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Anesthesia Principles 1 > Anesthesia for Laparoscopic and Robotic Assisted Surgery (Part 1) > Flashcards

Anesthesia for Laparoscopic and Robotic Assisted Surgery (Part 1) Flashcards

1
Q

_____ is performed for more complex diagnostic and therapeutic procedures and has almost entirely replaced traditional open approaches.

A

Laparoscopy

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2
Q

____ provide surgeons with improved dexterity and therefore greater stability of surgical instruments and improved outcomes.

A

Robotics

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3
Q

The benefits of laparoscopy include:

A

-Safer
-Less painful
-Minimally invasive alternative to open procedure
-Faster recovery times
-Decreased LOS
-Decreased infection
-Improved patient satisfaction

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4
Q

Some disadvantages of minimally invasive surgery:

A

-Pneumoperitoneum seqeula
*Entry into abdominal cavity and establishment of pneumoperitoneum are responsible for most significant problems that occur
-Positioning challenges
-Specialized training to use the equipment

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5
Q

Successful creation of artificial pneumoperitoneum requires what:

A

Proper installation of air or gas into the peritoneal cavity under controlled pressure

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6
Q

The two most common techniques for establishment of pneumoperitoneum are

A
  1. Closed technique
  2. Open (Hasson) procedure
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7
Q

What has become the gas of choice for pneumoperitoneum creation? Why?

A

CO2.
-It is nontoxic, nonflammable, and readily absorbed into the blood stream with low risk of air embolization.
-Also produces less hemodynamic changes

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8
Q

The ____ technique involves the use of a spring-loaded needle known as aVeress needleto pierce the abdominal wall at its thinnest point, around the umbilicus.

A

Closed

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9
Q

The ____ technique involves the development of a 1- to 2.5-mm midline vertical incision that begins at the lower border of the umbilicus and extends through the subcutaneous tissue and underlying fascia.

A

Open

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10
Q

___ ___ is responsible for most of the complications in laparoscopy.

A

Initial entry

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11
Q

The magnitude of pt response to the pneumoperitoneum depends on:

A
  1. Degree of IAP
  2. Length of surgery
  3. Position of pt
  4. Volume status
  5. Age and/or co-existing disease
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12
Q

Insufflation of the pneumoperitoneum is associated with what hemodynamic changes?

A

-Increased MAP, SVR, HR
-Release of neuroendocrine hormones (vaso, renin) due to intra-abdominal vessel compression
-Decrease in SV due to decreased venous return

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13
Q

Insufflation of the pneumoperitoneum is associated with what hemodynamic changes?

A

-Increased MAP, SVR, HR
-Release of neuroendocrine hormones (vaso, renin) due to intra-abdominal vessel compression
-Decrease in SV due to decreased venous return

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14
Q

T/F: The increase in MAP and SVR is only observed if the pneumoperitineum is created under high pressure.

A

FALSE.
-Increased MAP and SVR were observed in low pressure (12 mmHg) and high pressure (20 mmHg) creation.

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15
Q

Control patients experienced a CO reduction of ___-___%

A

25-50%
-This can be reduced with adequate fluid loading
-Can also assist in helping maintain SV

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16
Q

Methods that can help with maintaining SV in these pts:

A

-Adequate fluid loading
-Correct patient positioning
-Compression stockings to augment VR

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17
Q

Changes in _____ are found to have a GREATER effect on cardiac filling pressures than the pneumoperitoneum does

A

Positioning
**A starred and bolded point

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18
Q

The ___ position is associated with increased venous return –> increased intracranial pressures –> increased ocular pressures, etc.

A

Trendelenburg

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19
Q

The ____ ____ position is associated with reduced cardiac preload –> reduced CO.

A

Reverse Trendelenburg

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20
Q

____ ____ is described as a PaCO2 concentration of >___ and DOES cause myocardial depression and arrhythmias.

A

Severe hypercarbia
PaCO2 >60
-Mild hypercarbia (45-60) has little CV effect

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21
Q

Pneumoperitoneal effects on CV conduction can include:

A

-Prolonged QT leading to ventricular instability
-Bradycardia due to parasympathetic stimulation
-Increased arrhythmias
*don’t forget that positioning has greater effect, but pneumoperitoneum still does have a role

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22
Q

In the elderly population we can see a greater ____ in MAP and ____ in CVP.

