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N931 Advanced Principles of Anesthesia I > Anesthesia for General Surgery > Flashcards

Anesthesia for General Surgery Flashcards

1
Q

What are CRNAs responsible for during the preoperative evaluation?

A
  • determination of the medical status of the patient
  • develop a plan of anesthesia care
  • review with patient the proposed plan of care
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2
Q

pertinent information to review with patient/from preop eval

A
  • PMHx
  • lab/test results
  • physical exam
  • NPO status
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3
Q

qualities of an ideal anesthetic

A
  • 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
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4
Q

Advantages of using general anesthesia for general surgery

A
  • rapid onset of unconsciousness
  • controlled ventilation
  • allows for paralysis
  • more safely allows for positioning extremes
  • lower failure rate
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5
Q

Disadvantages of using general anesthesia for general surgery

A
  • increased stress response
  • full stomach - risk for aspiration
  • PONV
  • postoperative sedation
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6
Q

what BIS value is considered adequate GA

A

40-60

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7
Q

Advantages of using regional anesthesia for general surgery

A
  • maintenance of consciousness
  • skeletal muscle relaxation
  • contraction of GI tract
  • lower insufflation pressure
  • decreased stress response
  • faster recovery
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8
Q

advantages of spinal anesthesia

A
  • less time to perform
  • rapid onset sensory/motor anesthesia
  • less pain
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9
Q

advantages of epidural anesthesia

A
  • less risk of PDPH (post-dural puncture HA)
  • less hypotension
  • catheter
  • post-operative analgesia
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10
Q

Disadvantages of using regional anesthesia for general surgery

A
  • occasional failure to produce adequate levels of sensory anesthesia
  • hypotension due to SNS blockade (worse with hypovolemia)
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11
Q

advantages of peripheral nerve block

A
  • good option for superficial operations of extremities
  • consciousness
  • protective upper airway reflexes
  • isolated anesthetic effect (pulmonary/CV disease)
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12
Q

disadvantages of peripheral nerve block

A
  • unpredictable sensory and motor anesthesia
  • success rate related to experience of provider
  • patient cooperation
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13
Q

CV considerations for positioning

A
  • 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
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14
Q

Pulmonary considerations for positioning

A
  • 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
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15
Q

supine position

A
  • 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
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16
Q

lawn chair position

A
  • modified supine

- hips/knees slightly flexed

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17
Q

frog-leg position

A
  • modified supine

- hips/knees flexed and hips externally rotated

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18
Q

supine position complications

A
  • 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
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19
Q

what is the usual OR table weight limit?

A

200 kg

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20
Q

trendelenburg position

A
  • non-sliding mattress
  • shoulder braces not recommended (can cause brachial plexus injury)
  • significant CV/Resp effects
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21
Q

trendelenburg position complications

A
  • 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
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22
Q

reverse trendelenburg position

A
  • supine, head tilted upward
  • facilitates upper abdominal surgery by shifting contents caudad
  • detect hypotension due to decreased VR
  • reduced perfusion pressure to brain
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23
Q

lithotomy position

A
  • 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
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24
Q

lateral decubitus position

A
  • 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
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25
Q

prone position

A
  • 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
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26
Q

what is laparoscopic surgery?

A
  • 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
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27
Q

what types of surgery can be laparoscopic?

A
  • gastric
  • colonic
  • splenic
  • hepatic
  • gallbladder
  • gynecologic
  • urologic
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28
Q

advantages of laparoscopic surgery

A
  • 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)
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29
Q

disadvantages of laparoscopic surgery

A
  • impaired visualization
  • expensive equipment
  • requires specific surgical skill
  • limited ROM
  • altered depth perception
  • no tactile sensation
  • increased PONV
  • referred pain (frequently to shoulder)
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30
Q

relative contraindications for laparoscopic surgery

A
  • increased ICP
  • hypovolemia
  • VP shunt or peritoneal jugular shunt (LeVeen)
  • severe CV disease
  • severe respiratory disease
  • dense adhesions
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31
Q

what is the name of the needle used to create pneumoperitoneum?

