72 hours postoperatively 1

Multimodal Systemic Analgesia

• Administer a combination of two non-opioid analgesics (NSAID and paracetamol) to reduce opioid requirements 1
• Give ibuprofen 10 mg/kg IV every 8 hours or ketorolac 0.5-1 mg/kg (max 30 mg) as a single intraoperative dose 1
• Administer paracetamol 20-40 mg/kg loading dose during anesthesia 1
• Use opioids (fentanyl, tramadol, or nalbuphine) only as rescue medication 1

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Postoperative Care

Immediate Recovery

• Ensure complete reversal of neuromuscular blockade before extubation 1
• Desflurane allows rapid emergence with time to eye opening 4-5 minutes and time to state name 7-9 minutes after laparoscopic procedures 3
• Continue multimodal PONV prophylaxis in patients with ≥2 risk factors 1

Ward Management

• Continue oral or IV NSAIDs and paracetamol during the entire postoperative period 1
• Encourage early mobilization within 24 hours 1
• Remove urinary catheter within 24 hours unless high risk for retention 1
• Initiate early oral feeding as tolerated 1

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Common Pitfalls to Avoid

• Do not use excessive opioids during induction or maintenance, as this delays recovery and increases PONV 1, 2
• Avoid fluid overload, which can contribute to postoperative complications and delayed recovery 1
• Do not allow hypothermia to develop, as this increases surgical site infections and impairs recovery 1
• Ensure adequate neuromuscular reversal, as residual paralysis increases postoperative morbidity 1, 2
• Do not routinely place nasogastric tubes, as they should be removed before reversal of anesthesia 1