APA 2 - Anesthesia for Urologic Procedures Flashcards
Urologic endoscopy is performed to visualize and evaluate the upper and lower urinary tracts to diagnose and treat conditions such as
hematuria, pyuria, calculi, trauma, cancer
Upper urinary tract
ureter and kidney
lower urinary tract
bladder, prostate, urethra
Nerve injuries are a concern for these types of patients because they’re in the lithotomy position. What nerves are at risk?
common peroneal, saphenous, sciatic, obturator, femoral
Compression of the fibular head on the leg brace can result in injury to what nerve?
common peroneal
Compression of the tibial condyle can result in injury to what nerve?
saphenous nerve
Excessive external rotation of legs and excessive extension of the knees can result in injury to what nerve?
sciatic nerve
Excessive flexion of the groin can result in injury to what nerves?
obturator and femoral
When lowering the legs from the lithotomy position what may happen?
BP fall
Bladder rupture/injury secondary to ADDUCTOR muscle contraction from _______ ________ stimulation from electrocautery
obturator nerve
When is there an increased risk of Obturator reflex from stimulating the obturator nerve?
When resecting lateral wall tumors
________is passage of a rigid scope through the urethra
cystoscopy
Can a cystsocopy be done with 2% lidocaine jelly?
apparently yes
Urethral stimulation, dilation and distention of bladder can be painful requiring _____ or _______ anesthesia
general or regional
If regional anesthesia is chosen for a cystoscopy, a ___ to ___ sensory level is required and ___ for ureters
T9-T10 / T8
Review dermatome man on slide
16
Cystoscopy for retrograde ureteral catheterization is used for what?
to visualize the ureter and kidney, to place stents, to drain obstructions, to remove renal calculi
TURB
Transurethral resection of the bladder
TURB is where endoscopic resection and electrodesiccation are used to treat ________ __________ tumors
superficial bladder
What kind of anesthesia for a TURB and why?
General anesthesia - no coughing or straining wanted b/c increases risk of bladder perforation
If using regional anesthesia for a TURB, the bladder becomes ________ and may become thinner when ________, increasing the risk of _______
atonic / distended / perforation
If doing a TURB on an elderly person, ________ is better than general
regional
S/S of bladder perforation in the awake patient
If periotneal cavity entered will have shoulder discomfort, Nausea, vomiting
If a high-grade malignancy present and the bladder is perforated there is a risk of what as it relates to the cancer?
seeding the cancer cells into the peritoneum
Blood loss and bacteremia can also happen from a _____ _____
bladder perforation
Lavaging the bladder can result in ________, especially if perforated
hypothermia
The awake patient will experience _______ fullness, ________ spasm and PAIN with a bladder perforation
suprapubic / abdominal
______ and _____ are early signs of bladder perforation followed by SEVERE ________
HTN / Tachycardia / HYPOTENSION
Cool irrigation causes ___________ and results in systemic cooling. ____ _______ will decrease this risk
vasoconstriction / warm fluids
______ is a risk which is triggered by release of prostatic thrombogenic substances - especially with cancer of prostate
DIC
Have to be prepared to convert to an _____ _____
open procedure
TURP
Transurethral resection of the prostate
For a TURP, ______ or ______ prostate tissue is removed by electrosurgical resection under direct endoscopic vision
neoplastic / obstructive
TURP is performed by application of a high-frequency current to a wire loop. Hemostasis is achieved by sealing the vessels with the _________ current
coagulation
An optically clear, nonconductive, nonhemolytic, nontoxic solution is required to _______ the bladder for a TURP
distend
TURP general anesthesia considerations
coughing must be avoided b/c it increases the risk of bleeding
What anesthesia is preferred for TURP
spinal
What are the benefits for doing a spinal for TURPs?
