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Principles II N517 > Anesthesia for Urologic Procedures > Flashcards

Anesthesia for Urologic Procedures Flashcards

1
Q

What kind of patient populations do you see for urologic procedures?

A

patients may be of any age; most are elderly with coexisting medical illnesses

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2
Q

What should you consider anatomically about the ureter openings?

A

they are posterior and inferior on bladder itself

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3
Q

What drugs can be administered to find the ureter openings?

A

methylene blue and indigo carmine

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4
Q

What nerve lies close to the ureters and can be stimulated during cautery?

A

obturator nerve

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5
Q

How do the kidneys get their blood supply?

A

Via the renal arteries that branch off the aorta

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6
Q

How much of the CO do the kidneys get?

A

25% or 1200 mL/min

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7
Q

What MAP range are the kidneys able to autoregulate?

A

75-160 mmHg

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8
Q

What happens in the kidneys if the MAP drops below 60 mmHg?

A

filtration ceases

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9
Q

Where do the kidneys lie in the body?

A

retroperitoneal between T12 and L4 vertebrae

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10
Q

What level somatic blockade do you need to have if using spinal anesthesia for a urologic procedure?

A

T8-L3

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11
Q

What level of somatic blockade do you need for a procedure on the ureters?

A

T10 sensory level

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12
Q

How does anesthesia affect renal function?

A

reversible decreases in RBF, GFR, urinary flow, & Na+ excretion occur during regional or general anesthesia

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13
Q

What can partially offset the effects of anesthesia on renal function?

A

normal BP and intravascular volume

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14
Q

What is the most frequently used position for urologic procedures?

A

lithotomy

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15
Q

What should you consider when moving the patient’s legs into lithotomy position?

A

moving them simultaneously

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16
Q

What are some of the respiratory physiologic consequences of lithotomy position?

A

decreased FRC, decreased vital capacity, lung volume, and lung compliance which can result in atelectasis and hypoxemia

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17
Q

What are some of the cardiophysiologic consequences of lithotomy position?

A

altered venous return, acute increase or decrease in BP which is why you should always check the BP once the legs are raised

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18
Q

What nerve is commonly injured in the lithotomy position?

A

peroneal nerve with loss of dorsiflexion due to fibular head compression

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19
Q

What are some risk factors for nerve injury in the lithotomy position?

A

duration >4 hours

BMI

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20
Q

What other injuries (besides peroneal) can occur with the lithotomy position?

A

sciatic stretch
hand/finger injuries as foot of table is lowered
incidence of back pain (as high as 37%)

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21
Q

What are some of the physiolgoic consequences of extreme lithotomy?

A

increased central venous pressure which can result in cerebral edema (especially with a low BP since CPP = MAP - ICP)
facial edema/airway edema

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22
Q

What nerve commonly gets injured in the extreme lithotomy position?

A

brachial plexus injury resulting from hyperabducted arm

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23
Q

How should you position someone in the lateral flexed position?

A

iliac crest over the table break; kidney rest up
lower leg flexed at knee/upper leg straight
pad between legs and axillary roll
extend table to separate iliac crest and costal margin
watch eye, ear, and neck position

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24
Q

What are some of the respiratory effects of the lateral flexed position?

A
  • decreased FRC in the dependent lung
  • VQ mismatching (greater blood flow in the dependent lung while greater ventilation to the nondependent lung)
  • atelectasis in dependent lung and favors hypoxemia
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25
Q

What are some of the cardiac effects of the lateral flexed position?

A

decreased venous return

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26
Q

What is the hyperextended dorsal position?

A

lateral oblique position with table hyperextended, incision goes longitudionally up abdomen and up into thoracic area

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27
Q

What nerves can be injured in the hyperextended dorsal position?

A 
brachial plexus
peroneal
saphenous
ulnar
back strain
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28
Q

What complication is the patient at risk for in the hyperextended dorsal position?

A

VAE due to pelvis being above heart

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29
Q

Where is the hyperextended supine position?