A

Greater decrease in MAP
Greater increase in CVP

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23
Q

3 overarching categories of pulmonary effect by pneumoperitoneum:

A
  1. Displacement of thoracic structures
  2. Alteration in lung mechanics
  3. Disruption of gas exchange
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24
Q

Displacement of structures specifically effects the _____.

A

Diaphragm. Shifts cephalad and affects lung mechanics

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25
Q

Pneumoperitoneum causes what changes in lung mechanics?

A

-Decreases compliance, FVC, FEV1, FRC
-Increases PIP
**Positioning in the steep trendelenburg position may exacerbate these changes.

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26
Q

Maximum absorption of CO2 is noted at the intra-abdominal pressure of ___ mmHg.

A

10 mmHg

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27
Q

Increased PaCO2 from using CO2 in the pneumoperitoneum has to be offset by what?

A

Increased minute ventilation
(tidal volume (x) rr)

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28
Q

Misplaced trocars can allow for CO2 to track in what space?

A

Subcutaneous space

29
Q

Inhalation agents ____ the HPV (hypoxic pulm vasoconstrictor) reflex.

A

Attenuate (decrease effectiveness)

30
Q

Controlled mechanical ventilation with what changes maintain normocarbia in these pts?

A
  1. 20-30% increase in minute ventilation
  2. Increases in tidal volume instead of RR
  3. Pressure control more effective than volume control
31
Q

What “lung protective strategies” will we use in these pts?

A
  1. 6-8 mL/kg
  2. 6-8 cmH2O for PEEP
  3. Performing intra-operative recruitment maneuvers q30 mins
32
Q

Highest risk patients for pulmonary effects of pneumoperitoneum

A

-Anyone with even marginal cardiopulmonary dysfunction
-COPD patients
-?Morbidly? obese
ITS EXTREME SMH

33
Q

T/F: Mild pulmonary dysfunction is normal after laparoscopic surgery with pneumoperitoneum

A

TRUE.
-We will often observe them in a restrictive breathing pattern as effects of pain meds and anesthesia wear off.
-If it was a prolonged procedure, they may also have lingering effects of CO2 from insufflation

34
Q

Renal effects of pneumoperitoneum

A

-Increased cr clearance
-Decreased urine output, renal blood flow (renal vasoconstriction)
-ADH, renin, aldosterone release

35
Q

____% of patients will have elevated liver enzymes after pneumoperitoneum.

A

50%
-Decrease in liver perfusion and possible intestinal ischemia

36
Q

Immunologic effects of pneumoperitoneum

A

-Negative effect on local immune response
-Altered proinflammatory cytokines + angiogenic factors
-Possible cancer cell growth
-Negative effect on wound healing

37
Q

Major complications are very rare in laparoscopic sx. However, when it does occur it is associated with high ____ and ____.

A

Morbidity and mortality

38
Q

More than ___% of all complications occur during entry into the abdomen / insertion of trocars.

A

50%

39
Q

Most common trocar insertion injuries:

A

-Intestinal, urinary tract, vascular injury
-CO2 embolus*
-30-50% of these go unnoticed attributing to high mortality due to lack of action

40
Q

Mortality as high as ___% is reported with bowel or vascular injuries.

A

30%

41
Q

> 50% of ____ injuries go unrecognized intraoperatively and lead to peritonitis, sepsis, and possible multisystem organ failure.

A

Intestinal
-Use NG/OG tubes to decompress if noticed
-Hasson (open) technique has lower visceral injury rates

42
Q

If the patient has a high risk of urinary tract injury due to the procedure what should we do?

A

Place a foley and give methylene blue
-Allows for easy recognition

43
Q

T/F: Placement of the primary trocar under low pressure allows for the safest placement.

A

FALSE.
-Trocar placement under high pressure (~25mmHg - says 20mmHg earlier in PP) allows for safest placement due to larger distance between structures.

