Anesthesia for General Surgery Flashcards
What are CRNAs responsible for during the preoperative evaluation?
- determination of the medical status of the patient
- develop a plan of anesthesia care
- review with patient the proposed plan of care
pertinent information to review with patient/from preop eval
- PMHx
- lab/test results
- physical exam
- NPO status
qualities of an ideal anesthetic
- optimal patient safety and satisfaction
- excellent operating conditions for surgeon
- rapid recovery
- avoid post-operative side effects
- low in cost
- allow early discharge from PACU
- optimize pain control
- allow for optimal OR efficiency
Advantages of using general anesthesia for general surgery
- rapid onset of unconsciousness
- controlled ventilation
- allows for paralysis
- more safely allows for positioning extremes
- lower failure rate
Disadvantages of using general anesthesia for general surgery
- increased stress response
- full stomach - risk for aspiration
- PONV
- postoperative sedation
what BIS value is considered adequate GA
40-60
Advantages of using regional anesthesia for general surgery
- maintenance of consciousness
- skeletal muscle relaxation
- contraction of GI tract
- lower insufflation pressure
- decreased stress response
- faster recovery
advantages of spinal anesthesia
- less time to perform
- rapid onset sensory/motor anesthesia
- less pain
advantages of epidural anesthesia
- less risk of PDPH (post-dural puncture HA)
- less hypotension
- catheter
- post-operative analgesia
Disadvantages of using regional anesthesia for general surgery
- occasional failure to produce adequate levels of sensory anesthesia
- hypotension due to SNS blockade (worse with hypovolemia)
advantages of peripheral nerve block
- good option for superficial operations of extremities
- consciousness
- protective upper airway reflexes
- isolated anesthetic effect (pulmonary/CV disease)
disadvantages of peripheral nerve block
- unpredictable sensory and motor anesthesia
- success rate related to experience of provider
- patient cooperation
CV considerations for positioning
- central, regional and local mechanisms can blunt the effects of position changes to maintain perfusion to vital organs
- erect to supine –> increased VR –> preload, SV, CO augmented
- increased arterial BP –> baroreceptors activated –> decreased SNS outflow –> increased PSNS impulse to SA node –> decreased HR, SV, CO
- mechanoreceptors –> decreased SNS outflow
- atrial reflexes activated to regulate renal sympathetic activity
- GA, muscle relaxation, PPV, and neuraxial blockade interfere with VR, arterial tone, and autoregulation
- spinal/epidural - significant sympathectomy
- PPV - increases intrathoracic pressure, decreases VR
- PEEP - also increases mean intrathoracic pressure
- art BP labile immediately following induction + positioning
Pulmonary considerations for positioning
- anesthetized with spontaneous ventilation = reduced Vt and FRC
- anesthetized with PPV = adequate MV, some atelectasis [abnormal diaphragm shape, decreased V/Q matching, decreased PaO2]
- neuraxial = loss of abdominal/thoracic muscle function, retained diaphragmatic function
- any position that limits movement of diaphragm, chest wall or abdomen may increase atelectasis or intrapulmonary shunt
supine position
- most common
- arms either abducted or adducted (tucked)
- if abducted, ensure less than 90 degrees to minimized brachial plexus injury by caudad pressure in axilla from head of humerus
- supinated hand/forearm to protect ulnar nerve
- pad elbows, IV lines, and stopcocks
lawn chair position
- modified supine
- hips/knees slightly flexed
frog-leg position
- modified supine
- hips/knees flexed and hips externally rotated
supine position complications
- pressure alopecia
- backache (prevent by padding spine or flex hip/knee)
- soft tissue ischemia (bony prominences)
- peripheral nerve injury (ulnar most common)
- OR table weight limit
what is the usual OR table weight limit?