A

iliac crest over break in table and table extended then table tilted head down

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30
Q

What are some of the cardiac effects of the hyperextended supine position?

A

increased central venous volume which can cause airway edema/facial edema

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31
Q

What are the 3 common transurethral procedures?

A

cytoscopy
TURP
TURBT

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32
Q

What is the purpose of a cystoscopy?

A

Diagnosis of urologic problems
Resection of bladder tumors
Access to urinary system for stent placement

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33
Q

What types of anesthesia can you use for a cystoscopy?

A

local
MAC
Regional (T10 umbilicus)
General

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34
Q

What can be a heat source to start fires during a cystoscopy?

A

light on cystoscopy camera generates heat and when placed on drapes has the potential to start a fire

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35
Q

What is the common position for cystoscopies?

A

lithotomy with or without trendelenburg

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36
Q

What nerves can be injured during a cystoscopy?

A

sciatic
common peroneal
brachial plexus

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37
Q

What is a TURP procedure and why do we do them?

A

transurethral resection of prostate for BPH which causes obstructive uropathy

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38
Q

What is the size of the prostate gland in order to have a TURP?

A

prostate gland must be

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39
Q

What are the most common causes of death post-op after a TURP?

A

MI, PE, renal failure

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40
Q

What comorbidites do patients undergoing a TURP usually have?

A

pulmonary, cardiac, and renal disease (up to 60%)

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41
Q

What is the estimated surgical time and blood loss for a TURP?

A

1-2 hours

500 mL

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42
Q

What happens during the TURP procedure?

A

Performed with cautery loop resectoscope while bladder is continuously irrigated

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43
Q

What is a common complication with a TURP as a result of the continuous bladder irrigation?

A

excessive absorption of irrigation fluid into the large venous sinuses, cannot determine exact blood loss because of irrigation

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44
Q

What is the limit for resection time due to the continuous irrigation used?

A
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45
Q

What is the best way to keep track of how much fluid may have been absorbed?

A

Keep count of the irrigation bags used

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46
Q

What are the characteristics of the irrigation fluid used during a TURP?

A

non-electrolyte and hypotonic

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47
Q

About how many mLs per minute are absorbed during a TURP?

A

20 mL/min

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48
Q

How severe a dilutional syndrome is depends on what?

A

duration of resection and bag height, the higher the height the more pressure that is exerted on the bag

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49
Q

What physiologic disturbances do hypotonic solutions cause?

A

acute hyponatremia and hypoosmolality

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50
Q

What things can fluid overload with dilutional syndrome cause?

A

congestive heart failure
pulmonary edema
hypotension

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51
Q

When does dilutional syndrome occur with a TURP?

A

during procedure or immediately post-op

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52
Q

At what sodium level can you see confusion and restlessness?

A

120 mEq/L

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53
Q

At what sodium level can you see somnolence and nausea?

A

115 mEq/L

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54
Q

At what sodium level can you see seizures and coma?

A

110 mEq/L

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55
Q

How are most dilutional syndromes managed?

A

fluid restriction and loop diuretics

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56
Q

What is the final line of treatment for dilutional syndrome if fluid restriction and diuretics do not work?

A

administer 3% saline IV at no more than 100 mL/hr until sodium is above 125 mEq. Diurese with lasix and follow serum electrolytes

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57
Q

What is glycine toxicity?

A

caused by glycine put in irrigation fluid used for TURP

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58
Q

What is glycine/

A

inhibitory neurotransmitter in CNS

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59
Q

What is a byproduct of glycine metabolism?

A

ammonia which can also cause altered mental status and confusion

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60
Q

Why is glycine added to irrigation fluid

A

good optical effect and aids in prevention of dilutional syndrome

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61
Q

What can hyperglycemia from glycine toxicity lead to?

A

nausea, malaise, vomiting, confusion, stupid and coma, blindness, seizure

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62
Q

How can you treat glycine toxicity?

A

lasix and supportive therapy

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63
Q

What are 2 other complications that can occur during a TURP other than dilutional syndrome and glycine toxicity?