A

veress needle

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32
Q

pneumoperitoneum

A
  • abdomen inflated with CO2 or some other inert gas (He, Ar)
  • can also do a gasless laparoscopy but that is not frequently used
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33
Q

CO2 pneumoperitoneum

A
  • 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
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34
Q

effects of CO2 insufflation

A
  • 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
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35
Q

physiologic effects of pneumoperitoneum

A
  • increased = PaCO2, EtCO2, PAP, MAP, SVR, HR, CVP, IAP, ICP, Vd, regurg/aspiration
  • decreased = cardiopulmonary function, CO, VR, FRC, VC, renal function
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36
Q

clinical management of pulmonary changes

A
  • position changes (decrease degree of trendelenburg)
  • modify vent settings (pressure control)
  • use PEEP with caution
  • consider increasing volatile
  • consider bronchodilators
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37
Q

clinical management of CV changes

A
  • slow, gradual abdominal insufflation
  • vent abdomen if IAP>20 mmHg
  • evaluate intravascular volume (consider fluid bolus)
  • consider treatment for preexisting CV dysfunction
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38
Q

clinical management of renal/hepatic changes

A
  • closely monitor hourly UOP
  • administer IVF boluses
  • consider diuretics
  • maintain IAP < 15 mmHg
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39
Q

clinical management of cerebral blood flow changes

A
  • decreased degree of trendelenburg (adjust head up)

- vent abdomen if IAP > 20 mmHg

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40
Q

anesthetic considerations for laparoscopic surgery

A
  • 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
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41
Q

muscle relaxation in laparoscopic procedures

A

-not necessarily required BUT don’t want coughing or bucking because of the trocars

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42
Q

what volatile anesthetic is not used in laparoscopic procedures?

A

nitrous oxide

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43
Q

things to consider with conversion to open procedure

A
  • supine position
  • new fluid plan - increased 3rd space loss
  • new pain management plan
  • new vent settings (reduce RR, increase Vt)
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44
Q

what complications can occur with laparoscopic surgery

A
  • 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
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45
Q

What do you do if you experience bradycardia or asystole with pneumoperitoneum?

A
  • STOP insufflation (communicate with surgical team)
  • treat with atropine
  • increase depth of anesthesia before proceeding with insufflation again
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46
Q

how can a CO2 embolism occur?`

A
  • direct veress needle placement into a vessel

- gas insufflation into an abodominal organ

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47
Q

what are the S/S of a CO2 embolism

A
  • tachycardia
  • arrhythmias
  • hypotension
  • millwheel murmur
  • increased CVP
  • cyanosis
  • decreased EtCO2 wave form (SUDDEN)
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48
Q

pathophysiology of CO2 embolism

A
  • 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
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49
Q

IDEAL WORLD diagnosis of gas embolsim

A
  • TEE
  • Swan-Ganz
  • Precordial doppler
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50
Q

REAL WORLD diagnosis of gas embolism

A
  • pulse oximetry (hypoxic)
  • esophageal stethoscope (millwheel sound)
  • sudden EtCO2 decrease
  • aspiration of gas from CVP
  • hypotension
  • bronchospasm
  • increased PIP
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51
Q

gas embolism treatment

A
  • 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
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52
Q

subcutaneous emphysema

A
  • 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
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53
Q

what is the incidence of PONV in laparoscopic procedures?

A

40-75%

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54
Q

why can pain from laparoscopic surgery present as referred pain in the shoulder

A
  • irritation of the diaphragm and/or visceral pain from biliary spasm
  • tordol (ketorolac) is useful for referred shoulder pain
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55
Q

what are robotic assisted procedures?