200 kg
trendelenburg position
- non-sliding mattress
- shoulder braces not recommended (can cause brachial plexus injury)
- significant CV/Resp effects
trendelenburg position complications
- increased CVP, ICP, and IOP
- swelling of face, conjunctiva, larynx and tongue
- potential postop airway obstruction (ensure decreased swelling before extubation)
- decreased FRC and pulmonary compliance
- increased work of breathing in spontaneous vent
- in MV, higher airway pressure needed
- ETT preferred to protect airway from aspiration and atelectasis
reverse trendelenburg position
- supine, head tilted upward
- facilitates upper abdominal surgery by shifting contents caudad
- detect hypotension due to decreased VR
- reduced perfusion pressure to brain
lithotomy position
- gyno, rectal, urologic surgeries
- hips flexed 80-100 degrees
- legs abducted 30-45 degrees from midline
- legs held by stirrups (candy cane, knee crutch, or calf support)
- avoid crush injury to fingers when putting foot board down
- both legs raised and lowered together to prevent injury to hips
- increased preload, reduced lung compliance, decreased Vt, increased abdominal pressure
- common = peroneal nerve injury (lateral head of fibula)
- lower extremity compartment syndrome
lateral decubitus position
- thorax, retroperitoneal, or hip procedures
- balanced with anterior and posterior support, flexed dependent leg, arms positioned in front of patient
- prevent lateral rotation of neck and stretch of brachial plexus
- check ears, eyes, all pressure points
- axillary roll to avoid compression injury to dependent brachial plexus
- kidney rest - dependent iliac crest (IVC compression)
- can compromise pulm function, favors ventilation of nondependent lung and blood flow to underventilated dependent lung
prone position
- ventral decubitus
- posterior spine, buttocks, perirectal area, and lower extremities surgeries
- arms tucked or superman position
- anesthesia provider responsible for coordinating flip
- mayfield rigid pins
- elevated intraabdominal pressure (risk for decreased FRC and pulm compliance) –> make sure abdomen is free hanging
- avoid tissue injury
what is laparoscopic surgery?
- used for diagnostic and surgical intervention
- insufflation of abdomen w CO2
- view of abdominal contents through small incisions
- use of small instruments through trocars
- camera projects images onto monitor screen
- minimally invasive surgery
what types of surgery can be laparoscopic?
- gastric
- colonic
- splenic
- hepatic
- gallbladder
- gynecologic
- urologic
advantages of laparoscopic surgery
- lower pain scores and opioid requirement
- earlier ambulation and return to normal activities
- lower incidence of post-op ileus
- faster recovery, shorter LOS
- reduced post-op pulmonary complications
- decreased stress response
- lower cost (usually)
disadvantages of laparoscopic surgery
- impaired visualization
- expensive equipment
- requires specific surgical skill
- limited ROM
- altered depth perception
- no tactile sensation
- increased PONV
- referred pain (frequently to shoulder)
relative contraindications for laparoscopic surgery
- increased ICP
- hypovolemia
- VP shunt or peritoneal jugular shunt (LeVeen)
- severe CV disease
- severe respiratory disease
- dense adhesions
what is the name of the needle used to create pneumoperitoneum?
veress needle
pneumoperitoneum
- abdomen inflated with CO2 or some other inert gas (He, Ar)
- can also do a gasless laparoscopy but that is not frequently used
CO2 pneumoperitoneum
- insufflation of the abdomen (peritoneal cavity) with CO2
- CO2 = more soluble in blood than air, He, O2 or N2O
- easily absorbed by the tissue (high blood solubility) with rapid elimination
- eliminated via respiration
- non-combustible
- colorless, odorless, inexpensive
effects of CO2 insufflation
- sympathetic stimulation = HTN, tachycardia
- impaired VR = hypotension
- vagal stimulation = arrhythmia, brady
- reduced FRC, reduced compliance, increased ventilatory pressures, barotrauma, atelectasis
- reduced renal perfusion, activation of RAAS, increased ADH
- increased intra-abdominal pressure, risk of gastric regurg, splanchnic ischemia, embolus, extra-peritoneal spread of CO2
physiologic effects of pneumoperitoneum
- increased = PaCO2, EtCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd, regurg/aspiration
- decreased = cardiopulmonary function, CO, VR, FRC, VC, renal function
clinical management of pulmonary changes
- position changes (decrease degree of trendelenburg)
- modify vent settings (pressure control)
- use PEEP with caution
- consider increasing volatile
- consider bronchodilators
clinical management of CV changes
- slow, gradual abdominal insufflation
- vent abdomen if IAP>20 mmHg
- evaluate intravascular volume (consider fluid bolus)
- consider treatment for preexisting CV dysfunction
clinical management of renal/hepatic changes
- closely monitor hourly UOP
- administer IVF boluses
- consider diuretics
- maintain IAP < 15 mmHg
clinical management of cerebral blood flow changes
- decreased degree of trendelenburg (adjust head up)
- vent abdomen if IAP > 20 mmHg
anesthetic considerations for laparoscopic surgery
- GETA (cuffed ETT)
- controlled ventilation –> increased MV and PIP; adjust RR; Vt 6-8 mL/kg; individualized PEEP; goal EtCO2 35 mmHg, PIP low 30 cmH2O
- RA can be used but need a high block at T4-T5 which causes SNS denervation so it is harder to compensation for CV/respiratory changes
- IAP < 15 mmHg to avoid CV compromise
- if ASA III-IV, abnormal PaCO2/EtCO2 gradient may need invasive BP monitoring and serial ABGs
muscle relaxation in laparoscopic procedures
-not necessarily required BUT don’t want coughing or bucking because of the trocars
what volatile anesthetic is not used in laparoscopic procedures?