A

bladder perforation

severe blood loss/DIC

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64
Q

What happens if the surgeon perforates the bladder during a TURP?

A

irrigation goes into the abdomen causing abdominal pain, nausea, diaphoresis (may be masked by general anesthesia or heavy sedation)

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65
Q

What happens if there is severe blood loss during a TURP?

A

can result from glands 35-45 g or resection time >90 mins
resection may release fibrinolytic enzymes
dilutional thrombocytopenia

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66
Q

What is the obturator reflex during a transurethral procedure?

A

electrocautery stimulation causes an external rotation and adduction of thigh, patient’s legs will “box” surgeon, cannot be blocked by spinal anesthetic, only way to block it is with GA and paralysis

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67
Q

Can complication can occur for someone who is paralyzed pre-op undergoing a TURP?

A

autonomic hyperreflexia can occur if spinal cord lesion is above T6-T7, triggered by surgical manipulation, bladder distention; sympathetic hyperactivity from stimulation below cord lesion (will need anesthetic that can prevent this like a spinal)
Causes: severe HTN, bradycardia, and dysrhythmias

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68
Q

What anesthesia can you use for a TURP?

A

general (ETT or LMA)

spinal/epidural T10 sensory level

69
Q

If doing a spinal for a TURP, what LA and dose should you use?

A

hyperbaric bupivacaine 10-12 mg

70
Q

Why would it be ideal to do a spinal for a TURP?

A

to assess their mental status, best monitor for detecting early signs of TURP syndrome or bladder perforation

71
Q

Can you assess blood loss accurately with a TURP?

A

no because of the continuous bladder irrigation

72
Q

What are 3 major cancer surgeries that can be done on the urologic system?

A

radical prostatectomy
radical cystectomy
radical nephrectomy

73
Q

What is a radical retropubic prostatectomy (RRP)?

A

removal of prostate, seminal vesicles, and part of the bladder neck; remaining bladder neck anastomosed to urethra; done with lower, midline, abdominal incision; more “nerve sparing” so only 25% change of impotence; associated with major blood loss; can remove retroperitoneal lymph nodes

74
Q

What position is generally used for a RRP?

A

hyperextended supine

75
Q

What anesthesia can you do for a RRP?

A

patients generally cannot tolerate regional anesthesia because of the position, large amount of fluid and trendelenburg can lead to airway edema so general anesthesia preferred

76
Q

What are some of your concerns with a RRP?

A

massive blood loss (primarily during resection of the prostate and can have EBL of 1000-2000 mL)
venous air embolism
nerve injury from position

77
Q

What is a typical pain score after a RRP?

A

4-8

78
Q

What are some anesthetic considerations for a RRP?

A
  • ensure cross-matched blood available with fluid/blood warmers
  • 2 large peripheral IVs
  • patient will do bowel prep and will require rehydration
  • arterial line, +/- CVP (CVP depends on comorbidities and if in teaching facility where procedure may take longer)
  • Usually general anesthesia +/- epidural or intrathecal narcotics
  • surgical time of 3-5 hours
  • post-op to ICU
79
Q

What is a radical perineal prostatectomy?

A

removal of prostate through transverse curvilinear incision

80
Q

What position is used for radical perineal prostatectomy?

A

extreme lithotomy

81
Q

Is the abdomen entered for a RPP?

A

No

82
Q

Is a RPP generally nerve-sparing?

A

No

83
Q

What are some anesthetic considerations for a RPP?

A 
same as RRP
extreme lithotomy position
increased central venous pressure
increased peak inspiratory pressure 
make sure patient can handle position
84
Q

What comorbidity/habit is strongly associated with bladder cancer?

A

cigarette smoking

85
Q

What two comorbidities is bladder cancer usually associated with?

A

CAD and COPD

86
Q

What is the 2nd most common cancer of the GU tract?

A

bladder cancer

87
Q

What is a radical cystectomy?

A

removal of the bladder with ileal conduit or ileal pouch put in its place

88
Q

What is removed during a radical cystectomy in males?

