Anesthesia for gynecological surgery Flashcards
Describe what a D&C is.
Dilate cervix & curettage (scrape walls of) uterus to remove, often vacuum aspirate products of conception (1st trimester), cysts, or tumors
Anesthetic considerations for the patient undergoing a D&C include
emotional state baseline CBC intraoperative Hgb/Hct monitoring analgesia/antiemetics/uterine relaxation venous access x 1 volume status availability of T&S (typically not needed for 1st trimester D & C) positioning/lithotomy
A D&E is performed in
the 2nd trimester (between 12-24 weeks of pregnancy)
A dilation and evacuation is typically performed due to
miscarriage or elective pregnancy termination–> lots of psychosocial considerations
The anesthetic considerations for a D&E are
relatively same approach & considerations as D&C uses vacuum aspirator & forceps -might take a little longer -increased risk of bleeding than D&C -have drugs available
Uterotonic medications act
directly on uterine smooth muscle to increase tone, rate, & strength of rhythmic contractions
Oxytocin (Pitocin) is a
naturally produced hormone secreted by the posterior pituitary
uterotonic (stimulates uterine contractions, labor onset–> postpartum)
Benefits & uses of oxytocin include
prevent/treat postpartum hemorrhage (PPH)
ripen the cervix and induce labor
manage incomplete or elective abortion
Describe methergine
semi-synthetic ergot alkaloid
prevents & controls PPH
0.2 mg IM
avoid in patients with HTN
Pitocin is a
synthetic oxytocin & can be given IV or IM
What is Mifeprex?
synthetic steroid made from norethindrone
only non-surgical option for abortion during first 49 days of pregnancy
Describe hemabate.
prostaglandin
250 mcg IM
also used for elective abortion
AVOID with asthmatics
Describe Cervidil.
vaginal insert that causes cervical ripening
10 mg/insert
stimulates PGF-2a= sensitizes myometrium to oxytocin
Describe conization of the cervix.
excision of a cylindrical (cone-shaped) wedge from the cervix
Indications for conization of the cervix includes
definitive diagnosis of squamous or glandular intraepithelial lesions
excluding microinvasive carcinomas
conservative treatment of cervical intra-epithelial neoplasia
Methods used for conization of the cervix include
scalpel (cold-knife)
laser (excision or vaporization)
electrosurgical excision loop (LEEP)
large loop excision of the transformation zone (LLETZ)
combination (laser & completed with a cold-knife)
Describe the route, onset of action, DOA, and side effects of oxytocin.
route: IM
onset: 2-3 minutes
DOA: 15-30 minutes
Side effects: minimal (N/V, cardiac arrhythmia, anaphylaxis)
Describe the route, onset of action, DOA, and side effects of misoprostol.
route: PO
onset of action 3 to 5 minutes
duration of action: 75 minutes
SE: shivering, diarrhea, transient temperature >38 degrees C
Describe the route, onset of action, DOA, & SE of ergometrine.
IM
onset: 6-7 minutes
DOA: 120-140 minutes
SE: increased BP (vasoconstriction), HA, dizziness, nausea, vomiting, tinnitus, rash
Describe the route, onset of action, DOA, & SE of syntometrine.
IM
onset: 2 to 3 minutes
duration: 120-240 minutes
SE: N/V, HA, dizziness, hypertension, arrhythmia, & rash
Hysteroscopy is when they
visualize inside the uterus to diagnose or treat uterine problems
Indications for hysteroscopy include
abnormal uterine bleeding, fibroids, polyps, cancer biopsies, remove adhesions, sterilization, locate intrauterine device (IUD)
The surgical procedure of hysteroscopy involves
emptying of the bladder (in & out catheter)
speculum into the vagina
hysteroscope advanced through vagina, cervix, and into the uterus
project images onto a screen
Gas (CO2) or fluid (NS or LR) expands uterus
Describe the risks involved with hysterosocopy
uterine or cervical puncture/perforation, bleeding, infection, hypervolemia, hyponatremic encephalopathy/cardiac asystole, arrhythmia, hypercarbia/acidosis/gas embolism
Endometrial ablation is used to
treat heavy bleeding when medications are unsuccessful
Endometrial ablation involves
destroying the endometrium (thin lining of the uterus) to stop or reduce menstrual flow
Endometrial ablation is not performed
in post menopausal women
Endometrial ablation is not advised for the following conditions:
thin endometrium endometrial hyperplasia uterine cancer recent pregnancy current or recent uterine infection
Endometrial ablation risks include
bleeding, infection, uterine or bowel perforation, internal burns
Endometrial ablation surgical length is
30-60 minutes
no incisions are made
Colposcopy is typically an
office procedure but occasionally performed in the OR
used to view the cervix using colposcope magnified 2-60x
Colposcopy is used to assess
cervicitis, uterine polyps, pain, bleeding, & cervical warts
Tubal ligation is when the
fallopian tubes are pulled through navel, cut and closed (sutures, bands or clips)
Tubal ligation can be performed under
epidural, spinal, combine spinal-epidural, general anesthesia, or IV sedation with local anesthesia
-can be performed post-Caesarian section & it does not extend hospital stay
Risks of tubal ligation include
bleeding & infection
Endometriosis is the
endometrial growth outside uterus (ovaries, bowel, bladder, rectum, pelvic wall, etc.)