nitrous oxide
things to consider with conversion to open procedure
- supine position
- new fluid plan - increased 3rd space loss
- new pain management plan
- new vent settings (reduce RR, increase Vt)
what complications can occur with laparoscopic surgery
- vascular injury - in abdominal area usually from trocar insertion
- GI injury
- CV = dysrhythmias, increased vagal tone, BP changes
- SQ emphysema
- capnothorax, capnomediastinum, capnopericardium from CO2 insufflation
- CO2 embolism
What do you do if you experience bradycardia or asystole with pneumoperitoneum?
- STOP insufflation (communicate with surgical team)
- treat with atropine
- increase depth of anesthesia before proceeding with insufflation again
how can a CO2 embolism occur?`
- direct veress needle placement into a vessel
- gas insufflation into an abodominal organ
what are the S/S of a CO2 embolism
- tachycardia
- arrhythmias
- hypotension
- millwheel murmur
- increased CVP
- cyanosis
- decreased EtCO2 wave form (SUDDEN)
pathophysiology of CO2 embolism
- severity will depend on size of bubbles and rate of entrainment
- vapor lock in vena cava and RA
- obstruction to venous return
- VQ mismatch ensues (because blood not getting to the lungs; so DEAD SPACE)
- acute RV hypertension = paradoxical embolism
- circulatory collapse
IDEAL WORLD diagnosis of gas embolsim
- TEE
- Swan-Ganz
- Precordial doppler
REAL WORLD diagnosis of gas embolism
- pulse oximetry (hypoxic)
- esophageal stethoscope (millwheel sound)
- sudden EtCO2 decrease
- aspiration of gas from CVP
- hypotension
- bronchospasm
- increased PIP
gas embolism treatment
- STOP insufflation and desufflate
- STEEP trendelenburg and left lateral decubitus (Durant maneuver)
- D/C nitrous oxide and give 100% FiO2
- hyperventilate
- place CVC (aspirate the air)
- CPR
- consider CPB or ECMO
subcutaneous emphysema
- accidental insufflation of extraperitoneum
- be aware of increases in PaCO2 after plateau has been reached
- not contraindication for extubation
- can track to thorax and mediastinum
what is the incidence of PONV in laparoscopic procedures?
40-75%
why can pain from laparoscopic surgery present as referred pain in the shoulder
- irritation of the diaphragm and/or visceral pain from biliary spasm
- tordol (ketorolac) is useful for referred shoulder pain
what are robotic assisted procedures?
- minimally invasive surgery using robotics
- control console, patient side cart (robotic arms), equipment tower (screens)
advantages of robotic-assisted surgery
- 3D view
- depth perception intuitive movements
- increased precision 10-15x
- magnification increased
- free movement
disadvantages of robotic-assisted surgery
- massive system
- limited working space
- limited patient access
- limited instrument availability
- expensive
- maintenance costs
- longer setup
what do CRNAs need to do to prepare for a robotic case?
- 2 PIVs
- consider art line
- limit IVF initially
- position - trendelenburg, lateral, flexion
- limited access to patient
- padding!!
3 common laparoscopic GI procedures
- cholecystectomy
- herniorrhaphy
- appendectomy
cholecystectomy
- removal of diseased gall bladder either due to cholecystitis, cholelithiasis, or cancer
- can be done laparoscopic or open; conversion rate is 5-10%
- sphincter of oddi spasm can occur
treatment of sphincter of oddi spasm
- naloxone
- glucagon
risk factors for conversion to open chole
- acute cholecystitis with thickened gallbladder wall
- previous upper abdominal surgery
- males
- advanced age
- obesity
- bleeding
- bile duct injury
anesthetic considerations for cholecystectomy
- preop antibiotics controversial
- DVT prophylaxis needed
- positioning - surgeon on patient’s left (supine) or between patient legs (lithotomy); reverse T with left tilt so right side up
potential complications of chole
- bleeding from cystic artery and cystic duct liver laceration
- pneumothorax
herniorrhaphy
- defect in muscles of abdominal wall which can be inguinal, umbilical, incisional, abdominal, femoral, diaphragmatic
- outpatient and elective
- can be open or laparoscopic
- can be incarcerated if not reduced (incarcerated = urgent)
- strangulated = emergency bc can lead to necrotic bowel (need GA)
- avoid strain bc want a smooth emergence
anesthetic choice for herniorrhaphy
- GA, local, or regional (T8)
- can infiltrate the ilioinguinal and iliohypogastric nerves with local to help with pain
why is it important to talk about the cough plan with the surgeon?
