Venous Radiofrequency Ablation

Anesthesia Implications

Position: Supine, Lateral, arms at side on armboards
Time: 5-30 min (very short)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

Technique – Deep MAC. Some like 2 of versed + 100 mcg of fentanyl + propofol drip. I personally prefer 30 -50 mg of ketamine push + a 50 mcg/kg/min infusion of propofol. Makes for a quick wake up and uneventful procedure.

Position – If you hear this is going to be a “short” or “small” procedure, it means they are ablating the short/small saphenous vein. In this case, the patient will be in the lateral position (surgical side down). Some patients need the head of the bed up due to comorbidities (ie GERD). If the head is raised and the hips are flexed, it may occlude the area that will be ablated. In this case, it is better to utilize reverse trendelenburg to avoid hip flexure

Airways are your friend – most of these patients airways will obstruct with the level of sedation needed to keep them motionless.

Anticipate quick turnover.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.