A
  • minimally invasive surgery using robotics

- control console, patient side cart (robotic arms), equipment tower (screens)

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56
Q

advantages of robotic-assisted surgery

A
  • 3D view
  • depth perception intuitive movements
  • increased precision 10-15x
  • magnification increased
  • free movement
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57
Q

disadvantages of robotic-assisted surgery

A
  • massive system
  • limited working space
  • limited patient access
  • limited instrument availability
  • expensive
  • maintenance costs
  • longer setup
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58
Q

what do CRNAs need to do to prepare for a robotic case?

A
  • 2 PIVs
  • consider art line
  • limit IVF initially
  • position - trendelenburg, lateral, flexion
  • limited access to patient
  • padding!!
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59
Q

3 common laparoscopic GI procedures

A
  • cholecystectomy
  • herniorrhaphy
  • appendectomy
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60
Q

cholecystectomy

A
  • 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
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61
Q

treatment of sphincter of oddi spasm

A
  • naloxone

- glucagon

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62
Q

risk factors for conversion to open chole

A
  • acute cholecystitis with thickened gallbladder wall
  • previous upper abdominal surgery
  • males
  • advanced age
  • obesity
  • bleeding
  • bile duct injury
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63
Q

anesthetic considerations for cholecystectomy

A
  • 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
64
Q

potential complications of chole

A
  • bleeding from cystic artery and cystic duct liver laceration
  • pneumothorax
65
Q

herniorrhaphy

A
  • 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
66
Q

anesthetic choice for herniorrhaphy

A
  • GA, local, or regional (T8)

- can infiltrate the ilioinguinal and iliohypogastric nerves with local to help with pain

67
Q

why is it important to talk about the cough plan with the surgeon?

A

-surgeon may or may not want the patient to cough post-procedure to see if the hernia has been adequately reduced

68
Q

EBL of herniorrhaphy

A

50 mL

69
Q

postop pain for herniorrhaphy

A

4-6

70
Q

complications of herniorrhaphy

A
  • bradycardia due to peritoneal retraction

- treat with glyco/atropine

71
Q

appendectomy

A
  • most common acute surgical procedure of abdomen
  • obstruction/inflammation due to lymphoid tissue or fecal matter
  • appendicitis = pain, anorexia
72
Q

anesthetic technique/considerations for appendectomy

A
  • 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
73
Q

mortality of appendectomy

A

1% (2% if perforated)

74
Q

incidence of appendectomy

A

6%

75
Q

common GI Lab procedures

A
  • esophagogastroduodenoscopy (EGD)
  • endoscopic retrograde cholangiopancreatography (ERCP)
  • colonoscopy
76
Q

EGD

A
  • 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)
77
Q

EGD complications

A
  • perforation
  • bleeding
  • desaturation
  • laryngospasm
78
Q

EGD positions

A

supine or lateral decubitus

79
Q

colonoscopy

A
  • used to view lining of rectum and colon
  • diagnostic/therapeutic –> cancer screening or treatment of polyps
  • colon prep, clear liquid diet
80
Q

colonoscopy position

A

left lateral decubitus

81
Q

colonoscopy anesthetic technique

A

heavy sedation or GA

82
Q

colonoscopy potential complications

A
  • perforation
  • bleeding
  • desaturation
  • laryngospasm
83
Q

ECRP

A
  • used to diagnose and treat pancreatic and biliary disorders
  • uses contrast dye and fluoroscopy
84
Q

ECRP position

A

left lateral decubitus/prone

can change during procedure

85
Q

ECRP length

A

30 min up to several hours depending on extent of disease

86
Q

ECRP anesthetic technique

A

GETA or sedation

87
Q

ECRP complications

A
  • perforation
  • bleeding
  • desaturation
  • laryngospasm
88
Q

indications for esophageal surgery

A
  • GERD
  • Cancer
  • hiatal hernia
  • motility disorders
89
Q

patient symptoms that may be indicative of esophageal surgery

A
  • dysphagia
  • heartburn
  • hoarse voice
  • chest pain
90
Q

nissen fundoplication

A
  • fundus wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
  • laparoscopic or transthoracic approach
91
Q