44
Q

A ___ ____ is a direct entrainment of air/other medical gas into the venous or arterial system.

A

Gas embolism
-Can be life threatening with mortality up to 28%
-Occurs when open vessels with lower intravascular pressure than intra-abdominal pressures

45
Q

T/F: Most laparoscopic cases cause minor CO2 gas embolisms which can cause cardiopulmonary changes, but they resolve spontaneously

A

TRUE.

46
Q

Signs and symptoms of CO2 gas embolism

A

-Low EtCO2 and high EtN2
-Hypotension and hypoxia
-Tachycardia, dysrhythmias, hemodynamic instability

47
Q

Low ____ increases the risk of venous gas embolism.

A

Low CVP
-Adequate hydration for pts going for laparoscopic sx

48
Q

Diagnosis of CO2 gas embolism

A

TEE gold standard
but also, MILL WHEEL

49
Q

CO2 embolism management

A
  1. D/c insufflation give 100% O2
  2. Release pneumoperitoneum
  3. Flood surgical field with saline
  4. Place in left lateral position
  5. Aspirate gas via central line if we have one
  6. Support hemodynamics
50
Q

Due to migration of air to adjacent body cavities, we can also see what in these pts?

A

-Unilateral or bilateral pneumothorax
-Pneumomediastinum
-Pneumopericardium

51
Q

Although pneumothorax, pneumomediastinum, and pneumopericardium are rare - we see them most in lap ____ surgery.

A

Esophageal

52
Q

A pneumothorax caused by CO2 insufflation is usually treated how?

A

Self-resolving no intervention

53
Q

A pneumothorax caused by barotrauma is usually treated how?

A

Surgical decompression and chest tube placement

54
Q

Pneumothorax risk factors:

A

-Lap esophageal surgery
-Surgery >200 mins
-EtCO2 >50
-Bad surgeon / inexperience

55
Q

Pneumothorax signs and symptoms

A

-High PIP with low O2 sat and no breath sounds
-Hypotension / tachycardia

56
Q

Occurs as a result of gas entry into subcutaneous tissue

A

Subcutaneous emphysema

57
Q

T/F: Most cases of subcutaneous emphysema are clinically insignificant and spontaneously resolve.

A

TRUE
-Severe cases can sometimes cause severe hypercarbia and hemodynamic instability

58
Q

Why CO2 for insufflation over other choices?

A

Again, nontoxic, inflammable, safe in the body.
> Air or N2O = they support combustion
> Helium = low solubility and high gas embolism

59
Q

CO2 is a peritoneal/diaphragm irritant that can cause

A

Postoperative shoulder pain

60
Q

____ anesthesia is the most commonly used technique for diagnostic and laparoscopy surgery.

A

General anesthesia
-Good control of ventilation and patient comfort
-Good control for position changes and pneumoperitoneum

61
Q

Vent changes while under general anesthesia for lap procedure

A

-Increased minute ventilation, intraoperative recruitment, pressure control, PEEP usage

62
Q

T/F: NMB allow for better surgical operating conditions at lower insufflation pressures

A

FALSE.
-This was a hypothesis that has not been seen to be true

63
Q

T/F: N2O use contributes to bowel distention and increased PONV.

A

TRUE.

64
Q

Benefits of regional anesthesia when appropriate:

A

-Reduction of stress response
-Early ambulation with lower DVT risk
-Effective postoperative analgesia

65
Q

Downsides to regional anesthesia:

A

-May not always be the best due to high sensory levels required.
-May be difficult with pneumoperitoneum and proper positioning
-High incidence of shoulder pain, not treated by regional techniques

66
Q

_____ is a major concern for patients that underwent lap procedures.

A

PONV
-As high as 72% of ppl experience PONV
-Can cause dehiscence, aspiration, prolonged hospital stay

67
Q

Standard of care for PONV treatment

A

Multimodal
Always choose this if you see it as a choice
-Avoid N2O if possible

68
Q

Postoperative pain control methods

A

Multimodal
-ERAS
-NDSAIDs
-Glucocorticoids
-Local blocks

Anesthesia Principles 1 (7 decks)

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