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Advanced Principles of Anesthesia I > Anesthesia for Abdominal General Surgery > Flashcards

Anesthesia for Abdominal General Surgery Flashcards

1
Q

Common GI Associated Problems

A 
N/V
Ascites
Pain 
GERD
Obesity 
Cancer
Anemia
Fluid & Electrolyte Disorders
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2
Q

General Anesthesia for General Surgery

Advantages

A

allows paralysis, more safely allows positioning extremes, more reliable, lower failure rate

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3
Q

General Anesthesia for General Surgery

Disadvantages

A

increased stress response, known full stomach, increased risk for aspiration, more postoperative nausea and sedation

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4
Q

Regional Anesthesia for General Surgery

Advantages

A

requires lower insufflation pressures, patient breaths spontaneously, decreased stress response, faster recovery period

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5
Q

Regional Anesthesia for General Surgery

Disadvantages

A

occasional failure, sympathectomy

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6
Q

MAC/IV sedation for General Surgery

A

Combined with local anesthesia, patient breathes spontaneously, patient comfort level

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7
Q

Considerations for Anesthetic Management

A

choice of anesthetic, routine monitors, foley catheter, cuffed ETT, pneumoperitoneum, evacuation of gastric contents, positioning, smooth emergence/extubation, antiemetics, and pain management

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8
Q

Anesthesia for Laparoscopic Surgery

A

used for diagnostic & surgical intervention
insufflation of abdomen (CO2)
view of abdominal contents through small incisions
use of small instruments through trocars
camera projects images on monitor screen
minimally invasive surgery

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9
Q

Anesthesia for Laparoscopic Surgery

Advantages

A

lower pain scores & opioid requirement
earlier ambulation & return to normal activities
lower incidence of post-op ileus
usually faster recovery, shorter hospital stay
reduced post-op pulm/diaphragmatic dysfunction
less stress response & less wound complications
lower cost

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10
Q

Anesthesia for Laparoscopic Surgery

Disadvantages

A 
impaired visualization 
expensive equipment 
requires specific surgical skill 
limited ROM altered depth perception 
no tactile sensation 
increased PONV 
referred pain
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11
Q

Laparoscopy relative contraindications

A

Inc. ICP, hypovolemia, V/P shunt, severe CV or respiratory disease, and dense adhesions

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12
Q

Surgical Exposure - CO2 Pneumoperitoneum

A

insufflation of the abdomen with CO2, more soluble in blood than air, helium and oxygen or nitrous oxide
easily absorbed by the tissues with rapid elimination (via respiration)
non-combustible, colorless, odorless, and inexpensive

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13
Q

Effects of CO2 Insufflation

A

HTN, Tachy (sympathetic stimulation)
hypotension (impaired venous return)
arrhythmia, bradycardia (vagal stimulation)
reduced FRC, compliance, increased ventilatory pressures, barotrauma, and atelectasis
reduced renal perfusion, activation of RAAS, increased ADH
increased intra-abdominal pressures, risk of gastric regurg, splanchnic ischemia, CO2 embolus, extra peritoneal spread of CO2

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14
Q

Physiologic Effects of Pneumoperitoneum

A

increased: PaCO2, ETCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd (deadspace), risk of regurg/aspiration
decreased: cardiopulm function, CO, VR, FRC, VC, and renal function

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15
Q

Clinical Management of Physiological Pulmonary Changes

A 
position changes (decrease degree of trendelenburg) modify ventilatory support (pressure control) 
use PEEP w/ caution 
consider increasing volatile & bronchodilators
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16
Q

Clinical Management of Physiological Cardiovascular Changes

A

slow, gradual abdominal insufflations
vent abdomen if IAP>20mmHg
evaluate intravascular volume (IVF bolus)
consider treatment for preexisiting cardiac dysfunction

17
Q

Clinical Management of Physiological Renal/Hepatic Changes

A

closely monitor hourly UOP
administer IVF boluses
consider diuretics
maintain IAP <15 mmHg

18
Q

Clinical Management of Physiological Cerebral Blood Flow Changes

A

Decrease degree trendelenburg (adjust head up)

vent abdomen if IAP >20mmHg

19
Q

General Anesthesia for Laparoscopic Surgery

A

GA w/ cuffed ETT & controlled ventilation
increased min ventilation & PIP often required
adjust RR, Vt (6-8ml/kg), PEEP (5-10 cmH20)
Goals: ETCO2 35 mmHg, PIP low 30’s cmH20

20
Q

Regional Anesthesia for Laparoscopic Surgery

A

Regional has been used but risky
need high block T4-5 (SNS denervation) more difficult to compensate for CV, ventilatory changes, shoulder & distention pain incompletely alleviated

21
Q

Anesthesia for Laparoscopic Surgery

A

Intra-abdominal pressure limit of <15mmHg is best to avoid CV compromise
ASA 3-4 and/or abnormal gradient PaCO2:ETCO2 invasive monitors (blood gas and BP measurements)