nissen fundoplication surgical time

A

3-4 hours

92
Q

nissen fundoplication anesthetic considerations

A
  • 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
93
Q

nissen fundoplication meds used

A
  • H2 blockers
  • metoclopramide (2-4 hours preop)
  • antibiotic
  • antiemetics
94
Q

nissen fundoplication positioning

A

lithotomy and reverse T

95
Q

esophagectomy

A

majority of thoracic esophagus and nearby lymph nodes removed, stomach is moved up and attached to the remaining portion of the esophagus

96
Q

what types of patients get esophagectomy

A
  • ETOH
  • tobacco
  • chemo/radiation
97
Q

esophagectomy anesthetic considerations

A
  • surgical approach (many options so ask which one)
  • invasive monitors
  • double lumen tube
  • post op pain management
98
Q

esophagectomy surgical approach

A
  • 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
99
Q

gastrostomy

A

create opening through the skin and the stomach wall to provide nutritional support or GI compression

100
Q

gastrostomy indications

A
  • dysphagia

- high risk or active aspiration

101
Q

gastrostomy surgical approach

A
  • laparoscopic
  • percutaneous (PEG)
  • open
102
Q

gastrostomy surgical time

A

usually <1 hour

103
Q

gastrostomy anesthesia type

A

GA (RSI)

LA + sedation

104
Q

total gastrectomy anesthetic considerations

A
  • stable or acutely ill/malnourished
  • correct hypovolemia and anemia
  • chemo/radiation
  • cross-matched blood available
  • full stomach/NGT
  • invasive monitoring
  • warming
  • extubate
105
Q

types of intestinal surgery

A
  • small bowel resection
  • colectomy
  • colonoscopy
106
Q

indications for intestinal surgery

A
  • diverticulitis
  • cancer
  • Crohn’s
  • Ulcerative colitis (UC)
107
Q

small bowel resection

A
  • healthy bowel anastomosed or ileostomy created
  • usually involves bowel prep (hypokalemia, hypovolemia)
  • NEED - preop EKG, CBC, electrolytes, T&S
108
Q

indications for small bowel resection

A
  • obstruction
  • cancer
  • diverticulum
  • Crohn’s
109
Q

small bowel resection surgical time

A

2-4 hours

110
Q

small bowel resection EBL

A

usually < 500 mL

111
Q

small bowel resection anesthetic considerations

A
  • 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
112
Q

small bowel resection postoperative complications

A
  • pulmonary effusion
  • anastomotic leak
  • short bowel syndrome
  • sepsis
  • small bowel necrosis
113
Q

colectomy

A
  • 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
114
Q

liver facts

A
  • 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
115
Q

what are the four lobes of the liver

A
  • right
  • left
  • quadrate
  • caudate
116
Q

what is the total blood flow of the liver

A

-1.5 L/min

117
Q

portal vien

A

supplies 80% of hepatic blood flow

118
Q

hepatic artery

A

supplies 20% of hepatic blood flow

119
Q

liver resection preop H&P

A
  • 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
120
Q

liver resection preop work up

A
  • CT or MRI for tumor location
  • 12 lead EKG/ECHO
  • CXR
  • lab studies - CBC, coags (PT, PTT, bleeding time), chemistry profile, LFTs
121
Q

preop considerations for liver resection

A
  • 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
122
Q

preop optimization of patient undergoing liver resection includes correction of ….