retrograde menstruation with suspected immune system explanation
responds to hormonal changes
Endometriosis causes
pain, irregular bleeding, adhesions, and possibly infertility
Treatment options for endometriosis include
hormone therapy
surgical intervention-diagnostic laparoscopy, excision of endometrial tissue, hysterectomy, laparotomy
Ectopic pregnancy is when the
fertilized egg attaches outside of the uterus (most commonly in fallopian tubes)
The second leading cause of maternal mortality is
ectopic pregnancy
Symptoms of ectopic pregnancy include
vaginal bleeding, pelvic pain, dizziness, fainting, weakness, shoulder pain (rupture)
A rupture in ectopic pregnancy is
life-threatening (internal bleeding), may require salpingectomy
Ectopic pregnancy treatment includes
surgical excision of ectopic or medial management (methotrexate)
A hysterectomy is the
surgical removal of the uterus
The 2nd most common major surgery among women of childbearing age is
hysterectomy
A hysterectomy is the method of treatment for
uterine fibroids endometriosis uterine prolapse abnormal uterine bleeding chronic pelvic pain cancer
The approach for hysterectomy is dependent on
surgical intervention & patient health status
A subtotal hysterectomy involves removal of
the body of the uterus
A total hysterectomy involves removal of
body of uterus & cervix
A radical hysterectomy involves removal of
body of uterus, cervix, vagina, L& R parametrium
A laparoscopic hysterectomy can be performed via
total laparoscopic hysterectomy
laparoscopically assisted vaginal hysterectomy
robot- assisted laparoscopic hysterectomy
Describe total laparoscopic hysterectomy.
uterus detached, removed in pieces through incisions or passed through the vagina
Describe laparoscopically assisted vaginal hysterectomy
vaginal hysterectomy with laparoscopic assistance laparoscopic visualization & removal of organs removed through the vagina
Advantages of a laparoscopic hysterectomy include
smaller incisions, less pain, shorter hospital stay, shorter recovery, less risk of infection & other postoperative complications
Disadvantages of laparoscopic hysterectomy include
increased surgical time
increased risk for bladder injury
risks associated with pneumoperitoneum
Describe a radical hysterectomy
removes uterus, cervix, ovaries, fallopian tubes, upper vagina, parametrium, & pelvic lymph nodes
Indications for a radical hysterectomy include
uterine, cervical or ovarian cancer
endometriosis
fibroids
pelvic relaxation syndrome
Describe the surgical time, incisions, and EBL for radical hysterectomy
surgery time: 3-4 hours
incision: midline or low transverse
EBL: 1500 mL
need T&S, 2 large bore IVs and be prepared to administer blood products
Postoperative considerations for the patient with hysterectomy include
earlier risk for osteoporosis then menopausal women
treated with estrogen therapy-symptomatology determines treatment form
Oopherectomy effects caused by lack of estrogen include
hot flashes, vaginal dryness, sleep problems
Preoperative treatments for myomectomy include
multivitamins, iron supplements, gonadotropin releasing hormone agonist, oral contraceptives
Anesthetic considerations for myomectomy includes
T&C intraoperative hemoglobin/Hct monitoring IV fluid & blanket warming equipment third space fluid loss w/ open approach surgical approach determined by type of fibroids (hysteroscopic, abdominal, laparoscopic, robotic) general or regional anesthetic prophylactic antithrombotic therapy
A second look laparotomy is used for
diagnositic purposes
A second look laparotomy is the most accurate method of
assessing disease status in ovarian cancer
Second look laparotomy evalutes
effectiveness of treatment, size of tumor after treatment, & recurrence of tumor
Negative second look laparotomy is associated with
improved survival
has same anesthetic considerations as staging laparotomy
Anesthetic considerations for the radical vulvectomy includes
chemotherapeutics
bowel preparation
general, spinal, or epidural anesthesia
PCA or epidural for postoperative pain management
foley catheter
high risk for infection
Modified dorsal lithotomy- potential for nerve injury
Antiemetics to consider for PONV include
ondansetron 4 mg reglan 10 mg IV dexamethasone 4-8 mg IV propofol diphenhydramine 10-50 mg IV or IM phenegran 0.25-1 mg/kg granisetron 10-40 mcg/kg scopolamine patch 1.5 mg euvolemia
Pelvic exenteration is the
removal of all organs from pelvis
Indication for pelvic exenteration is
advanced or recurrent pelvic cancer
Morbidity & mortality with pelvic exenteration is
3-5% death intraoperatively; 5 year survival=60%
Pelvic exenteration involves the removal of
radical hysterectomy, total vaginectomy, bladder excision (urostomy), urinary diversion, bowel resection + colostomy (anterior=bladder removed, posterior=rectum removed)
neovagina construction available
Surgical risks of pelvic exenteration includes
hemorrhage (internal & common iliac arteries), sepsis, wound dehiscence, anastomotic breakdown at bowel, urinary pouch or ureteral sites, DVT, PE, stoma necrosis or reconstructive flap necrosis
Late complications of pelvic exenteration includes
fistula, bowel obstruction, ureteral stricture, renal failure, pyelonephritis, & chronic bowel obstructions
Positioning concerns with lithotomy includes
patient supine, legs flexed/abducted, feet at or above hip level
access to perineum (table edge)
prolonged lithotomy position associated with compartment syndrome
femoral or peroneal nerve injury
autotransfusion- transient hemodynamic changes
caution with PVD patients
simultaneous leg lift & hip flexion to avoid dislocation
With the combine lithotomy and Trendelenburg position we will see
Increased CVP & PAP
CO decreased
caution in patients with CAD
