Anesthetic Considerations for General Surgery

Question 1

CRNA’s responsibility in the preoperative evaluation

Answer 1

determining medical status of the patient
developing a plan of anesthesia care
reviewing with the patient the proposed plan of care

Question 2

Goals in determining our anesthetic technique

Answer 2

patient safety and comfort and ability of the surgeon

Question 3

Ideal anesthetic goals (8)

Answer 3

1. optimal patient safety and satisfaction
2. excellent operating conditions for the surgeon
3. rapid recovery
4. avoid postop side effects
5. low in cost
6. allow early discharge from PACU
7. optimize pain control
8. allow for optimal OR efficiency

Question 4

Advantages of General Anesthesia for General Surgery

Answer 4

rapid onset of unconsciousness
controlled ventilation
allows paralysis
more safely allows positioning extremes
lower failure rate

Question 5

Disadvantages of General Anesthesia for General Surgery

Answer 5

increased stress response
if full stomach - risk of aspiration
PONV
postop sedation

Question 6

Goals of maintenance of anesthesia

Answer 6

amnesia, analgesia, skeletal muscle relaxation, and SNS response control

Question 7

Advantages of regional anesthesia for general surgery

Answer 7

maintenance of consciousness
skeletal muscle relaxation
contraction of the GI tract
lower insufflation pressure
decreased stress response
faster recovery

Question 8

Disadvantages of regional anesthesia for general surgery

Answer 8

occasional failure to produce adequate levels of sensory anesthesia
hypotension d/t SNS blockade

Question 9

Peripheral nerve block advantages

Answer 9

good option for superficial operations of extremities
consciousness
protective upper airway reflexes
isolated anesthetic effect

Question 10

peripheral nerve block disadvantages

Answer 10

unpredictable sensory and motor anesthesia
success rate related to experience of provider
patient cooperation

Question 11

Monitored anesthesia care (MAC) considerations

Answer 11

not benign! held to the same standard as any other anesthetic
*can lead to unexpected general anesthetic!
local anesthesia toxicity
provides anxiolysis, analgesia, sedation

Question 12

Positioning possible complications

Answer 12

hypotension from impaired venous return
oxygen desaturation d/t VQ mismatch
peripheral nerve injuries

Question 13

Positioning general considerations

Answer 13

ensure patient safety!
peripheral joint extremities well padded
support normal lumbar spine curvature
head midline
no pressure on the eyes
safety straps/prevent falling

Question 14

Positioning CV considerations

Answer 14

going supine = increased VR –> preload, SV, CO augmentation
increased BP = afferent baroreceptors –> decrease SNS outflow
PPV increases intrathoracic pressure

Question 15

Supine positioning

Answer 15

arms: tucked (adducted) or abducted <90 degrees with palms supinated
hips/knees: flexed slightly

Question 16

Supine complications

Answer 16

pressure alopecia, backache, soft tissue ischemia, peripheral nerve injury

Question 17

Trendelenburg considerations

Answer 17

nonsliding mattress, don’t use shoulder braces, significant CV/respiratory effects

Question 18

Trendelenburg physiologic changes

Answer 18

increase CVP, ICP, IOP
swelling in face, larynx, and eyes
decreased FRC and compliance
increased work of breathing

Question 19

Reverse trendelenburg considerations

Answer 19

facilitates upper abdominal surgery by shifting abdominal contents caudad
decreased venous return and CPP

Question 20

Lithotomy considerations

Answer 20

used for gynecologic, rectal, urologic surgeries
hips are flexed
legs abducted and held by stirrups
raise and lower both legs together

Question 21

Which position can cause crush injury to the fingers?

Answer 21

lithotomy

Question 22

what is the most common nerve injury in lithotomy position?

Answer 22

peroneal nerve

Question 23

lithotomy physiologic changes

Answer 23

increased preload, reduced lung compliance, decreased tidal volume, increased abdominal pressure

Question 24

lateral decubitus considerations

Answer 24

used for thorax, retroperitoneal, hip surgeries
anterior and posterior support
flex dependent leg
arms positioned in front of patient
axillary roll and kidney rest

Question 25

Why do we place an axillary roll for lateral decubitus positioning?

Answer 25

avoid compression injury to the dependent brachial plexus

Question 26

lateral decubitus physiologic changes

Answer 26

can compromise pulmonary function

favors ventilation of nondependent lung and blood flow to underventilated, dependent lung

Question 27

prone positioning considerations

Answer 27

used for posterior spine, buttocks, perirectal, and lower extremities
arms tucked or superman