-surgeon may or may not want the patient to cough post-procedure to see if the hernia has been adequately reduced
EBL of herniorrhaphy
50 mL
postop pain for herniorrhaphy
4-6
complications of herniorrhaphy
- bradycardia due to peritoneal retraction
- treat with glyco/atropine
appendectomy
- most common acute surgical procedure of abdomen
- obstruction/inflammation due to lymphoid tissue or fecal matter
- appendicitis = pain, anorexia
anesthetic technique/considerations for appendectomy
- GA (RSI)
- OGT
- avoid N2O
- antibiotics
- fluid and electrolyte deficits (b/c usually come in vomiting)
- aspiration precautions
- avoid metoclopramide with obstruction
- skeletal muscle relaxation
mortality of appendectomy
1% (2% if perforated)
incidence of appendectomy
6%
common GI Lab procedures
- esophagogastroduodenoscopy (EGD)
- endoscopic retrograde cholangiopancreatography (ERCP)
- colonoscopy
EGD
- diagnostic/therapeutic
- minimally invasive
- conscious sedation/topical, GA
- shared airway/limited access
- mouth piece inserted by endoscopist to prevent biting
- may consider GETA (obese or risk factors)
EGD complications
- perforation
- bleeding
- desaturation
- laryngospasm
EGD positions
supine or lateral decubitus
colonoscopy
- used to view lining of rectum and colon
- diagnostic/therapeutic –> cancer screening or treatment of polyps
- colon prep, clear liquid diet
colonoscopy position
left lateral decubitus
colonoscopy anesthetic technique
heavy sedation or GA
colonoscopy potential complications
- perforation
- bleeding
- desaturation
- laryngospasm
ECRP
- used to diagnose and treat pancreatic and biliary disorders
- uses contrast dye and fluoroscopy
ECRP position
left lateral decubitus/prone
can change during procedure
ECRP length
30 min up to several hours depending on extent of disease
ECRP anesthetic technique
GETA or sedation
ECRP complications
- perforation
- bleeding
- desaturation
- laryngospasm
indications for esophageal surgery
- GERD
- Cancer
- hiatal hernia
- motility disorders
patient symptoms that may be indicative of esophageal surgery
- dysphagia
- heartburn
- hoarse voice
- chest pain
nissen fundoplication
- fundus wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
- laparoscopic or transthoracic approach
nissen fundoplication surgical time
3-4 hours
nissen fundoplication anesthetic considerations
- GETA (cuffed ETT)
- induction, position (may want elevated HOB because patient may not be able to lie flat), RSI, cricoid pressure
- 54-60 french esophageal dilator (bougie)
- NGT 12-24 hours post op
- DVT prophylaxis - pneumatic compression stockings
- smooth extubation bc don’t want to disrupt suture line
nissen fundoplication meds used
- H2 blockers
- metoclopramide (2-4 hours preop)
- antibiotic
- antiemetics
nissen fundoplication positioning
lithotomy and reverse T
esophagectomy
majority of thoracic esophagus and nearby lymph nodes removed, stomach is moved up and attached to the remaining portion of the esophagus
what types of patients get esophagectomy
- ETOH
- tobacco
- chemo/radiation
esophagectomy anesthetic considerations
- surgical approach (many options so ask which one)
- invasive monitors
- double lumen tube
- post op pain management
esophagectomy surgical approach
- depends on patient condition, portion of esophagus to be removed, surgeon skill/preference
- surgical complications and anesthetic considerations can change based on the approach
- types of incisions include cervical, abdominal, R chest, L thoraco-abdominal
gastrostomy
create opening through the skin and the stomach wall to provide nutritional support or GI compression
gastrostomy indications
- dysphagia
- high risk or active aspiration
gastrostomy surgical approach
- laparoscopic
- percutaneous (PEG)
- open
gastrostomy surgical time
usually <1 hour
gastrostomy anesthesia type
GA (RSI)
LA + sedation
total gastrectomy anesthetic considerations
- stable or acutely ill/malnourished
- correct hypovolemia and anemia
- chemo/radiation
- cross-matched blood available
- full stomach/NGT
- invasive monitoring
- warming
- extubate
types of intestinal surgery
- small bowel resection
- colectomy
- colonoscopy
indications for intestinal surgery
- diverticulitis
- cancer
- Crohn’s
- Ulcerative colitis (UC)
small bowel resection