A

bladder prostate
seminal vesicles
part of urethra

89
Q

What is removed during a radical cystectomy in females?

A 
uterus
cervix
ovaries
part of urethra
anterior vaginal vault
90
Q

What are some anesthetic considerations for a radical cystectomy?

A

ensure cross-matched blood available with fluid/blood warmers (EBL 500-1000 mL)
2 large peripheral IVs (bowel prep requiring rehydration)
arterial line +/- CVP
general anesthesia +/- epidural or intrathecal narcotics (avoid N2O)
pain score 7-9
surgical time >4 hours
post-op to ICU

91
Q

What is a radical nephrectomy done for?

A

adenocarcinoma of kidney

92
Q

What happens in 5-10% of patients with adenocarcinoma?

A

tumors extends into the renal vein and inferior vena cava as a thrombus

93
Q

What should you ensure if the patient has an adenocarcinoma with the tumor extending into the renal vein and inferior vena cava?

A

Ensure that the facility where you are doing the procedure has cardio-pulmonary bypass machine, may need to clamp inferior vena cava to suture and complete the procedure

94
Q

What is a risk factor for adenocarcinoma?

A

smoking, CAD, COPD

95
Q

What incisions may be used for an adenocarcinoma?

A

anterior subcostal, flank, midline, or thoracoabdominal incision

96
Q

What complication is possible during a radical nephrectomy with a thoracoabdominal approach?

A

pneumothorax

97
Q

What are some anesthetic considerations for a radical nephrectomy?

A 
massive blood loss (EBL 500-2000 mL)
hypotension with kidney rest up
preservation of remaining kidney function
thrombus in IVC
emsure cross matched blood available
two large PIVs
arterial line +/- CVP
general anesthesia +/- epidural or intrathecal narcotics
post-op to ICU
98
Q

What is the surgical time for a radical nephrectomy?

A

3-5 hours

99
Q

What position is used for a laparoscopic nephrectomy?

A

flank position as in open nephrectomy

100
Q

What is the technique for a laparoscopic nephrectomy?

A

3-4 trochars used
pneumoperitoneum of 14-16 mmHg
may have to be hand assisted so will have larger incision so surgeon can stick in their hand to assist

101
Q

What kind of tumors are in majority of testicular cancer cases?

A

95% germ cell tumors and can be seminomas or nonseminomas

102
Q

What is the initial treatment for testicular cancer?

A

radical orchiectomy (removal of testicle)

103
Q

How are seminomas treated?

A

retroperitoneal radiotherapy

104
Q

How are nonseminomas treated?

A

retroperitoneal lymph node dissection and chemotherapy (Bleomycin, increased risk for pulmonary insufficiency)

105
Q

What are some anesthetic considerations for testicular cancer removals?

A

may use general or regional anesthesia
standard monitors
minimal blood loss
watch for reflex bradycardia from traction on spermatic cord
consider ilioinguinal/iliohypogastric nerve blocks

106
Q

What is the position for a urethroplasty?

A

lithotomy

107
Q

What is the incision for a urethroplasty?

A

perineal

108
Q

What is the surgical time for a urethroplasty?

A

3 hours

109
Q

What is the EBL for a urethroplasty?

A

100 mL

110
Q

What is the pain score for a urethroplasty?

A

3

111
Q

What is the position for a urethrectomy?

A

lithotomy

112
Q

What is the incision for a urethrectomy?

A

perineal

113
Q

What is the surgical time for a urethrectomy?

A

2hours

114
Q

What is the EBL for a urethrectomy?

A

300 mL

115
Q

What is the pains core for a urethrectomy?

A

3

116
Q

What is the position for insertion of a sphincter?

A

lithotomy

117
Q

What is the incision for insertion of a bladder sphincter?

A

perineal and scrotal

118
Q

What is the surgical time for insertion of a bladder sphincter?

A

3 hours

119
Q

What is the EBL for insertion of a bladder sphincter?

