7: OPERATIVE HYSTEROSCOPY

Question 1

Signs of neurologic toxicity with local anesthetics

Answer 1

Perioral numbness
Metallic taste (early symptom)
Mental status changes
Visual changes
Muscle twitches
Seizures
Respiratory depression

Question 2

Signs of cardiac toxicity with local anesthetics

Answer 2

Arrhythmia
Cardiac arrest

Question 3

Max dosing 0.25% Bupivicaine

Answer 3

Without epi: 2.5mg/kg
With epi: 3mg/kg

Question 4

Max dosing 0.5% Ropivicaine

Answer 4

Without epi: 3mg/kg
With epi: 3.5mg/kg

Question 5

Max dosing 1.5% Mepivicaine

Answer 5

Without epi: 5mg/kg
With epi: 7mg/kg

Question 6

Max dosing 2% Lidocaine

Answer 6

Without epi: 4.5mg/kg
With epi: 5mg/kg

Question 7

Benefits of epinephrine

Answer 7

Allows for delayed vascular absorption
Increases duration of action
Decreases risk of toxicity

Question 8

A/E of epinephrine

Answer 8

Risk of ischemia and necrosis (therefore avoid in areas with limited blood supply)

Question 9

Doses of misoprostol for cervical prep

Answer 9

200, 400, 800mcg
Off-label use

Question 10

Dose of dinoprostone

Answer 10

0.5mg
Off-label use

Question 11

Incidence of perforation of HSC (diagnostic and operative)

Answer 11

Diagnostic: <0.1%
Operative: 0.1%

Question 12

Most common location of perforation

Answer 12

Fundus, also A/P walls

Question 13

Diagnosis of uterine perforation

Answer 13

Loss of adequate distention
Loss of visualization
Rapid increase in fluid deficit
Visualization of false passage/perforation
Visualization of omentum/bowel
Excessive bleeding from uterus
Adipose tissue found on pathology

Question 14

Indications for expectant management with uterine perforation

Answer 14

Vitals stable
Blunt instrument
No electrosurgery
Fundal location
Mo immediate or later concern for vascular injury
SHOULD TERMINATE PROCEDURE AND OBSERVE IN PACU

Question 15

Indications for surgical exploration after uterine perforation

Answer 15

Unstable vital signs
Severe bleeding
Use of electrosurgery at time of injury
Lateral or cervical laceration
If procedure must be completed (ex: D&C for uterine evacuation of pregnancy)
Suspected injury to nearby organs

Question 16

Vasopression ___ SVR, ___ MAP

Answer 16

Increases SVR
Increases MAP

Question 17

Benefits of vasopressin

Answer 17

Cervical dilation
Decreases blood loss
Decreases fluid absorption

Question 18

Risks of vasopressin

Answer 18

Profound HTN > vasovagal bradycardia > possible cardiac arrest/intraoperative mortality

Question 19

Ideal concentration of vasopressin, then recommendations per AAGL

Answer 19

0.1-0.2U/mL
AAGL: 5U/100cc (0.05U/mL)

Question 20

Concentration of vasopressin to avoid

Answer 20

Avoid >1U/cc
MAX: <5U should be injected at one time

Question 21

What type of fluid does resectoscope use?

Answer 21

Electrolyte poor, hypotonic (because monopolar energy)

Question 22

Examples of electrolyte-poor, hypotonic fluid

Answer 22

1.5% Glycine
3% Sorbitol
5% Mannitol

Question 23

Risks of electrolyte-poor, hypotonic fluid

Answer 23

Fluid overload
Electrolyte abnormalities
Neurologic sequelae

Question 24

Examples of electrolyte-rich, isotonic fluids

Answer 24

NS
LR

Question 25

A/E of electrolyte-rich, isotonic fluid

Answer 25

Fluid overload
Pulmonary edema

Question 26

Max fluid defecits

Answer 26

Electrolyte-poor, hypotonic: 1000cc
Electrolyte-rich, isotonic: 2000cc
Consider lower if comorbidities

Question 27

Areas of thinnest myometrium

Answer 27

Cornua
Area of previous c/s scar

Question 28

When to do LSC for isthmocele

Answer 28

> 3mm