22
Q

General Endotracheal Tube Anesthesia vs. LMA

A 
ETT: secure airway (aspiration protection) and control of ventilation 
ProSeal LMA (controversial): spontaneous ventilation, lower incidence of sore throat, lower pain scores, less analgesic medications, less PONV. Unable to secure airway (aspiration risk), control ventilation, & administer muscle relaxation
23
Q

Anesthesia for Laparoscopic Surgery: Positioning

A

Prevent nerve injury - common peroneal nerve (lithotomy) & brachial plexus (shoulder braces)
Tilt not to exceed 15-20 degrees
Make changes slowly, recheck ETT position after every position change, consider less aggressive fluid replacement in head down position (edema)

24
Q

Anesthesia for Laparoscopic Surgery: GA Maintenance

A

balanced techniques appropriate using volatile agent, opioids, or TIVA (no N20)
consider propofol TIVA if PONV
continue muscle relaxation, careful monitoring of pulmonary and hemodynamic status
watch for endobronchial intubation during position changes (head up or down)

25
Q

Conversion to open procedure

A

supine position, new fluid plan (3rd space losses will increase), new pain management plan (increase opioid requirements), new ventilator settings (may need to increase RR and increase Vt

26
Q

Monitoring for Intraop Complications

A

Vascular injury: trocar insertion/veress needle- aorta, ICV, iliac vessels, cystic/hepatic arteries, retroperitoneal hematoma
GI: bowel, liver, spleen, mesenteric
Cardiac: dysrhythmias- hypercarbia, increased vagal tone with peritoneal traction, BP changes
SQ Emphysema: extra peritoneal insufflation
Capnothorax/Capnomediastinum/Capnopericardium: diaphragm defect, pleural tear, bullae rupture, high degree of suspicion can be lifesaving
CO2 Embolism: direct needle placement in vessel, gas insufflation into abdominal organ

27
Q

Gas Embolism Patho

A

depends on size of bubbles and rate of entrainment
vapor lock in vena cava and RA
obstruction to venous return
actue RV hypertension = paradoxical embolism
circulatory collapse

28
Q

Gas Embolism Diagnostic Tools

A

TEE, swanganz catheter, precordial dopplers

real world: pulse ox, sudden ETCO2 decrease, aspiration of gas from CVP, hypotension, bronchospasm, and increased PIP

29
Q

Gas Embolism Treatment

A

stop insufflation and desufflate
positioning (steep trendelenberg, left lateral decubitus)
D/C N20 and give 100% FiO2
hyperventilate, place CVP, CPR, and consider CPB

30
Q

Sub Q Emphysema

A

accidental insufflation of extraperitoneum
increases in PaCO2 after plateau has been reached
not a contraindication for extubation
can track to thorax and mediastinum
(worry when airway becomes deviated)

31
Q

Common Laparoscopic GI Procedures

A

Cholecystectomy: removal diseased gall bladder (cholecystitis, cholelithiasis, cancer)
Herniorrhaphy: defect in muscles of the abdominal wall (inguinal, umbilical, incisional, abdominal, femoral, diaphragmatic)
Appendectomy: most common acute surgical procedure of the abdomen. Etiology: obstruction with inflammation by lymphoid tissue or fecal matter

32
Q

Cholecystectomy

A

laparoscopic venous return (rate of conversion 5-10%)
sphincter of oddi spasm
Risk factors for conversion to open:
actue cholecystitis w/ thickened gallbladder wall, previous upper abdominal surgery (adhesions), males, advanced age, obesity, bleeding, bile duct injury

33
Q

Herniorrhaphy

A

outpatient, elective surgery
open or laparoscopic
potential for incarceration if not reduced (urgent surgery)
strangulated: emergency surgery with GA, can lead to necrotic bowel requiring bowel resection. higher morbidity & mortality

34
Q

Appendectomy

A 
low mortality 1% (2% if perforated) 
incidence: 6% of population 
perforation: septic shock, peritonitis
F&E deficits from N/V 
aspiration precautions, ABX, avoid Reglan w/ obstruction
skeletal muscle relaxant usual with RSI
35
Q

Anesthesia for Laparoscopic Surgery: GA Emergence & Postop Considerations

A

procedures associated with intra-abdominal, incisional, and shoulder pain (irritation of diaphragm and/or visceral pain from biliary spasm)
opioids + NSAIDS + acetaminophen + decadron + local anesthetic infiltration (incisional and intraperitoneal)
PONV 40-75%

36
Q

Herniorrhaphy

A

avoid strain, general, local or regional (T8) anesthesia
discuss plan w/ surgeon regarding pt cough, EBL 50 mL, postop pain 4-6, LA infiltraton of ilioinguinal & iliohypogastric nerves, bradycardia results from peritoneal retraction

Advanced Principles of Anesthesia I (1 decks)

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