A

minimal

120
Q

What is the pain score for insertion of a bladder sphincter?

A

4

121
Q

What is the position for brachytherapy?

A

lithotomy

122
Q

What is the incision for brachytherapy?

A

none

123
Q

What is the surgical time for brachytherapy?

A

2 hours

124
Q

What is the EBL for brachytherapy?

A

minimal

125
Q

What is the pain score for brachytherapy?

A

3

126
Q

Why are circumcisions done?

A

phimosis (obstruction of urine flow)

recurrent infection

127
Q

What anesthetic can you do for a circumscision?

A

any anesthetic of choice

128
Q

What are some implications for a penile prosthesis and anesthetic considerations with it?

A 
semi-rigid or inflatable
organic impotence
supine position
can do anesthetic of choice
pain score of 5
129
Q

What procedures can be done for urinary incontinence in females?

A

Stamey procedure
Raz bladder neck suspension
Sling procedures

130
Q

What is the position, surgical time, and anesthetic implications for vaginal procedures for urinary incontinence?

A

lithotomy position
surgical time about 1 hour
anesthetic of choice
pain score of 5

131
Q

What are some causes of ESRD?

A

IDDM (31%) caucasians
chronic glomerulonephritis (28%) (hispanics and asians)
polycystic kidney disease (12%)
nephrosclerosis (9%) (Af. am. with HTN and nephrosclerosis)
SLE (3%)
interstitial nephritis (3%)

132
Q

What are contraindications for kidney transplant?

A

infection

cancer

133
Q

What are relative contraindications for kidney transplant?

A

> 60 years old

severe cardiovascular disease

134
Q

What is the 3 year survival rate for cadaveric transplants?

A

80-90%

135
Q

What should you worry about with a kidney transplant?

A
  • hypo/hypervolemia depending on dialysis-surgery interval

- hyperkalemia (should be

136
Q

What are some anesthetic considerations for kidney transplants?

A
  • supine position
  • preoperative antibiotics (immunosuppressed due to chronic uremia)
  • lower quadrant curvilinear incision
  • generally use general anesthesia
  • avoid Sevoflurane due to Chloride issue
  • consider cisatracurium, atracurium, rocuronium, or vecuronium
  • morphine clearance is reduced
137
Q

What are some anesthetic considerations regarding the curvilinear incision used for a kidney transplant?

A
  • donor kidney placed extraperitoneally into iliac fossa; renal vessels –> iliac vessels; ureter –> bladder
  • heparin prior to temporary clamping of iliacs
  • IV mannitol after reperfusion
138
Q

How can you maximize renal blood flow at time of graft reperfusion during kidney transplant?

A

blood volume expansion (CVP 10-12)
mannitol
furosemide

139
Q

When should you administer immunosuppression during a kidney transplant and what is commonly administered?

A

administer prior to graft reperfusion
corticosteroids
cyclosporine
azathioprine

140
Q

What should you closely monitor during a kidney transplant

A
  • serum electrolytes (hyperkalemia occasionally reported following arterial vascular clamp release)
  • urine output every 30 minutes (watch for brisk urine flow following arterial anastomosis)
  • maintain normal to elevated arterial BP and CVP to maximize renal blood flow
141
Q

Why is a percutaneous lithotripsy done?

A

indicated for large stones that will not pass beyond the renal pelvis, percutaneous sheath placed into renal pelvis, nephroscope inserted and stone is shattered with ultrasonic probe, stones then irrigated out of kidney

142
Q

What position is used for a percutaneous lithotripsy?

A

prone on cystoscopy table

143
Q

What anesthesia is usually done for a percutaneous lithotripsy?

A

general anesthesia, patient may be 180 degrees

144
Q

What are some anesthetic considerations for a percutaneous lithotripsy?

A

watch for severe bleeding
large PIV
potential for kidney injury from high pressure fluid delivery for nephroscope

145
Q

How is a laser lithotripsy done?