- healthy bowel anastomosed or ileostomy created
- usually involves bowel prep (hypokalemia, hypovolemia)
- NEED - preop EKG, CBC, electrolytes, T&S
indications for small bowel resection
- obstruction
- cancer
- diverticulum
- Crohn’s
small bowel resection surgical time
2-4 hours
small bowel resection EBL
usually < 500 mL
small bowel resection anesthetic considerations
- aspiration precautions
- RSI with cricoid pressure
- NGT
- foley
- avoid metoclopramide (esp if obstruction, DO NOT USE)
- consider epidural for pain mgmt
- large third space fluid loss due to large open abdomen (10-15 mL/kg/hr)
- hypothermia
small bowel resection postoperative complications
- pulmonary effusion
- anastomotic leak
- short bowel syndrome
- sepsis
- small bowel necrosis
colectomy
- removal of part or all of the colon
- can be open or laparoscopic
- requires bowel prep
- clear liquids 1-2 days preop
- they will be volume and electrolyte depleted
- NEED - pre op lytes
- IV/PO antibiotic preop
- thoracic epidural for post op pain
- corticosteroid supplements
liver facts
- metabolic and hematolic roles
- four lobes, eight segments
- only organ capable of regenerating functional parenchyma within 24 hours of resection (70% can be regenerated in animal models)
- HIGHLY vascular
what are the four lobes of the liver
- right
- left
- quadrate
- caudate
what is the total blood flow of the liver
-1.5 L/min
portal vien
supplies 80% of hepatic blood flow
hepatic artery
supplies 20% of hepatic blood flow
liver resection preop H&P
- bruising
- anorexia or weight changes
- N/V or pain with fatty meals
- pruritis or fatigue
- abodominal distention/ascites
- GI bleeding
- scleral icterus (yellow pigment of sclera)
- hepatomegaly or splenomegaly
- palmar erythema
- gynecomastia
- asterixis (tremor of hand when wrist extended)
- spider angiomata, petechiae, ecchymosis
liver resection preop work up
- CT or MRI for tumor location
- 12 lead EKG/ECHO
- CXR
- lab studies - CBC, coags (PT, PTT, bleeding time), chemistry profile, LFTs
preop considerations for liver resection
- optimization of patient
- PT or INR - parenteral vit K, recombinant factor VII, FFP in emergency
- consider plt infusion if <100,000
- assume full stomach (ascites) - H2 blocker, metoclopramide, sodium citrate
- sedative pre-med
preop optimization of patient undergoing liver resection includes correction of ….
- ETOH dependency
- coagulopathy
- pH
- electrolyte abnormalities (esp K+)
- malnutrition
- anemia
- esophageal varices
- hepatic encephalopathy
monitoring for those undergoing liver resection
- large bore IV
- a-line
- CVP or PA cath (if pulm HTN)
- TEG to guide blood product admin
- foley
- OGT/NGT
- TEE
intraoperative considerations for those undergoing liver resection
- local/MAC - adequate sedation is essential to minimize SNS stim and resultant decrease in hepatic flow and O2 delivery
- GETA - RSI or awake intubation; sevo/iso agents of choice
- fluids - no evidence that colloids better than crystalloids
- altered PK
- consider epidural for pain control post op
benzos with liver disease
- increased cerebral uptake
- decreased clearance
- prolonged half-life
dexmedetomidine with liver disease
decreased clearance and prolonged half-life
propofol with liver disease
- single dose = similar response as normies
- recovery times may be longer after infusions
- drugs of choice with encephalopathy
morphine with liver disease
- prolonged elim half life
- increased bioavailability in oral form
- decreased plasma protein binding
- exaggerated sedative and resp depressive effects
meperidine with liver disease
- 50% reduction in clearance and doubling of the half-life
- may experience neurotoxicity from accumulation of normeperidine
fentanyl with liver disease
- plasma clearance is decreased
- repeated dose or infusion may produce more exaggerated and pronounced effects
sufentanil with liver disease
- PK not significantly altered
- some difference in half-life
- repeated dose or infusion may produce more exaggerated and pronounced effects
alfentanil with liver disease
- elim 1/2 doubled and higher free fraction of drug
- prolonged DOA and enhanced effects
remifentanil with liver disease
elimination unaltered
NMBD with liver disease
- increased Vd may require higher initial dose