the bladder will be atonic with a large capacity and thus glycine infusion pressure can be low, emptying less frequent which fascilitates resection. Post-op bladder spasm is prevented allowing for hemostasis. AWAKE PATIENTS MAY SUPPLY EARLY DETECTION OF COMPLICATIONS
Complications of TURP
Blood loss and venous absorption of irrigation fluid
Early signs of venous absorption
hypertension and tachycardia
With venous absorption, CVP may rise as cardiac ________ occurs. The awake patient may complain of ______ or ________. Hypoxia and/or Hyponatremia causes ______ syndrome
decompensastion / dyspnea and nausea / TURP
TURP syndrome is AKA
Water intoxication or Glycine Toxicity
The awake patient may exhibit as a result of TURP syndrome
apprehension, disorientation, convulsions, coma
Glycine disadvantages
Risk of blindness or post op visual impairment, less likelihood of TURP syndrome
Sorbitol disadvantages
less likelilhood of TURP syndrome but can cause hyperglycemia and lactic acidosis
Mannitol disadvantages
nonmetabolized, osmotic diuresis which causes hypervolemia
Treatment for TURP syndrome
Ask surgeon to control bleeding and finish surgery fast, send blood sample for Sodium level (less than 120 mEq/L is serious), correct hypervolemia and hyponatremia with fluid restrictions and diuretics (furosemide 10-20 mg), correct hyponatremia with hypertonic solutions cautiously, NS or LR will postpone if sodium level is less than or equal to 125
With an open prostate radical prostatectomy what is seen in 50% of patients
impotence
Position for a suprapubic (retropubic) approach for a radical prostatectomy
supine, flex table , trendelenburg
Position for a perineal approach for a radical prostatectomy
extreme lithotomy position
Which approach has more hemorrhage for radical prostatectomy
Retropubic
With radical prostatectomy, blood loss occurs during control of ____ _____ _____
dorsal venous complex (get up and look at suction)
Radical prostatectomy can be done under regional or general anesthesia but regardless, a large _____ is a must
IV
During a radical prostatectomy what diagnosistic dye can cause hypotension and drop your oxygen saturation?
methylene blue (can cause sat to go to 65% for 1-2 minutes)
Indigo carmine dye has an alpha sympathomimetic effect to increase ____
BP
Indications for nephrectomy
chronic infection, trauma, cystic or calculus disease, neoplasm
A nephrectomy is perfromed by _____ _______ or _____ _____ incicsion
lateral retroperitoneal / anterior abdominal
For nephrectomy you will be using a _____ flex table and KIDNEY BAR which may cause vena cava ______ and _______. General or combined general with regional anesthesia is used for this surgery
lateral / compression / hypotension
Considerations prior to renal transplant
optimize prior, serum potassium should be normal, metabolic acidosis should be corrected, Anemia is common
Renal transplant position
supine with roll under hip
For renal transplant IV access should not be on the same side as the ______
fistula
What muscle relaxer for renal transplant?
atracurium
For a renal transplant, regional anesthesia is contraindicated by preexisiting __________ and or ___________
coagulopathy / immunosuppression
You want what fluids for renal transplant?
NS. Avoid LR and K+
Adequate hydration is critical for renal transplants, so cyrstalloid, colloid, and blood should be used for _____________ of the kidney
revascularization
With renal transplant, ______ ______ and ________ help discourage rejection and diuresis
methyl prednisone / diuretics
With renal trasnsplants, low dose _______ used if oliguric
dopamine
3 major complications of kidney transplant
hyperkalemia, delayed renal function, graft failure
Cold storage solutions are used to preserve kidney graft survival and minimize tissue necrosis and edema. ____ degrees celsius is goal to reduce _______ demands
4 / metabolic
Continuous perfusion of the kidney causing pulsatile flow of cold perservation is pumped at ___ to __ mmHg.
40 to 60
What is in the solution for cold preservation of kidney?
glucose, potassium, magnesium, ABX, HC03, and heparin (which can trigger hypersensitivity reaction in recipient)
POPS
Portable Organ Preservation System (has changed time frame from 48 hrs to 72 hrs)
Anesthetic considerations for Radical Cystectomy
Done in supine position, general or combined anesthesia, arterial and CVP, Large IV, Fluid shifting can be extensie and unable to monitor urine so need the CVP, diuretics may be needed to stimulate output, indigo carmine or methylene blue used at times
Complications of Radical cystectomy
hypothermia, inadequate fluid replacement, need for post-op ventilation
What sensory level block needed for orchiectomy and urogenital plastics procedures?
T9
A/V shunts and fistulas are placed for dialysis access. Patient lies in ______ postion with arms ________. General, regional and local infiltration are all acceptable. Can do these as MAC as well. Their blood pressure are very _______.
supine / extended / labile
ESWL
Extracoroporal Shock Wave Lithotripsy
ESWL breaks ________ urinary tract stones with external shock waves. Cushion the interface with skin or patient is submerged in a tank of water.
upper
With ESWL, the shock delivered is triggered by the _____
QRS
With ESWL, there will be stents placed as well usually so the patient will need to be in the _______ position for that.
lithotomy
After ESWL, adequate _______ and __________ help pass stone fragments
hydration / diuretics
