What is the recommended anesthetic technique for a healthy reproductive‑age woman (ASA I–II) undergoing abdominal myomectomy with chromopertubation?

Anesthesia for Abdominal Myomectomy with Chromopertubation

Recommended Anesthetic Technique

General anesthesia with endotracheal intubation is the recommended technique for abdominal myomectomy with chromopertubation in healthy reproductive-age women (ASA I-II). 1

This procedure requires:

• Muscle relaxation to facilitate surgical exposure and safe entry into the peritoneal cavity 1
• Controlled ventilation with low tidal volumes (6-8 mL/kg predicted body weight) and PEEP ≥5 cm H₂O 1
• Rapid sequence induction if the patient has not fasted appropriately, using rocuronium 0.9-1.2 mg/kg or succinylcholine 1-2 mg/kg 1

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Preoperative Preparation

Fasting and Aspiration Prophylaxis

• Clear liquids permitted up to 2 hours before surgery; solid foods avoided for 6-8 hours 1, 2
• Administer nonparticulate antacid (sodium citrate 30 mL) within 60 minutes of incision 1
• Consider adding ranitidine 50 mg IV and/or metoclopramide 10 mg IV for additional aspiration prophylaxis 1

Preemptive Analgesia

• Acetaminophen 1000 mg PO 1-2 hours preoperatively 2
• Celecoxib 200-400 mg PO or other NSAID if no contraindications exist 1, 2

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Induction and Maintenance

Induction Agents

• Propofol 2-2.5 mg/kg IV for induction, providing smooth onset and reduced PONV 3, 4
• Rocuronium 0.9-1.2 mg/kg for neuromuscular blockade to facilitate intubation and maintain surgical relaxation 1

Maintenance Strategy

• Balanced anesthesia using volatile agent (sevoflurane or desflurane) with oxygen/air mixture 1, 3
• Total intravenous anesthesia (TIVA) with propofol + remifentanil is preferred if patient has ≥2 PONV risk factors (female sex, non-smoker, history of PONV, anticipated postoperative opioid use) 5

Intraoperative Opioid Management

• Remifentanil 0.25-0.5 μg/kg/min infusion provides superior intraoperative control with faster emergence compared to longer-acting opioids 4
• Fentanyl 1-2 μg/kg IV bolus as alternative if remifentanil unavailable 5
• Administer longer-acting opioid (morphine 0.1-0.15 mg/kg IV or hydromorphone 0.02 mg/kg IV) 30-45 minutes before end of surgery to prevent emergence pain when using remifentanil 4

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Intraoperative Monitoring and Management

Standard Monitoring

• Continuous pulse oximetry, ECG, non-invasive blood pressure, capnography, and temperature monitoring 1, 2
• Quantitative neuromuscular monitoring at the adductor pollicis muscle to ensure adequate reversal before extubation 1

Neuromuscular Blockade

• Maintain deep neuromuscular blockade (post-tetanic count 1-2) during abdominal entry and myoma enucleation to optimize surgical conditions 1
• Monitor train-of-four ratio and ensure TOF ratio ≥0.9 before extubation 1
• Reverse with sugammadex 2-4 mg/kg (preferred over neostigmine for faster, more reliable reversal) 1

Temperature Management

• Active warming with forced-air device and warmed IV fluids to maintain core temperature ≥36°C 1
• Monitor core temperature continuously using esophageal or nasopharyngeal probe 1

Ventilation Strategy

• Tidal volume 6-8 mL/kg predicted body weight 1
• PEEP ≥5 cm H₂O, titrated to flow-volume loops and clinical evaluation 1

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PONV Prophylaxis

Risk Assessment

Abdominal myomectomy patients have ≥3 PONV risk factors (female, non-smoker, major abdominal surgery, postoperative opioids), classifying them as high-risk. 1, 5

Multimodal Prophylaxis (High-Risk Patients)

• Dexamethasone 4-8 mg IV at induction 1, 5
• Ondansetron 4 mg IV or other 5-HT₃ antagonist 30 minutes before skin closure 1, 5
• Consider adding droperidol 0.625-1.25 mg IV or metoclopramide 10 mg IV 5
• Use TIVA (propofol + remifentanil) instead of volatile agents if feasible 5

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Postoperative Analgesia

Multimodal Regimen

• Scheduled acetaminophen 1000 mg PO/IV every 6 hours 1, 2, 5
• Scheduled NSAID (ketorolac 15-30 mg IV every 6 hours or ibuprofen 400-600 mg PO every 6 hours) unless contraindicated 1, 2
• Opioid rescue (oxycodone 5-10 mg PO every 4 hours PRN or morphine 2-4 mg IV every 2 hours PRN) for breakthrough pain (NRS >4) 2

Alternative Techniques

• Transversus abdominis plane (TAP) block with 20 mL of 0.25% bupivacaine bilaterally reduces opioid consumption and improves early mobilization 1
• Intravenous lidocaine infusion (1.5 mg/kg bolus followed by 1.5 mg/kg/hr until skin closure) decreases postoperative pain and opioid requirements 1, 5

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Critical Safety Considerations

Airway Management

• Have difficult airway equipment immediately available (videolaryngoscope, supraglottic airways, flexible bronchoscope) 1
• Assess for predictors of difficult mask ventilation (BMI >30, Mallampati III-IV, reduced thyromental distance) 1

Infection Prevention

• Administer broad-spectrum IV antibiotics within 60 minutes before skin incision (cefazolin 2 g IV or clindamycin 900 mg + gentamicin 5 mg/kg if penicillin-allergic) 1
• Preoperative skin antisepsis with chlorhexidine-alcohol solution 1

Blood Loss Management

• Have large-bore IV access (16-18 gauge) and blood products available given potential for significant hemorrhage during myomectomy 1, 6, 7
• Maintain euvolemia with balanced crystalloids (Ringer's lactate) at 2-4 mL/kg/hr 1

Local Anesthetic Systemic Toxicity

• Have lipid emulsion 20% immediately available if using TAP blocks or local anesthetic infiltration 2, 8

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Common Pitfalls to Avoid

• Do not use neuraxial anesthesia alone for abdominal myomectomy—muscle relaxation and controlled ventilation are essential for safe surgical exposure 1
• Do not delay reversal of neuromuscular blockade—residual paralysis increases postoperative pulmonary complications 1
• Do not rely on volatile agents alone for PONV prophylaxis—these patients require multimodal antiemetic therapy 1, 5
• Do not forget preemptive analgesia before remifentanil discontinuation—this prevents severe emergence pain 4