- prolonged elim of vec, roc, panc, and mivacurium (increased DOA)
- atracurium + cis = hoffman so fine in liver disease
- succ prolonged due to decreased cholinesterase levels
- sugammadex not affected
catecholamines with liver disease
- decreased response because of circulating vasodilators like bile acids and glucagon
- impaired ability to translocate blood from pulm and splanchnic blood reservoirs to systemic circ
- consider increased doses or addition of non-adrenergic vasoconstrictor
- patients with biliary obstruction are particularly intolerant of blood loss
intraop fluid management of liver procedures
- volume loading –> distention of vessels with difficulty controlling blood loss
- limit fluid pre-resection
- portal triad clamping
- post-resection restore euvolemia
potential intraop complications of liver resection
- hemorrhage, coagulopathy
- hypocalcemia
- hypoglycemia
- VAE
- pulmonary disturbances
potential post-op complications of liver resection
- bleeding
- bile leak
- portal vein/hepatic artery thrombosis
- liver failure
spleen facts
- located in upper left abdomen, just inside rib cage (9, 10, 11 ribs)
- part of lymphatic system
- filters foreign substances from blood and removes blood cells
- regulates blood flow to the liver and sometimes stores blood cells
- HIGHLY vascular organ 300 mL/min
splenectomy
- can be done open or laparoscopically
- only treatment for hereditary spherocytosis and cancers of spleen
- other indications - trauma, abscesses, idiopathic thrombocytopenic purpura (ITP), hodgkin’s staging
preop anesthetic considerations for splenectomy
-evaluate underlying disease process and implications
intraop anesthetic considerations for splenectomy
- asepsis
- large bore venous access
- warming measures
- epidural for post-op pain
potential complications splenectomy
- atelectasis
- pneumothorax
- infection
- hemorrhage
- VAE
indicators for bariatric surgery
- BMI > 40 kg/m2
- BMI > 35 kg/m2 with related comorbidities not well controlled by medical therapy
bariatric surgery
surgical alteration of small intestine or stomach to promote weight loss
malabsorptive procedures
- limits the amount of nutrients the body absorbs by bypassing a portion of the small intestine
- jejuno-ileal bypass
- biliopancreatic diversion
restrictive procedures
- reduces the size of the stomach
- limits the amount of food that can be consumed and creates a feeling of fullness
- gastroplasty (VBG)
- adjustable gastric banding (AGB)
combined restrictive and minimal malabsorptive
roux-en-y gastric bypass (RYGB)
what is the greatest cause of bariatric periop 30 day mortality
PE
AGB
- adjustable band placed on stomach
- tubing with port attached to band
- special needle can be inserted in port to add or remove fluid (add = band smaller; remove = band bigger)
roux-en-y gastric bypass
- part of stomach detached form rest to create a small pouch
- pouch connected to a lower part of the small intestine by a piece of small intestine (resembles Y)
- parts of stomach and small intestine bypassed
- digestive juices can still mix with the food to enable the body to absorb vitamins and minerals
- reduced risk of nutritional deficiencies
laparoscopic bariatric surgery advantages
- less post-op pan
- lower morbidity
- faster recovery
- less fluid 3rd spacing
- decreased wound infection
- smaller incisions
laparoscopic bariatric surgery disadvantages
- complete NMB important
- positioning requirements increase fall risk
- high risk for R mainstem (d/t insufflation)
- incidence of rhabdomyolysis in obese patients higher compared to open procedure
laparoscopic bariatric surgery anesthetic considerations
- may need to facilitate the proper placement of an intragastric balloon for pouch sizing
- prior to gastric diversion, ensure all endogastric devices are removed
- after gastric pouch in place, avoid blind NGT insertion
implantable gastric stimulator
- 2 lead electrodes on greater curvature of stomach
- SQ electric pulse generator implanted on abdominal wall
- stimulate gastric smooth muscle, decrease peristalsis
- in theory patient feels less hungry
- laparoscopic
anesthetic considerations for implantable gastric stimulator
- avoid N/V
- valsalva may dislodge electrodes
- ECG interference
