Position: Lithotomy, Trendelenburg
Time: 2-4 hours (long)
Blood Loss: High (200 – 500 ml)

Maintenance Paralytic: Yes

The procedure is highly stimulating and requires full muscle relaxation.

If using regional anesthesia, the patient requires a T4-T6 sensory level block. This can be done using a spinal, epidural or combined approach.

Have atropine or glycopyrrolate (Robinul) available. These drugs are to counteract bradycardia associated with the trendelenburg position and/or vagal stimulation commonly seen with uterine procedures.

The procedure will likely be more than 2 hours, so generally a foley is placed.

PONV common. Consider using a multimodal approach to prevent PONV – one of the most common is 4 mg Dexamethasone and 4 mg of Ondansetron.

Surgeon may inject epinephrine or vasopressin to decrease local bleeding (monitor for brady/tachydysrythmias).

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.