A

performed through uteroscope with patient in lithotomy position, fiber-optic probe is placed against stone which is fragmented with laser light, useful for smaller stones

146
Q

What are the anesthetic considerations for a laser lithotripsy?

A

same as cystoscopy

can use regional or general anesthesia

147
Q

What is extracorporeal shock wave lithotripsy?

A

disrupts kidney stones with high-energy shock waves (calcium oxalate monohydrate, calcium phosphate, and cystine calculi are resistant to fracture with ESWL)
- employed for stones in the renal pelvis or upper two-thirds of ureters (above iliac crest)

148
Q

What are some common elements of all lithotriptors?

A
  • ability to localize stone target (fluoroscopy or US)
  • generation of acoustical shock waves
  • mechanism for focusing shock waves onto targeted stone
  • technique for coupling shock wave generator to the patient
    (most lithotriptors brought in on truck so will have to drag anesthesia machine/equipment out there)
149
Q

What is underwater ESWL?

A

high-voltage spark generated underwater –> water vaporization and cavitation bubble with rapid expansion and then collapse of cavitation bubble which creates a shock wave that is deflected to converge on the stone

150
Q

What is the goal of ESWL?

A

pulverize calculi to allow urinary excretion over following week

151
Q

How many shocks may be required for a ESWL and about how long can be treatment last?

A

1000-4000 shocks lasting about 60 minutes

152
Q

What can you do to decrease the surgical time for a ESWL?

A

increase the heart rate since the shock wave is synchronized 20 ms after R wave and corresponds it to ventricular refractory period

153
Q

What are some absolute contraindications to ESWL?

A

pregnancy, coagulopathy, intra-abdominal calcific processes (AAA), orthopedic implants in lumbar/pelvic areas

154
Q

What are relative contraindications to ESWL?

A

morbid obesity and pacemakers/AICD

155
Q

What are first generation lithotriptors?

A

require immersion in water bath which serves as acoustic coupling substance

156
Q

What are second generation lithotriptors?

A

membrane over shock wave generator allows patient to remain dry

157
Q

What are third generation lithotriptors?

A

smaller, lighter, enhanced focal point

multifunctional devices for urinary tract and biliary tract

158
Q

What anesthetic techniques can be used for lithotriptors?

A

local, regional, and/or IV sedation

159
Q

What should you remember regarding ventilation for a patient having lithotripsy?

A

ventilate with small tidal volumes to minimize stone displacement (LMA or intubate)

160
Q

What anesthesia is preferred for immersion-type lithotriptors?

A

regional anesthesia

161
Q

What level is required for a regional block for a lithotripsy?

A

T4-6

162
Q

Is epidural or spinal preferred for lithotripsy?

A

epidural because spinal has high incidence of PDPH and patient will have increased pressure of H2O that causes CSF leakage, epidurals also allow greater control of sensory level

163
Q

What is one disadvantage of regional anesthesia for lithotripsy?

A

inability tocontrol diaphragmatic movement, can displace stone in excess of 12 mm

164
Q

What does ESWL have a high association with?

A

dysrhythmias (10-14%) despite synchronization with ECG
PACs and PVCs most frequently noted
patients with pacemakers and history of dysrhythmias
R wave important in shock wave timing (20 ms after R wave)

165
Q

What should you do if the patient is getting immersed for an ESWL?

A
  • cover ECG pads with water-proof dressing (R wave triggered shocks can induce supraventricular or ventricular arrhythmias)
  • use clip-type cuff
  • pulse ox probe on nose or ear
  • closely monitor body temp if immersed
166
Q

What are common pediatric urologic procedures?

A

circumcision
urethral meatotomy
orchiopexy (undescended testicle)
Wilms’ tumor (nephroblastoma) - less common and occurs in small infants

167
Q

What are some anesthetic considerations for pediatric urologic procedures?

A

general anesthesia (mask, LMA, ETT)
consider caudal analgesia
penile block (no epinephrine)
ilioinguinal nerve block

168
Q

What sensory level is satisfactory for nearly all cystoscopic procedures?

A

T10

Principles II N517 (7 decks)

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