A
  • ETOH dependency
  • coagulopathy
  • pH
  • electrolyte abnormalities (esp K+)
  • malnutrition
  • anemia
  • esophageal varices
  • hepatic encephalopathy
123
Q

monitoring for those undergoing liver resection

A
  • large bore IV
  • a-line
  • CVP or PA cath (if pulm HTN)
  • TEG to guide blood product admin
  • foley
  • OGT/NGT
  • TEE
124
Q

intraoperative considerations for those undergoing liver resection

A
  • 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
125
Q

benzos with liver disease

A
  • increased cerebral uptake
  • decreased clearance
  • prolonged half-life
126
Q

dexmedetomidine with liver disease

A

decreased clearance and prolonged half-life

127
Q

propofol with liver disease

A
  • single dose = similar response as normies
  • recovery times may be longer after infusions
  • drugs of choice with encephalopathy
128
Q

morphine with liver disease

A
  • prolonged elim half life
  • increased bioavailability in oral form
  • decreased plasma protein binding
  • exaggerated sedative and resp depressive effects
129
Q

meperidine with liver disease

A
  • 50% reduction in clearance and doubling of the half-life

- may experience neurotoxicity from accumulation of normeperidine

130
Q

fentanyl with liver disease

A
  • plasma clearance is decreased

- repeated dose or infusion may produce more exaggerated and pronounced effects

131
Q

sufentanil with liver disease

A
  • PK not significantly altered
  • some difference in half-life
  • repeated dose or infusion may produce more exaggerated and pronounced effects
132
Q

alfentanil with liver disease

A
  • elim 1/2 doubled and higher free fraction of drug

- prolonged DOA and enhanced effects

133
Q

remifentanil with liver disease

A

elimination unaltered

134
Q

NMBD with liver disease

A
  • 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
135
Q

catecholamines with liver disease

A
  • 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
136
Q

intraop fluid management of liver procedures

A
  • volume loading –> distention of vessels with difficulty controlling blood loss
  • limit fluid pre-resection
  • portal triad clamping
  • post-resection restore euvolemia
137
Q

potential intraop complications of liver resection

A
  • hemorrhage, coagulopathy
  • hypocalcemia
  • hypoglycemia
  • VAE
  • pulmonary disturbances
138
Q

potential post-op complications of liver resection

A
  • bleeding
  • bile leak
  • portal vein/hepatic artery thrombosis
  • liver failure
139
Q

spleen facts

A
  • 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
140
Q

splenectomy

A
  • 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
141
Q

preop anesthetic considerations for splenectomy

A

-evaluate underlying disease process and implications

142
Q

intraop anesthetic considerations for splenectomy

A
  • asepsis
  • large bore venous access
  • warming measures
  • epidural for post-op pain
143
Q

potential complications splenectomy

A
  • atelectasis
  • pneumothorax
  • infection
  • hemorrhage
  • VAE
144
Q

indicators for bariatric surgery

A
  • BMI > 40 kg/m2

- BMI > 35 kg/m2 with related comorbidities not well controlled by medical therapy

145
Q

bariatric surgery

A

surgical alteration of small intestine or stomach to promote weight loss

146
Q

malabsorptive procedures

A
  • limits the amount of nutrients the body absorbs by bypassing a portion of the small intestine
  • jejuno-ileal bypass
  • biliopancreatic diversion
147
Q

restrictive procedures

A
  • 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)
148
Q

combined restrictive and minimal malabsorptive

A

roux-en-y gastric bypass (RYGB)

149
Q

what is the greatest cause of bariatric periop 30 day mortality

A

PE

150
Q

AGB

A
  • 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)
151
Q

roux-en-y gastric bypass

A
  • 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
152
Q

laparoscopic bariatric surgery advantages

A
  • less post-op pan
  • lower morbidity
  • faster recovery
  • less fluid 3rd spacing
  • decreased wound infection
  • smaller incisions
153
Q

laparoscopic bariatric surgery disadvantages

A
  • 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
154
Q

laparoscopic bariatric surgery anesthetic considerations

A
  • 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
155
Q

implantable gastric stimulator

A
  • 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
156
Q

anesthetic considerations for implantable gastric stimulator

A
  • avoid N/V
  • valsalva may dislodge electrodes
  • ECG interference

N931 Advanced Principles of Anesthesia I (19 decks)

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